june 2006 – volume 8 summer 2007 – volume 9 issn 1088-4661 published annually by the department of counseling & clinical psychology, teachers college, columbia university graduate student journal of psychology jessica a. keith traci r. stein editors graduate student journal of psychology the graduate student journal of psychology is a publication of the department of counseling and clinical psychology, teachers college, columbia university. editors jessica a. keith traci r. stein clinical psychology program teachers college, columbia university editorial board ben adams samantha boris karpel sadia r. chaudhury rachel khurgin jesse a. metzger rebecca p. prince erica roizen lisa sara rosenzweig jeanette a. sawyer mun-yi shea karen a. shoum vijayeta k. sinh anitha venkataramani-kothari department advisor barry a. farber, ph.d. director of clinical training, clinical psychology program, department of counseling and clinical psychology aims and scope. founded in 1998, the graduate student journal of psychology (gsjp) is a peer-reviewed publication devoted to clinical and counseling psychological research and practice. the gsjp is published annually and includes original empirical research articles, case studies, theoretical articles, and brief reports in the areas of adult and child psychopathology, the psychotherapeutic process, community mental health, multiculturalism, assessment, child development, ethics, professional development, and other topics with a relationship to research or practice in clinical or counseling psychology. manuscripts. the manuscript submission deadline for next year’s volume is december 10, 2007. submit manuscripts according to the submission guidelines printed in this issue. please submit 3 printed copies of the manuscript along with an emailed electronic copy to: editors, graduate student journal of psychology, department of counseling and clinical psychology, box 102, teachers college, columbia university, 525 west 120th street, new york, ny 10027; email gsjp@tc.edu; www.tc.columbia.edu/publications.gsjp. cover photography: jeanette a. sawyer copyright and permissions. those who wish to reuse material copyrighted by the gsjp must secure written permission from the editors to reproduce a journal article in full or journal text of more than 500 words. the gsjp normally grants permission contingent on permission of the author and inclusion of the gsjp copyright notice on the first page of reproduced material. access services may use unedited abstracts without the permission of the gsjp or the author. address requests for reprint permissions to: graduate student journal of psychology, department of counseling and clinical psychology, box 102, teachers college, columbia university, 525 west 120th street, new york, ny 10027. dear reader, we are thrilled to present to you the ninth edition of the graduate student journal of psychology. this year, for the first time, we invited submissions from counseling and clinical psychology graduate programs across north america. we received our greatest number of submissions yet, from a range of programs on a wide variety of topics. the articles in this volume of the journal address important clinical, ethical, and empirical issues within the fields of clinical and counseling psychology, including the challenge of treating adolescents with depression, the application of mindfulness techniques to parenting, and the importance of sound ethical decision-making in regards to multiple relationships with clients. we are particularly pleased to include a special paper in this edition that focuses on strategies for graduate students interested in developing a career in academic psychology. we believe that the recommendations of the authors of this paper, who are academic psychologists themselves, will be of great interest and value to our readership. we would like to offer our sincere appreciation to professor barry farber for his ongoing support and mentorship, as well as to the department of counseling and clinical psychology for its financial support of the journal. we are also grateful to our dedicated editorial staff for their considerable efforts, without which this journal would not be possible. much work has gone into this year’s journal, and we hope you enjoy the outcome. sincerely, jessica a. keith traci r. stein editor editor microsoft word gsjp_masthead.doc _____________________________________________________________________________________ the graduate student journal of psychology is a publication of the department of counseling and clinical psychology teachers college, columbia university. _____________________________________________________________________________________ editors-in-chief anitha venkataramani-kothari jessica a. keith clinical psychology program teachers college, columbia university editorial board copy editor brian sherman copy-editing team joseph mcgowan lisa rosensweig jeanette sawyer layout editor and printing manager mia ihm cover editor and distribution manager nidhi khurana website editor sadia chaudhury additional staff ben adams rachel khurgin david rivera erica roizen karen shoum nicole watkins nicole yoskowitz department advisor barry a. farber ph.d. director of clinical training, clinical psychology program, department of counseling and clinical psychology ___________________________________________ cover image courtesy of www.shutterstock.com. cover design courtesy of jim wagner, www.freelancedude.com. aims and scope. founded in 1998, the graduate student journal of psychology is a peer-reviewed publication devoted to clinical and counseling psychological research and practice. the gsjp is published annually and includes original empirical research articles, case studies, theoretical articles, and brief reports in the areas of adult and child psychopathology, the psychotherapeutic process, community mental health, multiculturalism, assessment, child development, ethics, professional development, and other topics with relevance to research or practice in clinical or counseling psychology. manuscripts. the manuscript submission deadline for next year’s volume (volume 11) is december 12, 2008. submit manuscripts according to the submission guidelines printed in this issue. please submit 3 printed copies of the manuscript along with an e-mailed electronic copy to: editors, graduate student journal of psychology, department of counseling and clinical psychology, box 102, teachers college, columbia university, 525 west 120 th street, new york, ny 10027; e-mail gsjp@tc.edu. copyright and permissions. those who wish to reuse material copyrighted by the gsjp must secure written permission from the editors to reproduce a journal article in full or journal text of more than 500 words. the gsjp normally grants permission contingent on permission of the author and inclusion of the gsjp copyright notice on the first page of reproduced material. access services may use unedited abstracts without the permission of the gsjp or the author. address requests for reprint permissions to: graduate student journal of psychology, department of counseling and clinical psychology, box 102, teachers college, columbia university, 525 west 120 th street, new york, ny 10027. more information available online at: www.tc.columbia.edu/gsjp/publications jim wagner, www.freelancedude.com graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 the poverty of affluence: addiction to wealth and its effects on well-being brian j. sherman teachers college, columbia university although children in affluent families are generally presumed to be at low risk for developmental disturbances, recent evidence suggests otherwise. affluent children show elevated levels of depression, anxiety, and substance use when compared to national norms in preadolescent and teenage cohorts and when compared to their low-income, inner-city counterparts. these adjustment problems are directly linked to the ecological context of affluent communities, particularly parentaland peer-socialization factors. this paper briefly summarizes extant evidence, provides fresh insight into the negative effects of affluence, discusses limitations of current findings, and directions for future research. children from affluent communities are often considered to be at low risk for mental health problems. however, while financial security may provide luxuries and opportunities otherwise precluded, there are certain negative outcomes of excessive affluence. children of affluent parents show elevated rates of clinical depression up to three times higher than national norms, and substance use is significantly higher in affluent samples than in their inner-city counterparts. furthermore, internalizing symptoms have been linked to substance use, suggesting that these children are self-medicating their depression (luthar & d’avanzo, 1999; luthar & becker, 2002). findings implicate achievement pressures and feelings of isolation as contributors to these outcomes. this brief report examines further the ecological context of affluent communities and the negative effects on well-being. understanding abnormal development one of the first studies on adjustment problems in children from affluent communities was conducted by luthar and d’avanzo (1999). the authors examined associations between substance use and two contextual constructs, personal psychopathology and social competence, by comparing low-income inner-city tenth graders with tenth graders from an affluent suburban high school. personal psychopathology was defined by internalizing and externalizing problems, while social competence measures included quality of peer relations and academic performance. results showed significantly higher tobacco, alcohol, and marijuana use in affluent children than in their inner-city counterparts. among affluent males, substance use was highly correlated with peer acceptance, implicating peer acceptance in substance use. correspondence concerning this article should be addressed to brian j. sherman, 180 claremont avenue, apt. 21, new york, ny 10027; email: bjs2125@columbia.edu. clinical rates of depression were three times higher among tenth grade affluent girls than the national norm for all tenth grade girls (21% vs. 7%, respectively), indicating a significant problem among this subgroup warranting further investigation. in addition, substance use was linked with depression and anxiety in the affluent female subgroup. this finding is of particular concern as it suggests that these girls are possibly self-medicating, a trend which has become more common among females than males (kandel, ravies, & davies, 1991). moreover, research indicates that self-medicating substance use is more harmful to overall development than socially stimulated substance use (cooper, 1994), placing these girls at even higher risk for longterm psychological distress. as a follow-up, luthar and becker (2002) examined substance use, particularly alcohol, tobacco, and marijuana use, and internalizing symptoms in sixth and seventh graders from affluent communities. additional constructs of achievement pressures and isolation from parents were included as hypothesized predictive factors. results were consistent with luthar and d’avanzo (1999); specifically, clinically significant rates of depression in seventh grade girls were twice as high as in normative samples (luthar & becker, 2002). additionally, peer approval was associated with substance use in seventh grade boys. internalizing symptoms—anxiety and depression—were linked with substance use in boys and girls, again suggesting that these children are self-medicating. as hypothesized, achievement pressures and isolation from parents were both correlated with elevated distress among this sample. these two studies demonstrate consistency across age groups indicating significant problems with substance use and internalizing symptoms in affluent communities. furthermore, these problems may reinforce each other in a negative feedback loop via self-medication. a more broad-based longitudinal study, following over two thousand teenagers through high school and beyond, compared happiness and self-esteem among affluent, mid30 sherman 31 dle-class, and low-income populations. csikszentmihalyi and schneider (2000) had participants record their moods continuously in their natural environment, making the data particularly powerful. findings revealed an inverse relationship between socioeconomic status (ses) and teenagers’ happiness and self-esteem. teens from affluent communities had lower self-reported happiness and self-esteem than both their middle-class and low-income counterparts. this study illustrates an overall trend of poor psychological well-being among affluent children, and when paired with the aforementioned studies brings to the forefront an issue in dire need of further research. given that children in affluent communities show elevated rates of substance use, internalizing symptoms, and overall poor psychological functioning and contextual factors such as peer acceptance, achievement pressures, and isolation from parents play a causal role, we must look further at the ecological context of affluent communities to fully understand the etiology of these harmful realities. material wealth: the addiction of american affluence attaining wealth and status is part of the “american dream.” it is ingrained in the social fabric of america and is often mistakenly equated with happiness. while money is necessary to obtain food, clothes, and shelter, the question remains: does wealth breed happiness? evidence suggests otherwise. extensive research on the united states indicates that over the past fifty years, while the gross national product (gnp) has more than tripled, life satisfaction has not changed (diener & seligman, 2004). this appears to refute the belief that money invariably leads to happiness. furthermore, some research indicates that those in economically developed nations show elevated levels of depression (buss, 2000) and lower subjective well-being (deiner & biswas-deiner, 2002) compared to less developed nations. however, before we conclude that wealth breeds unhappiness and depression, we must consider other factors that may mediate the relationship between financial success and poor psychological functioning. as luthar (2003) suggests, “it is not the surfeit of riches in itself, but rather, an overemphasis on status and wealth that is likely to compromise well-being” (p.1589). along these lines, whybrow (2005) likens striving for material wealth to any addiction where the need for material gain can “hijack our reward system” (p. 93). expanding on this idea, other research has shown that once survival needs are secured (i.e. food, clothing, and shelter), there are diminishing returns from increased wealth; in wealthy nations, well-being is dependent on relative wealth, such that more and more money is required to maintain the same level of well-being (myers, 2000; diener & seligman, 2004). in such societies the endless pursuit of relative wealth often leads to poor mental health and interpersonal deficiencies, affecting not only the individuals but their families as well. in summary, increases in material wealth do not necessarily result in increased life satisfaction and have actually been linked with lower psychological wellbeing. how does one wind up in such a predicament? some point to personal value systems to explain the links between acquiring wealth and personal distress and unhappiness. kasser and ryan (1996) examined the effects of valuing intrinsic versus extrinsic rewards on personal well-being and distress. participants who valued intrinsic rewards, including self-acceptance, community service, and personal growth, showed lower levels of distress and higher wellbeing, than participants who valued extrinsic rewards such as financial success, appealing appearance, and social recognition. those who viewed financial success as a central life goal showed particularly high levels of anxiety and depression. by focusing on the external rewards of financial success, intrinsic, self-actualizing tendencies that promote personal growth and well-being are neglected. a clearer picture begins to emerge as we see the associations between extrinsic reward systems and distress and well-being. a longitudinal study by nickerson, schwarz, diener and kahneman (2003) provides perhaps the most compelling evidence for the deleterious effects of affluence on psychological well-being and family cohesion. nickerson et al. (2003) compared data from a 1976 survey of incoming college students assessing importance of financial success (“financial goal”) with a 19 year follow-up survey assessing overall life satisfaction and satisfaction in other specific domains including family, job, and physical health. financial goal was negatively correlated with overall life satisfaction, while income level was positively correlated with overall life satisfaction. this finding suggests that it is not the money itself, since having money can facilitate happiness; rather, it is the excessive preoccupation with acquiring financial success that compromises psychological health. moreover, quality of family life suffered the most out of all the specific domains assessed among people with high financial goals. family relationships may be particularly vulnerable because having high financial goals requires spending late nights at work and often, frequent business travel. consequently, family interactions can become restricted and inadequate. specifically, not only are children precluded positive parental support and love, they learn to value extrinsic rather than intrinsic rewards (kasser &ryan, 1996). it is no wonder isolation and achievement pressure have been implicated in the mental health problems of affluent children. case studies by levine (in press) explain this phenomenon. when one or both parents spend excessive time away from home, and “when money becomes overly important…work, friendship, marriage, hobbies, parenting, spiritual development, and intellectual challenges can all fall by the wayside” (p.47). in addition, affluent parents generally underestimate the effects of these absences on their children, while children are often painfully aware that they are not a top priority. the poverty of affluence 32 interventions: informing normal development as stated previously, underage drinking has become commonplace among affluent suburban high schools across the nation (luthar & sexton, 2004), and curbing this trend requires parents to monitor their children’s activities. not only is monitoring children’s behaviors significantly linked with lower rates of drug use and sexual promiscuity, it is positively correlated with better academic achievement and higher self-esteem (dishion & kavanagh, 2003). in addition, deeper within the ecological context, there exists the issue of parents’ awareness and attention to their own mental health problems. research suggests that affluent parents may deny their own psychological problems that are in need of attention (luthar & latendresse, 2005). considering the associations among the acquisition of wealth, unhappiness, and the erosion of family structure, psychological interventions aimed at affluent parents may be helpful to both parents and children. summary and conclusion recent evidence indicates that children in affluent communities are at elevated risk for adjustment problems. significantly elevated rates of depression among girls and substance use among boys and girls were found in both seventh and tenth grade cohorts. peer relations, achievement pressures, and isolation from parents are implicated in these affluent samples. thus, the socioeconomic status of affluent children by no means inoculates them from psychopathology and in fact, may contribute to its development. while the evidence shows elevated rates of depressive symptoms and substance use in affluent children, it still begs the question: how serious are these symptoms over the course of development? additional longitudinal studies examining the predictive value of these findings are needed. also, as all of the research on specific indicators of affluent youth problems comes from northeast samples (luthar, 2003; luthar and sexton, 2004), it is important to conduct similar studies with affluent youth from geographically diverse areas. finally, in the interest of public health, researchers must expand on this body of research and inform parents of the risks associated with addiction to affluence. references buss, d. m. (2000). the evolution of happiness. american psychologist, 55, 15-23. cooper, m. l. (1994). motivations for alcohol use among adolescents: development and validation of a four factor model. psychological assessment, 6, 117-128. csikszentmihalyi, m., & schneider, b. (2000). becoming adult: how teenagers prepare for the world of work. new york: basic books. diener, e., & biswas-diener, r. (2002). will money increase subjective well-being? social indicators research, 57, 119-169. diener, e., & seligman, e. p. (2004). beyond money. psychological science in the public interest, 5(1): 1-31. dishion, t. j., & kavanagh, k. (2003). intervening in adolescent problem behavior: a family-centered approach. new york: guilford press. kandel, d. b., ravies, v. h., & davies, m. (1991). suicidal ideation in adolescence: depression, substance use, and other risk factors. journal of youth and adolescence, 20, 289-309. kasser, t., & ryan, r. m. (1996). further examining the american dream: differential correlates of intrinsic and extrinsic goals. personality & social psychology bulletin, 22, 280-287. levine, m. (in press). the price of privilege. new york: harpercollins. luthar, s. s. (2003). the culture of affluence: psychological costs of material wealth. child development, 74, 1581-1593. luthar, s. s., & becker, b. e. (2002). privileged but pressured: a study of affluent youth. child development, 73, 1593-1610. luthar, s. s., & d’avanzo, k. (1999). contextual factors in substance use: a study of suburban and inner-city adolescents. development and psychopathology, 11, 845867. luthar, s. s., & latendresse, s. j. (2005). children of the affluent: challenges to well-being. current directions in psychological science, 14(1): 49-53. luthar, s. s., & sexton, c. c. (2004). the high price of affluence. in r. v. kail (ed.), advances in child development, 32. san diego, ca: academic press. myers, d. g. (2000). the american paradox: spiritual hunger in an age of plenty. new haven, ct: yale university press. nianyang, w., & dongyun, z. (2004). a study of the correlation between parent-child relations and the mental health level of teenagers. psychological science, 27(4): 812-816. nickerson, c., schwarz, n., diener, e., & kahneman, d. (2003). zeroing in on the dark side of the american dream: a closer look at the negative consequences of the goal for financial success. psychological science, 14(6): 531-536. whybrow, p. c. (2005). american mania: when more is not enough. new york, ny: w.w. norton & company, inc. graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 interpersonal psychotherapy (ipt) for schizophrenia ori elis teachers college, columbia university although developed in order to treat depression without psychotic symptoms, interpersonal psychotherapy (ipt) may prove to be a useful treatment for patients with schizophrenia. conceptually, ipt may help to form and structure a treatment model that takes into account specific characteristics of schizophrenia, such as a disorganized thought process and pervasive interpersonal deficits. this paper provides a brief critique of two frequently used psychotherapeutic models, cognitive behavioral therapy (cbt) and insight-oriented therapy, which appear to be fundamentally incongruous with current conceptualizations of schizophrenia. it then lays out a preliminary conceptual adaptation of ipt for use as both an intervention and a maintenance therapy for patients with schizophrenia. schizophrenia is a psychotic disorder characterized by disorganized thoughts and behaviors, pervasive interpersonal deficits, and an array of symptomatology that can be divided into positive and negative symptoms. positive symptoms may consist of delusions, hallucinations, disorganized speech or behavior, and inappropriate affect, while negative symptoms include flattened affect, anhedonia, poverty of speech, avolition, and social withdrawal (cornblatt, green, & walker, 1999). it is an organic disease of the brain characterized by a chronic and pervasive course (cornblatt, green, & walker, 1999). the current trend in psychotherapeutic interventions for patients with schizophrenia falls into one of two conceptual spheres: cognitive behavioral therapy (cbt), and psychodynamic or insight-oriented therapy. psychotherapy for any psychotic disorder is optimally put into place in conjunction with medications including, but certainly not limited to, antipsychotic medication. because schizophrenia is an organic disease, at least in part, medication is necessary to bring about stability. most medications target positive symptoms (johns, sellwood, mcgovern, & haddock, 2002), although they may exacerbate negative symptoms, as side effects include sedation, reduced drive, psychomotor retardation, and flattened affect (beck, 2004). the goal of psychotherapy, then, should be to reduce and help patients cope with those symptoms medication does not alleviate, and to increase general functioning. currently, even with the combination of antipsychotic medication and psychotherapy, 25-60% of patients continue to exhibit psychotic symptoms. the need for a more disorder-relevant treatment is thus abundantly clear (jones, despaul, & van os, 2003). correspondence concerning this article should be addressed to ori elis; e-mail: ori_elis@yahoo.com. cognitive behavioral and insight-oriented therapies cognitive behavioral therapy, or some variation of it, is the most widespread psychotherapeutic model used in treating patients with schizophrenia. in the cognitive behavioral approach, patients are first given a rationale for the treatment, including educational information about their diagnosis and symptomatology. the interaction between thoughts and behaviors is then explained in a clear, logical manner, and patients are taught “reality testing” skills in order to reduce positive symptoms. finally, delusions are restructured using cognitive restructuring techniques (gaudiano, 2005). there is evidence that despite some efficacy, a cognitive behavioral approach may not be the best form of therapy for persons with schizophrenia. indeed, it only proves to be significantly efficacious in approximately half of test subjects (jones, despaul, & van os, 2003). one study examining the efficacy of cbt on patients with schizophrenia who had intellectual deficits showed that while 60% of subjects had improved scores on the aberrant behavior checklist, only 40% of patients showed an increase in the frequency or nature of their community involvement (kingdon & turkington, 2005). in a study examining the efficacy of cbt for negative symptomatology, although subjects showed a significant reduction in avolition, they did not improve significantly in their negative symptoms, and there were no significant differences on the subjective experience of negative symptoms, a scale measuring awareness of negative symptoms in addition to associated disruption and distress (johns et al., 2002). the main problem with cbt is that the approach relies on the patient’s ability to understand his or her thoughts— delusional or otherwise—in a rational manner (stuart & noyes, 2005). people who have schizophrenia, however, are often characterized by “pervasive disabilities in social cognition that often seemed to conspire against a more 14 elis 15 complete clinical and social recovery” (hogarty et al., 1997, p. 1505). for similar reasons, psychodynamic, or insightoriented, therapy has proven less effective than other psychotherapeutic techniques in the treatment of people with schizophrenia. psychodynamic therapy relies upon a patient’s presumed ability to draw logical conclusions from insights, which may not be applicable for this patient population, most of whom have delusional thoughts (hogarty, et al , 1997). additionally, there is a high dropout rate in patients participating in studies of the efficacy of psychodynamic therapy for patients with schizophrenia, a finding that is at least partly due to the relatively high degree of “cognitive demands, which may exceed the patient’s capacities at different stages of recovery” (hogarty et al., 1997, p. 1506). the governing principles behind both cognitive behavioral and psychodynamic therapies expose a conceptual understanding of delusional thoughts as constructed and interpreted in the same manner as normal thoughts. in his text, jaspers (1963) postulates that delusional thoughts are distinct from normal thoughts, in that the former involve a change in the mechanism of belief. delusional thoughts differ from normal thoughts not in their content, but in their formation, such that the awareness of meaning itself is transformed. these thoughts are “impervious to counterargument because of a change in belief fixation”(jones, despaul & van os, 2003, p. 2). if this is indeed true, it is possibly the strongest argument against cognitive approaches, which rely most heavily on the very capacity that this population is characteristically lacking. interpersonal therapy unlike the cognitive behavioral and psychodynamic models, interpersonal psychotherapy does not rely on insight or the ability to transform abstract notions to concrete ones (weissman, markowitz, & klerman, 2000). the basic premise of ipt is that symptoms are initiated and maintained through one’s interpersonal issues (crowe & luty, 2005). while the model recognizes biological, biochemical, developmental, genetic, and intrapsychic factors, it shifts the focus from the etiology of the disease to the triggers of symptom onset, making it, at its core, more tangible and achievable. ipt’s approach is further characterized by its focused, time-limited nature, which helps the patient address one or two specific problem areas while not becoming overly dependent on the therapist (weissman et al., 2000). interpersonal psychotherapy is conducted in three distinct phases, aptly named the initial, middle and final phases. the goals of the initial phase are to complete a diagnostic evaluation, obtain an in-depth psychological history (including an interpersonal inventory that reviews current social functioning, close relationships, etc.), and define the focus and structure of treatment. in the initial phase, the patient is assigned the “sick role,” which allows him or her to take leave of certain overwhelming social obligations, recognizing that the patient is, in fact, sick, and unable to perform optimally at that point in time. in the initial phase, the symptomatology is linked to a problem area. ipt defines four major problem areas, or domains, which trigger symptoms, at least one of which is present for the patient: grief, interpersonal role disputes, role transitions, and interpersonal deficits. it is the latter two which relate to an ipt conceptualization of schizophrenic symptomatology. the last part of this phase involves explaining to the patient the principles of ipt, agreeing on treatment goals and duration of treatment, and discussing other logistical information (weissman et al., 2000). the middle phase focuses on the goals and strategies of treatment with regard to the key domain identified as the major problem area during the initial phase. the goals for a patient for whom interpersonal deficits are considered to be the primary domain, for example, include reducing the patient’s social isolation and encouraging new relationships. for a patient whose problem area is a role transition, the goals are geared toward mourning the loss of the old role while learning to accept and become comfortable in the new role. the strategies incorporated are to reduce those aspects of the patient’s interpersonal relationships which trigger or contribute to symptomatology. for example, strategies for those with interpersonal deficits involve reviewing symptoms, relating symptoms to the key domain, and reviewing past relationships realistically, thereby isolating patterns (weissman et al., 2000). the general treatment techniques used in the middle phase are consistent across all domains, but the specifics are tailored to the individual. the session always begins by focusing on how things have been since the last session. a main feature of the middle phase is the use of communication analysis in order to help the patient move from the general to the specific, and to get a sense of the patient’s actions, intents, expectations, and discrepancies between these and what was actually communicated. this grounds the treatment firmly in the present, and allows the patient to isolate and identify, in a concrete manner, specific incidents which are characteristic of patterns (weissman et al., 2000). the final phase begins in the last few weeks of therapy. this phase involves explicitly discussing termination, acknowledging that termination will likely have an effect on the patient and should be treated as a mourning period, and “[moving] toward patient recognition of independent competence” (weissman et al., 2000, p. 24). the patient and therapist should also discuss the continuation and maintenance of treatment, when applicable (weissman et al., 2000). adapting interpersonal therapy for schizophrenia in order to begin to conceptualize how interpersonal psychotherapy can be adapted for use in helping patients cope with symptoms of schizophrenia, it is important to recognize several things. first and foremost, a prerequisite for treatment should involve a regimen of antipsychotic ipt for schizophrenia 16 medication. schizophrenia is an organic disease, and without adherence to an appropriate course of medication, the efficacy of any psychotherapy is diminished significantly (hogarty et al., 1997). second, ipt treatment should be conceptualized in terms of two key domains, interpersonal deficits and role transition, recognizing that role disputes in this population are most likely a by-product of interpersonal deficits and that these deficits may also result in many of the negative symptoms of schizophrenia. a focus on role transitions would ostensibly be appropriate for those who have recently had their first psychotic episode, are recently diagnosed, etc., because coming to terms with this diagnosis is difficult—not only does the individual have to accept that they have a mental illness, but that this specific mental illness is characterized by its chronic and increasingly debilitating course (helgeland & torgeson, 2005). as interpersonal deficits are pervasive in this population, the goals and strategies of this particular domain will be consistently present. lastly, because cognitive deficits are present to varying degrees, it is recommended that before progressing to the next phase of ipt, the patient should meet phasespecific criteria (hogarty et al., 1997). thus far, there have been few trials examining the applicability or efficacy of ipt to patients with schizophrenia. there have, however, been empirical studies utilizing ipt for patients with hypochondriasis and dementia, the characteristics and symptomatology of which are conceptually, if not concretely consistent with characteristics of schizophrenia. for example, a person with hypochondriasis is persistent in his or her beliefs about somatic illnesses in the same way that a person with schizophrenia is about his or her delusional thoughts. individuals in both groups exhibit a consistent failure to respond to external assurances and concrete proof that the illness (or the delusional thought content) does not, in fact, exist in any concrete manner. lastly, both groups are characterized by poor insight regarding their illness (stuart & noyes, 2005). like people with schizophrenia, people who have dementia have a difficult time “moving between abstract and concrete modes of thinking” (james, postma, & mackenzie, 2003, p. 451). some forms of dementia are characterized by such symptoms as a “fluctuating cognitive ability… [and] hallucinations” (james, postma, & mackenzie, 2003, p. 452). both illnesses are characterized by their increasingly debilitating course. it is reasonable to conjecture then, that characteristics of ipt that have been found to be effective in the treatment of hypochondriasis and dementia can be applied to patients with psychotic symptoms. an interpersonal approach to treating patients with schizophrenia begins by mirroring that of traditional ipt (hogarty et al., 1997). during this time, the patient and therapist should negotiate the treatment contract and discuss the importance of medication compliance, and the therapist should provide a basic education about the nature and course of the illness and its symptomatology. though the patient should be assigned the sick role, due to the tendency of patients with schizophrenia to withdraw from social activities, it may be necessary to also construct a comprehensive plan for the patient to resume daily activities. patients should also be encouraged to explore the “relationship between stressors as possible triggers to symptom exacerbation” (hogarty et al., 1997, p.7). in order to progress to the middle phase, the patient should meet the following criteria: symptom stability, medication stability, and social skills strategies application. most important in the initial phase is to establish an empathic, mutually respectful therapeutic alliance and to develop excellent rapport with the patient. especially for individuals with paranoid type schizophrenia, it is crucial that they learn to view the therapist, not as an omniscient and omnipotent being, but as one who is unequivocally and indisputably there for them. the intermediate phase would include more advanced education about the nature and course of schizophrenia and the learning of adaptive strategies, tactics for successful rehabilitation, and early warning signs of psychosis or psychotic episodes. ideally, it is in the intermediate phase that ideas from other therapies can be incorporated. the most useful aspects of the intermediate phase are probably communication analysis and decision analysis. using communication analysis, the therapist can begin to introduce the notion that communication is challenging and multifaceted, misinterpretations are common, and intent is not always conveyed accurately (stuart & noyes, 2005). once such notions take hold, it may be possible to begin to construct an understanding of psychotic symptomatology that is mutually acceptable to both patient and therapist. the interpersonal approach does not focus on the validity of the patient’s delusions, for example, but on his or her “ability to cope with them and to enlist social support to assist in that task” (stuart & noyes, 2005, p. 274). that is, it is not as important that the patient no longer experiences delusional thoughts as it is that he or she finds a way to recognize and cope with these thoughts in manner that makes him or her able to lead a less impaired existence. decision analysis is a method of helping the patient to explore options, eliciting opinions from the patient, and at times, retrospectively evaluating how the patient could have altered the course of an interpersonal interaction that did not go in the direction intended. the reason decision analysis is used in therapy with depressed patients is because they characteristically feel as though they have no options, that they have reached a dead-end. exploring decisions with the therapist serves a triple purpose: to help the patient discover options, to elucidate that the patient has the ability to come up with options, and to act as the first step in beginning to implement these options (weissman et al., 2000). similar parallels can be drawn for the patient with schizophrenia. decision analysis can have particular benefits for patients who hear voices. this process acknowledges that whether the voices are real or not (this is no longer a point of contention using an interpersonal conceptualization), the relationship that the person experiences with the voices is real. helping the patient explore options for this relationelis 17 ship, even avoidance tactics, is a very disorder-relevant treatment. the final phase of this approach follows a traditional ipt approach; explicitly discussing termination, acknowledging this as a time to grieve, supporting the patient, and helping them to recognize their individual ability to manage and negotiate their own lives (weissman et al., 2000). another factor to consider in employing an interpersonal approach with this population is that, unlike a traditional time-limited ipt approach, patients with schizophrenia may benefit from an open-ended treatment. this is due to the fact that schizophrenia is for the most part a debilitating, chronic disease in which impairment is increased with every psychotic episode, decompensation, and hospitalization (hogarty et al., 1997). in part, this means that with every psychotic episode, the patient needs to reevaluate and redefine his or her primary support systems, including (and perhaps especially) that of the therapist. an open-ended treatment would allow the patient and therapist to establish a long term supportive relationship. there have not been many studies examining the efficacy, or even the theoretical applicability of an interpersonal approach for patients with schizophrenia. a threeyear study comparing the effectiveness of ipt to other therapies yielded the following results: all patients consistently and significantly improved, regardless of the psychotherapeutic model used during the first year of the trial. the data from the second year showed less dramatic but still consistent improvements across all test conditions. it was only after the second year of therapy that significant changes occurred. in every therapy except ipt, patients began to plateau in effects and improvements. patients in the ipt group, however, continued to improve in residual symptoms. ipt patients continued to show improvements throughout the third year (hogarty et al., 1997). one of the measures included in determining efficacy of treatment was a social adjustment scale. according to the research, patients in the ipt group showed less impairment “regarding aspects of friction and distress experienced in their primary work role…. [subjects exhibited] sensitivity in relationships, loneliness and self appraisal.” (hogarty et al., 1997, p. 9). additionally, subjects in this group improved in their participation and level of involvement in leisure activities. the authors reached the conclusion that ipt has “pervasive effects on the social adjustments of patients with schizophrenia that are independent of relapse preventions.” (hogarty et al., 1997, p. 2). conclusion in conclusion, there is agreement that symptom management and coping are more realistic and functional goals for patients with schizophrenia than is symptom removal, and that unlike cbt or insight-oriented approaches, ipt offers “a means of engaging the patient that may be more effective than a challenge of the patient’s firmly entrenched beliefs” (stuart & noyes, 2005, p. 280). a significant portion of studies examining the efficacy of cbt and insightoriented therapies indicate that a considerable number patients are fairly unresponsive to these forms of psychotherapy (gaudiano, 2005). rather than indicating that psychotherapy is useless in helping people with schizophrenia to cope with or reduce their symptoms, these findings may be the result of using therapies that are not disorder-relevant. in light of the fact that schizophrenia is, among other things, a cognitively-debilitating illness, it seems almost inappropriate to apply techniques which presume the patient’s ability to examine rationally and logically his or her thought process, which may be impervious to logical counterarguments (jaspers, 1963). instead, patients may benefit from the introduction of an interpersonal approach, one which emphasizes current issues, disputes, and anxieties, and which helps patients perceive their symptomatology on a more concrete level than cognitive behavioral or psychodynamic approaches. references crowe, m., & luty, s. (2005). interpersonal psychotherapy: an effective psychotherapeutic intervention for mental health nursing practice, international journal of mental health nursing, 14, 126-133. cornblatt, b. a., green, m. f., & walker, e. f. (1999). schizophrenia: etiology and neurocognition. in t. millon, p. h. blaney & r. d. davis (eds.), the oxford textbook of psychopathology (vol. 4, pp. 277-310). new york: oxford university press. gaudiano, b. a. (2005). cognitive behavior therapies for psychotic disorders: current empirical status and future directions. clinical psychology: science and practice, 12, 33-50. helgeland, m. i., & torgerson, s. (2005). stability and prediction of schizophrenia from adolescence to adulthood. european child adolescent psychiatry, 14, 8394. hogarty, g. e., kornblith, s. j., greenwald, d., dibarry, a. l., cooley, s., ulrich, r. f., carter, m., & flesher, s. (1997) three-year trials of personal therapy among schizophrenic patients living with or independent of family. american journal of psychiatry, 154, 1504-1513. james, i. a., postma, k., mackenzie, l. (2003). using an ipt conceptualization to treat a depressed person with dementia. behavioural and cognitive psychotherapy, 31, 451-456 kingdon, d., & turkington, d. (2005). cognitive therapy of schizophrenia. new york: guilford press. jaspers, k. (1963). general psychopathology. manchester: manchester university press. johns, l. c., sellwood, w., mcgovern, j., & haddock, g. (2002). battling boredom: group cognitive behaviour therapy for negative symptoms of schizophrenia. behavioural and cognitive psychotherapy, 30, 341-346. ipt for schizophrenia 18 jones, h., delespaul, p., & van os, j. (2003). jaspers was right after all—delusions are distinct from normal beliefs. the british journal of psychiatry, 183, 285-286. stuart, s., & noyes jr., r. (2005). treating hypochondriasis with interpersonal therapy. journal of contemporary psychotherapy, 35, 269-283. weissman, m. m., markowitz, j. c., klerman, g. l. (2000). comprehensive guide to interpersonal therapy. new york: basic books. cognitive behavioral and insight-oriented therapies interpersonal therapy graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 spouse caregivers and dementia relationships chari i. hirshson ferkauf graduate school of psychology yeshiva university a review of the literature shows an association between depression and perceived burden in caregivers of dementia patients. these caregivers are often the spouses of cognitively impaired elders, and they experience an emotional toll with negative effects on their mental health and well-being. findings from past research focus on spouses as caregivers and the influences of primary and secondary stressors on their depressive mood symptoms. the experiences of male caregivers with demented spouses differ from those of female caregivers with demented spouses, suggesting that either the gender of the patient, the gender of the caregiver, or both affect the experience of caregiving. the potential reasons for this difference are highlighted and compared. implications for future work are discussed, such as the need to create and research interventions and assessments that can recognize and reduce caregiver burden and depression. depression in caregivers of dementia patients dementia poses a significant public health problem because of the debilitating and progressive nature of the decline. problematic aspects associated with dementia include the loss of independence, social limitations and interpersonal withdrawal, and personality and/or behavior changes that result from cognitive, behavioral and affective losses in functioning (moritz, kasl & berkman, 1989). dementia affects more than just the patient – it can negatively impact the people that bear the responsibility for their care. it is estimated that 8.5 million people care for a dementia patient at home (gallicchio, siddiqi, langenberg, & baumgarten, 2002). caregivers within this population experience considerable psychological and physical morbidity (dunkin & anderson-haley, 1998), with the most consistent and deleterious of these effects experienced in the mental health domain (george, 1994). caregivers for demented patients versus non-demented patients experience higher levels of strain and burden due to the nature of dementia symptoms, such as wandering, screaming, and destroying property (ory, hoffman, yee, tennesedt, schulz, 1999; schulz, o’brien, bookwala, fleissner, 1995). primary stressors affecting the caregiver (such as feelings of loss in the marital relationship, functional capabilities of the impaired, and the impaired’s level chari i. hirshson is a phd candidate in clinical psychology at albert einstein college of medicine/yeshiva university, ferkauf graduate school. correspondence concerning this article should be addressed to chari i. hirshson, ferkauf graduate school, yeshiva university, 1165 morris park avenue, bronx, ny 10461; email: charicohen@gmail.com. of problem behaviors) combined with secondary contextual factors associated with the caregiver (sociodemographic, gender, and economic strain) have been correlated with negative caregiver outcomes (bookwala & schulz, 2000; moritz et al., 1989; whitlatch, schur, noelker, ejaz, & looman, 2001). dementia caregivers are negatively affected by “employment complications, caregiver strain, mental and physical health problems, time for leisure and other family members, and family conflict” (ory, et al., 1999, p. 184). negative symptoms arising from the caregiving situation can include significant distress (karlawish, casarett, klocinski, & clark, 2001), poor psychological well-being (schulz et al., 1995), depression and anxiety, medical problems, and deterioration in occupational and social functioning (chentsovadutton et al., 2002). in the research on this topic, the terms caregiving burden and caregiving impact are often used interchangeably, although the two concepts are distinct. impact is used to describe the change in the caregiver’s life, such as health, social activities, occupation and familial relationships. burden describes the subjective experience of caregiving tasks (moritz et al., 1989). distinguishing between these similar terms is imperative in clarifying the findings of various studies. in addition to the importance of differentiating between burden and impact, there is evidence of a difference in experience between male and female caregivers, and understanding this gender difference is an important aspect of understanding caregiving depression. there have been inconsistent findings in the literature regarding gender differences in terms of depression and caregiver burden with demented patients (gallicchio et al., 2002). select studies indicate that female caregivers are more likely to report greater burden (miller & cafasso, 1992; yee & schulz, 2000), while other 19 hirshson 20 studies have failed to find gender differences (hinrichsen & niederehe, 1994; shields, 1992). the discrepancy among the results may be attributed to women constituting 73% of the caregiving population (ory et al., 1999), yielding an over-representation of women in caregiving research. differences in study designs, including lack of control groups, may have created results that suggest a greater impact upon women rather than men in the caregiving role (moritz et al., 1989). this contradiction points to a need to further examine gender differences in the effects of caregiving. both the caregiving experience and the interpersonal relationship between the caregiver and their demented spouse need to be considered. the effects of caregiving for a patient with dementia have not been systematically reviewed. accordingly, the existing literature is scattered and unable to provide a complete and representative picture of the experience of a dementia caregiver. the goal of this review is to examine critically caregiver depression and burden, investigating the emotional experiences of spousal caregivers of dementia patients. the investigation into this matter will consider different studies and meta-analyses that have identified specific stressors and predictors of caregiver depression and evaluated gender differences among caregivers. further, the review will interpret theoretical and practical implications of caregiver depression for designing interventions and educational programs. general differences among caregivers and caregiving situations data shows that dementia caregivers experience varying levels of distress in their response to the challenge of caregiving. two classes of primary stressors affect the caregiver’s mental health: the level of impairment of the patient and involvement of the caregiver in the caregiving situation (miller & cafasso, 1992; bookwala & schulz, 2000). secondary variables, which are defined as the stressors that are triggered because of the primary caregiving stressors, include the caregiver’s relationship to the patient (schulz et al., 1995) and attributional style (stull, kosloski, kercher, 1994; schulz et al., 1995). primary stressors: level of impairment and involvement of the caregiver according to the meta-analysis of correlates of psychiatric morbidity in caregivers by schulz and colleages (1995), a number of patient characteristics were unrelated to caregiver distress, but the one patient characteristic that powerfully predicted caregiver depression was the degree to which the dementia patient experienced problem behaviors. problem behaviors, which include wandering, screaming, and destroying property, are generally a result of a decrease in the cognitive functioning of the patient and the increase in the level of severity of the illness. evidence of such problem behaviors in the patient predicted caregiver depression (schulz et al., 1995) and poor coping mechanisms of the caregiver (hinrichesen & niederehe, 1994). moritz et al. (1989) found living with a cognitively impaired elderly spouse negatively affected the health and well being of the caregiver. male caregivers exhibited an increase in depressive symptoms as their wives’ level of cognitive functioning decreased. however, the reverse was not the case, as wives did not show a significant relationship between cognitive functioning in their husbands and their own levels of depression and perceptions of burden. in at least some caregiving situations, however, the level of the severity of impairment and evidence of problem behaviors were implicated as predictors of caregiver depression. the findings underscore the importance of recognizing problem behaviors and seeking additional help when these behaviors arise. secondary stressors: attributional style and relationships of the caregiver the analyses thus far encourage further understanding of the etiology of caregiver depression. are specific individuals more resilient to stress and burden in the caregiving situation? are there personal attributes of the caregiver, or an attributional style, that allow one to persist longer in this role than others or cause an individual to seek support or treatment? attributional style refers to the way a person determines which forces they hold responsible for successes and failures. for our purposes, attributional style in caregiving refers to the way a caregiver perceives the caregiving situation. psychosocial and personality variables predictive of depression in caregivers have not been fully identified (dunkin & anderson-haley, 1998). however, specific attributes of the caregiver are predictive of the caregiving outcome. this includes the feeling of perceived enrichment in the caregiver’s life and the caregiver’s ability to find personal meaning through his or her relationship (stull et al., 1994). conversely, it is also possible that caregivers’ attributional styles can leave them more vulnerable to depression, as caregivers may have basic assumptions about caregiving being burdensome. therefore, they may have a preconceived belief regarding how they are supposed to feel about providing care. the attributional style of the caregiver in terms of other relationships has been evaluated in the literature and judged to be of importance. in addition, the presence of a strong social network for the caregiver was protective, and satisfaction with this support was predictive of positive outcomes (dunkin & anderson-haley, 1998). furthermore, the quality of the relationship between the caregiver and the patient has been shown to impact the level of depression and/or burden experienced within the caregiving situation (schulz et al., 1995). tower and colleagues (1997) found that closeness of the spousal relationship moderated the impact of depressive symptoms of male caregivers whose depression in spousal caregivers 21 wives were cognitively impaired. those whose marriages were described as being closer prior to the cognitive impairment were more affected by depressive symptoms than those who were less close before the onset of their spouse’s dementia. however, this result was found with male caregivers only. female caregivers’ levels of depression were not significantly associated with their husbands’ levels of cognitive impairment, regardless of the strength of the spousal relationship. beeson and colleagues (2000) hypothesized that increases in loneliness and depression in the caregiver resulted from experiencing the loss of closeness in the relationship due to cognitive changes in the patient. they found that caregivers who experienced higher loneliness and depression also experienced higher levels of relational depravity and a higher dissatisfaction with the lower quality of the current relationship with the patient. in contrast to tower and colleagues (1997), beeson and colleagues (2000) found that female spouse caregivers reported a significantly higher level of relationship depravity, loneliness and depression than the daughter caregivers. thus suggests that the nature of the relationship between the caregiver and the care receiver is important in determining likelihood of caregiver depression and subsequent quality of the relationship between the caregiver and demented family member. gender differences and gender role socialization in the caregiving experience previous research has examined gender as a variable relative to caregiver depression, yet results have been inconsistent as to the effect of gender. is it possible that gender can be a risk or protective factor for caregiver depression? yee and schulz (2000) compiled a review of empirical research from 1985 to 1998 on caregiver differences in psychiatric morbidity in terms of gender, including depression as an index measure. in investigating gender differences in caregiving with the elderly (physically ill and demented adults), the authors found higher distress in female caregivers versus male caregivers. the 30 articles reviewed suggested that women exhibit more psychiatric symptoms than men, specifically on the domains of depression, anxiety, general psychiatric symptoms and lower life satisfaction. compared to women who are not in the caregiving role, caregiving women experience more psychiatric morbidity attributable to caregiving. it is suggested that women have a greater susceptibility to psychiatric morbidity then men because they respond differently to all stages of stress. in addition, men do not tend to engage in behaviors that would put them at a greater risk for psychiatric morbidity. for example, they are more likely than women to seek additional help or relinquish the caregiving role (yee and schulz, 2000). conversely, more recent research has suggested a different gender effect. gallicchio and colleagues (2002) investigated the relationship of gender, burden and depression among 259 female and 68 male caregivers working with the dementia population. they found female caregivers to have a significantly higher risk of experiencing caregiver burden and stress. on average, women reported greater burden than the males but did not exhibit depressive symptoms, indicating burden was not a risk factor for depression for women. it is suggested that the burden women experience is not correlated with the caregiving situation, but instead reflects gender differences in nurturing roles seen within the general population (gallicchio et al, 2002; hooker, manoogiano’dell, monahan, frazier & shifren, 2000) and within the age cohort (moritz et al., 1989). observed gender differences may be attributed to the gender-role socialization and social roles that women and men each assume (miller & cafasso, 1992; collins & jones, 1997). women have been found to experience a greater burden because of their sense of responsibility to provide good care. they also tend to feel more comfortable in expressing their feelings and reporting their depression and burdensome feelings (miller & cafasso, 1992). it is possible that female caregivers are affected by different dynamics and therefore experience different consequences than their husbands (tower et al., 1997). miller and cafasso (1992) initiated the first analysis of gender differences in caregiving, and their findings support the notion of gender differences in the larger population rather than in the caregiving sample. the authors aimed to provide a foundation of the implications of gender differences in caregiving, however they did not specifically measure depression. within the parameters of their analysis, they found women were more likely to report caregiver burden, but could not specifically explain how this burden was expressed. these results supported elements of a hypothesis based on both gender-role and social role socialization. even though there was an effect for gender, this was small, and did not specifically explain which aspects of gender socialization contributed to the overall caregiving stress effect in women. summary of major findings given the narrow field of empirical and practical studies in the literature, the evidence linking psychiatric health effects and caregiving is robust, with virtually all studies reporting elevated levels of distress and depressive symptoms among caregivers (schulz et al., 1995). although the literature clearly demonstrates a link between the burden and psychological distress of caregiving, the underlying cause of this distress may relate to a number of different factors. in terms of primary stressors within caregiver relationships, the level of impairment in the patient and the caregiving situation impacted the level of caregiver depression. the evidence of problem behaviors in a patient (which goes hand in hand with cognitive impairment) was implicated as leading to greater depressive symptomotology in caregivers. in addition, living with a cognitively impaired elder also predicted negative effects for the caregiver. the level hirshson 22 of impairment was found to be associated with depressive symptoms in males as their wives’ cognitive impairment decreased, but this was only found for the male caregivers. female caregivers did not exhibit more depressive symptoms when caring for a cognitively impaired husband. in terms of secondary stressors, having a social network was found to be protective for both male and female caregivers. however, the level of closeness in the spousal relationship before the onset of illness was protective for females, but a risk factor for males. the literature suggests that while female caregivers may exhibit psychiatric morbidity, they do not exhibit more depressive symptoms than male caregivers. this suggests that other differences experienced by male and female caregivers may be more related to overall social role differences that exist between the sexes in general. limitations of current research and future directions several limitations of the literature emerged from this review. in terms of research design, caregivers were often recruited from support groups, educational classes, or other support services. using these samples may over represent the negative effects of caregiving. furthermore, most studies used relatively small sample sizes and did not control for other factors known to influence mental health outcomes, such as level of involvement in the caregiving role and sociodemographics (ory et al., 1999). the lack of control groups and the overall predominance of women caregivers may point to women being more negatively affected, but this may not be an accurate representation. there is also a lack of valid and reliable measures in caregiving research. the zarit burden interview (zarit et al., 1980) is heavily relied on for research on caregivers, yet it may not clearly delineate the degree of encumbrance the patient causes or the ways in which patients burden caregivers. to further understand other factors possibly implicated, a measure needs to be able to capture the entire clinical picture. in addition, baseline levels of depression should be assessed, requiring prospective research designs. including a measure that looks retrospectively at life prior to the onset of the illness would possibly control for the perceived gender role-socialization difference. moreover, research in this field would benefit from using a different measure that evaluated the patient-caregiver relationship, as well as the quality of other relationships between patients and family members prior to the onset of the patient’s dementia. as stated previously, major limitation of research on caregivers surrounds conclusions about gender differences. women are historically over-represented in caregiving research and account for almost three-quarters of the caregiving population. further studies need to take into account the higher levels of emotional stress found in women before considering the caregiving situation. the meta-analyses reviewed clearly indicated that women tend to report higher levels of emotional distress in the life course—without the caregiving aspect being considered (miller & cafasso, 1992). examining differences within caregiving in terms of both impact and burden is important to the field for both needs assessment and intervention purposes. the data gathered from this research can be used for informing mental health professionals and primary care physicians responsible for treating this population. conclusion further research on caregivers of demented spouses is imperative. future directions should include better recruitment, more stringent study design and thorough, well validated measures. gender, interpersonal relationships, and characteristics of the patient and the patient’s experience have been examined in this review; future research should continue to focus on these factors, all important aspects of the caregiving stress model, and work to clarify how each affects caregiving outcomes. references beeson, r., horton-deutsch, s. h., farran, c., & neundorfer, m. (2000). loneliness and depression in caregivers of persons with alzheimer’s disease or related disorders. issues in mental health nursing, 21, 779-806. chentsova-dutton, y., shucter, s., hutchin, s., strause, l., burns, k., dunn, l., miller, m., & zisook, s. (2002). depression and grief reactions in hospice caregivers: from pre-death to 1 year afterwards. journal of affective disorders 69, 53-60. collins, c., & jones, r. (1997) emotional distress and morbidity in dementia carers: a matched comparison of husbands and wives. international journal of geriatric psychiatry, 12, 1168-1173. dunkin, j. j., & anderson-hanley, c. (1998). dementia caregiver burden: a review of the literature and guidelines for assessment and intervention. neurology, 51(1), s53-s60. george, l. k. (1994). caregiver burden and well-being: an elusive distinction. the gerontologist, 34(1), 6-7. hinrichsen, g. a., & niederehe, g. (1994). dementia management strategies and adjustment of family members of older patients. the gerontologist, 34(1), 95102. hooker, k., manoogian-o’dell, m., monahan, d. j., frazier, l. d., & shifren, k. (2000). does type of disease matter? gender differences among alzheimer’s and parkinson’s disease spouse caregivers. the gerontologist, 40(5), 568-573. gallicchio, l., siddiqi, n., langenberg, p., & baumgarten, m. (2002). gender differences in burden and depression among informal caregivers of demented elders in the community. international journal of geriatric depression in spousal caregivers 23 psychiatry, 17, 154-163. karlawish, j. h. t., casarett, d., klocinski, j., & clark, c. m. (2001). the relationship between caregivers global ratings of alzheimer’s disease patients’ quality of life, disease severity, and the caregiving experience. journal of the american geriatric society, 49, 1066-1070. miller, b., & cafasso, l. (1992). gender differences in caregiving: fact or artifact? the gerontologist, 32(4), 498-507. moritz, d. j., kasl, s.v., & berkman, l. f. (1989). the health impact of living with a cognitively impaired elderly spouse: depressive symptoms and social functioning. journal of gerontology, 44(1), s17-27. ory, m. g., hoffman, r. r., yee, j. l., tennstedt, s., & schulz, r. (1999). prevalence and impact of caregiving: a detailed comparison between dementia and nondementia caregivers. the geronotologist, 39(2), 177-185. schulz, r., o’brien, a., bookwala, j., & fleissner, k. (1995). psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates and causes. the gerontologist, 35(6), 771-791 shields, c. g. (1992). family interaction and caregivers of alzheimer’s disease patients: correlates of depression. family processes, 31,19-33. stull, d. e., kosloski, k., & kercher, k. (1994). caregiver burden and generic well being: opposite sides of the same coin? the gerontologist, 34(1), 88-94. teng, e. l., & chui, h.c. (1987). the modified minimental state examination. journal of clinical psychiatry 48: 314-317. tower, r. b., kasl, a. v., & moritz, d. j. (1997). the influence of spouse cognitive impairment on respondents’ depressive symptoms: the moderating role of martial closeness. journal of gerontology: social sciences, 52b (5), s270-s278. whitlatch, c. j., schur, d., noelker, l. s. , ejaz, f. k., & looman, w. j. (2001). the stress process of family caregiving in institutional settings. the gerontologist, 41(4), 462-474. yee, j. l., & schulz, r. (2000). gender differences in psychiatric morbidity among family caregivers: a review and analysis. the gerontologist, 40(2), 147-164. zarit, s. h., reever, k. e., & bach-peterson, j. (1980). relatives of the impaired elderly: correlates of feelings of burden. gerontologist, 20, 649-655. graduate student journal of psychology copyright 2 graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 the effects of patient age and diagnosis on perceived necessity of psychological and medical treatment by young adults julie blundon, jessica neubauer, kristin candan, jacqueline mesnik, and janet a. sigal fairleigh dickinson university perceptions of and attitudes towards the elderly as related to the perceived necessity of treatment for physical and psychological symptoms were examined. eighty participants from undergraduate classes at a medium-sized university in the northeastern united states were randomly assigned to read one of four vignettes, which were identical with the exception of the age (30 and 80) and diagnosis (major depressive episode and arthritis) of the vignette character. contrary to original hypotheses, participants reported that it was more important for an 80-year-old to obtain medical treatment than a 30-year-old. when analyzing the importance of obtaining psychological treatment, no statistically significant differences were found based on the age of the character. medical treatment was universally rated as more important regardless of the age of the character in the scenario. ageism has been defined as the deliberate or subconscious discrimination based on age (lachs & boyer, 2003). discrimination can manifest itself as a lack of available services as well as overall negative attitudes towards the elderly. a review of the literature suggests that this discrepancy, especially its relationship to the delivery of mental health services and its impact upon this population, has not been adequately measured. however, it is apparent that negative stereotypes of the elderly exist in both the general population as well as in the professional world (e.g., doctors and psychologists). “ageism is so firmly embedded within the social fabric of u.s. culture that few people even question the fact that age is considered a legitimate reason for limiting access to health care and productive employment” (pasupathi, carstensen, & tsai, 1995, p. 160). negative perceptions of the elderly vary depending on the population surveyed. however, in general, these perceptions are that the elderly are not open-minded or flexible, not sexually active, not useful members of the community, and not bright or alert (praseedom, tube, vourdas, rafnar, & woodfield, 1999). it has also been suggested that ageism is so ingrained in our society that psychological research is biased against elderly subjects in their under-representation and in the assumption of their homogeneity as a group (schaie, 1993). a meta-analysis by kite and johnson (1988) revealed that attitudes towards older people were more negative than attitudes towards younger people across all rating dimensions. the most extreme negative results were found in ratings of physical attractiveness and competence. results from more recent studies, however, indicate correspondence concerning this article should be addressed to julie blundon, t-wh01-1, psychology department, fairleigh dickinson university, 1000 river road, teaneck, nj 07601; e-mail: julieblundon@hotmail.com. that differences between evaluations of older and younger people were smaller than past research would suggest. in fact, it appears that younger people hold a variety of positive, negative and neutral beliefs about older people (slotterback & sarnio, 1996). attitudes of college students towards the elderly schmidt and boland (1986) examined the multitude of stereotypes college students report towards the elderly. they found that the term “old person” elicits both positive and negative stereotypes depending on the type of elderly person the student is referencing. for example, a student may think of his beloved grandparent, and consequently describe an “old person” as warm, caring and generous. on the other hand, the phrase “older person” may bring to mind thoughts of a sick, elderly neighbor who could be seen as miserly, incompetent and needy. the study found that stereotyping of the elderly is likely to occur at a more specific level (e.g., grandparent vs. elderly neighbor) because “the elderly” is not a homogeneous group and thus draws many different descriptions. therefore, ageism may be more directed at the elderly who are perceived to represent negative stereotypes than towards those who represent positive ones (schmidt & boland, 1986). with the exception of the previous study, the attitudes of college students towards the elderly have been found to be consistently negative over time (schwalb & sedlacek, 1990). slotterback (1996) has argued that negative perceptions of the elderly are the result of generational influences. for example, younger adults view those from a previous generation as different from themselves, not only because they are older, but because of the historical context in which they developed. operating under a generational influence, young people would likely find it difficult to relate 33 blundon et al. 34 to the wartime mentality of elderly adults who grew up with few material possessions. slotterback and sarnio (1996) investigated whether the assessment of negative attitudes towards the elderly was affected by the type of instrument used (a rating task vs. an open-ended task) and the type of attributes assessed (cognitive, personal-expressive, and physical). they found that negativity was most apparent in open-ended tasks and when rating physical characteristics of the elderly. mcconatha, schnell, volkwein, riley, and leach (2003) examined undergraduates’ discrimination towards older adults using the anxiety about aging scale, which highlights four dimensions of ageism: fear of old people, psychological concerns, changing physical appearance, and fear of losses. cultural differences in attitudes toward aging also were investigated, as the study included participants from both the united states and germany. results indicated significant differences between the american and german samples in three of the anxiety subscales, as well as gender differences in the raters. german participants reported greater fear of old people, more psychological concerns about aging, and more fear of losses associated with aging than did american participants. additionally, both american and german women scored significantly higher than male participants on items regarding concerns about physical appearance. ageism in health and mental health service providers the underutilization of mental health services in the elderly population may be a function of ageism on the part of mental health providers (gatz, karel, & wolkenstein, 1991). many service providers lack training with the geriatric population and have negative expectations concerning treatment effectiveness with this group (gatz & pearson, 1988). james and haley (1996) found some evidence of age bias in a sample of 371 psychologists who responded to detailed vignettes of a client presenting with symptoms of depression. however, they found stronger evidence of health bias regardless of client age, meaning that healthier clients were viewed more positively. this suggests that mental health service providers, psychologists in particular, have more negative attitudes towards physically ill individuals as opposed to healthier individuals, regardless of age. such a bias may have implications for service delivery, considering the common presentation of depression and other psychological disorders with concomitant health problems in the elderly. the negative attitude concerning treatment outcome of elderly patients is not confined to the mental health community. uncapher and arean (1999) found that physicians are less likely to treat suicidal ideation in older patients. these findings were based on a study in which 215 primary care providers rated a vignette of a suicidal, depressed patient. the only difference between the vignettes was the age of the patient and employment status. the physicians recognized depression and suicidal risk in both the adult and geriatric vignette, but reported less willingness to treat the older patient. physicians reported that the suicidal ideation on the part of the older patient was both normal and rational. therefore, doctors were less willing to use therapeutic strategies to treat older patients and did not believe that psychiatrists or psychologists should be consulted. grant (1996) discussed specific biases that may be present in health care workers, which can be partly explained by both a lack of education concerning geriatric health issues and a lack of exposure to elderly patient populations. these biases include providing disabling support (as opposed to enabling support) as well as managing symptoms (as opposed to promoting health) when working with geriatric populations. these biases on the part of health care workers have led to increased dependence and less aggressive treatment plans. cultural differences in perceptions of the elderly studies of family relationships in asian american cultures have found that the majority of adolescents and college-age students espouse the values of deference and respect towards their family elders. white american teenagers and college students do not display the same level of reverence for the elderly as their asian american counterparts (ying, coombs, & lee, 1999). white american adolescents instead tend to separate and individuate, and to focus primarily on their own goals as opposed to those set forth by their families. ying and colleagues (1999) also found that asian american adolescents (chinese, japanese and korean) tend to maintain the eastern orientation of valuing the opinion of the elderly despite the american cultural emphasis on autonomy and independence. this positive perception of the elderly seems to be an integral part of the asian american cultures and provides a significant contrast to white americans’ mixed perceptions of the older population. young, jeong, knight, and benton (1999) examined the differences in familism values (in which the family takes precedence over individual interests) and attitudes toward caregiving among korean, korean american, and white american dementia caregivers. they found that koreans reported the highest level of distress associated with caregiving, followed by korean americans and white americans. a possible explanation for these results may be related to the correlation between familism and distress; higher ratings of the importance of family were correlated with higher levels of anxiety and depression concerning the caretaking of demented elders. it can be postulated that the more interdependent a family, the more distressing it is for one of the family members to fall ill and require care. the present study the research reviewed clearly demonstrates the presence and impact of ageist attitudes in our society. there is effect of patient age and diagnosis on treatment 35 some evidence suggesting that ageism plays a role in the perceptions of symptom severity, decisions regarding whether or not to treat geriatric patients, and the quality of care that is received. however, there is a need for further research in order to better understand those areas in which ageist attitudes most severely influence treatment decisions, particularly in terms of the perceived necessity of clinical services. this line of study could have direct implications for the training of health care professionals working with older adults and general treatment planning for geriatric patients. the present study explores not only the attitudes of a college student population towards the elderly, but how such attitudes impact upon the perceived necessity of psychological and mental health treatment for elderly individuals. three hypotheses were tested. the first is that subjects will rate treatment necessity higher for the younger characters presented in the vignettes, regardless of the type of condition (medical vs. psychological). second, psychological treatment will be rated as less important than medical treatment, regardless of the age. third, the perceived social value of the elderly will be influenced by the country of origin and culture of the respondent. the overarching purpose of this study was not to examine how malleable ageist attitudes may be in response to an intervention, but rather how such attitudes are expressed in terms of perceived need for treatment. method participants participants were 92 undergraduate students enrolled in classes from a variety of disciplines at a medium sized university in the northeastern united states. a manipulation check was conducted to test participants’ recall of the age and possible diagnosis of the individual in the vignette, and the 12 participants who failed the check were not included in the final analyses. participants ranged in age from 17 to 33, with a median age of 18. twenty-nine (36.3%) of participants were male; 51 (63.8%) were female. the majority of participants were caucasian (36.3%), followed by african american (20%), asian (17.5%), latino (12.5%), and caribbean american (5%). materials two vignettes featured an individual presenting with symptoms indicative of a major depressive episode as classified by the diagnostic and statistical manual of mental disorders, fourth edition (dsm-iv, 1994). these symptoms included sleep disturbances, lack of interest in usual activities, lack of energy, trouble with concentration, and lack of appetite. the other two vignettes portrayed an individual experiencing the symptoms of arthritis. symptoms included severe joint pain, fatigue, lack of agility, and lack of concentration. in each of these two conditions, the vignettes were identical with the exception of the age of the person being portrayed; the individual described in the vignette was either 30 or 80 years old. the sex of the vignette character was not specified so as to eliminate gender of the vignette character as a confounding variable. participants were randomly assigned to one of four conditions: a 30 year-old individual experiencing symptoms of arthritis; a 30 year-old individual experiencing symptoms consistent with a major depressive episode; an 80 year-old individual experiencing symptoms of arthritis; and an 80 year-old individual experiencing symptoms consistent with a major depressive episode. all participants completed four likert-type questionnaire items created for this study that focused on the importance of seeking medical and psychological treatment, as well as symptom severity for the individual described in the vignette. the four questions were: 1) “how likely is it that pat will receive medical treatment?”; 2) “how important is it that pat receive medical treatment?”; 3) “how likely is it that pat will receive psychological treatment?”; and 4) “how important is it that pat will receive psychological treatment? for the two items addressing the likelihood that the vignette character will seek medical or psychological treatment (questions 1 and 3), the likert scale ranged from 1 (completely unlikely) to 7 (completely likely). the likert scale for the two questions regarding the importance of seeking medical or psychological treatment (questions 2 and 4) ranged from 1 (not at all important) to 5 (extremely important). finally, the social value of the elderly scale of the aging opinion survey, developed by kafer, rakowski, lachman, and hickey (1980), was used as an additional measure to assess participants’ perceptions of elderly individuals. this measure is comprised of fifteen likert-type questionnaire items covering several content areas, including the contribution of elderly individuals to the community (e.g., “after retirement one should not have much influence in public policy making”) and general perceptions of elderly individuals (e.g., “old people usually interfere with their adult-children’s child-rearing practices”). the likert scale for each item ranged from 1 (completely disagree) to 5 (agree completely). design and procedure the study used a 2 (age of character in vignette: 30 years old vs. 80 years old) x 2 (diagnosis: major depressive episode vs. arthritis) design. participants were told that they would be participating in a study regarding perceptions of people. the age and diagnostic condition of the character were not identified as significant variables. after providing informed consent, participants were randomly assigned to one of four vignette conditions (see table 1). participants in all conditions were asked to read a short vignette and answer four likert-type questionnaire items. next, participants were asked to complete the social value of the elder blundon et al. 36 table 1 number of participants per condition age of diagnosis of number of participants character character (n) per condition 30 depression 24 30 arthritis 20 80 depression 21 80 arthritis 15 ly scale of the aging opinion survey and three short manipulation check items. finally, participants were asked for demographic information and debriefed. results univariate analyses of variance (anova) revealed a statistically significant difference regarding the perceived importance of medical treatment across the four groups. specifically, the respondents believed that it was more important for an 80 year-old individual to obtain medical treatment than a 30-year-old regardless of the presenting symptoms (f = 6.877, p = 0.011). no statistically significant differences were found between the ages of the vignette character and the perceived importance of obtaining psychological treatment. on average, the importance of obtaining medical treatment, regardless of whether a major depressive episode or arthritis was depicted in the vignette, was rated as a 4.11 on a five-point likert scale (1 = not at all important, 5 = extremely important). on the same scale, the importance of obtaining psychological treatment was rated, on average, as 3.08. these results were seen regardless of the age of the character. given symptomatology consistent with a diagnosis of a major depressive episode, the average ratings of the importance of obtaining medical and psychological treatment were examined as a function of the age of the individual portrayed in the vignette (see table 2). the average rating of the importance of obtaining medical treatment was 3.54 for the 30-year-old character, and 4.17 for the 80-year-old character. the average rating of the importance of obtaining psychological treatment was 3.38 for the 30-year-old character, and 3.33 for the 80-year-old character. no statistically significant differences were found between these ratings (see figure 1). table 2 perceived importance of treatment, symptoms of major depressive episode age 30 age 80 medical treatment 3.54 4.17 psychological treatment 3.38 3.33 0 1 2 3 4 5 medical psych age 30 age 80 figure 1. perceived importance of treatment for vignettes with symptoms of major depression for those vignettes in which arthritic symptoms were depicted, the average rating of the importance of obtaining medical treatment as a function of vignette character’s age was 4.35 for the 30-year-old character, and 4.60 for the 80year-old character (see table 3). the average rating of the importance of obtaining psychological treatment was 2.60 for the 30-year-old character, and 2.87 for the 80-year-old character. no statistically significant differences were found between these ratings (see figure 2). table 3 perceived importance of treatment, symptoms of arthritis age 30 age 80 medical treatment 4.35 4.60 psychological treatment 2.60 3.33 0 1 2 3 4 5 medical psych age 30 age 80 figure 2. perceived importance of treatment for vignettes with symptoms of arthritis expecting some difference by ethnicity of respondent in terms of social value of the elderly, total scores on the social value of the elderly scale were tabulated and averaged across the ethnic backgrounds of the respondents. caucasians had a mean score of 43.41; african americans, 41.69; caribbean americans, 9.50; latinos, 42.00; and asians, 42.43. an anova revealed no statistically significant differences among the ethnic groups in terms of the averaged total scores on this measure of ageist attitudes. effect of patient age and diagnosis on treatment 37 discussion contrary to our hypotheses, no evidence of ageist attitudes were found in this sample, as seen by the lack of difference in perceived need for psychological treatment across age groups. in regard to medical treatment, respondents rated importance of obtaining care as more important for elderly individuals, which is suggestive of non-ageist attitudes in this population. as predicted, the overall perceived need for psychological treatment was less than the perceived need for medical treatment when controlling for diagnosis. in fact, looking specifically at those participants who received psychological disorder vignettes, medical treatment was seen as more important than psychological treatment. it is possible that participants did not fully understand the psychological treatment options available, or perceived the somatic complaints associated with the major depressive episode to necessitate medical interventions. no overall differences were found on total score of the social value of the elderly scale based on ethnic background of the respondents. because the current study did not investigate why respondents answered in terms of necessity of treatment, future research focused on positive or negative reasons for treatment would be warranted. for example, examining whether viewing the elderly as being in greater need of medical care is based on something positive (such as honoring elders) or something negative (such as the elderly as being frail) would further clarify ageist or non-ageist attitudes. the current findings are important, as they suggest an absence of ageist attitudes in this sample. they may indicate that the trend, noted earlier, of college-aged people viewing the elderly in a negative light, may be changing. however, it may be more likely that the heterogeneity of this sample is indicative of the heterogeneity of the environment from which the participants were drawn, and that the immersion in such an environment fosters an overall, general attitude of acceptance and tolerance. should this be the case, our subjects would be less prone, as compared to individuals from a more homogeneous environment, to engage in discriminatory actions and beliefs, and might be less inclined to exhibit ageist attitudes. certainly more research is needed to explore whether being a member of a heterogeneous population disinclines one to prejudice and discriminatory tendencies. additionally, while medical and psychological treatment were both rated as important, medical treatment was universally rated as more important regardless of diagnosis. this finding suggests the need for the education of caregivers and the community at large regarding the efficacy of psychological treatment for various psychological disorders. it is possible that this finding reflects a general tendency to treat various psychological conditions with medication, which is often obtained from a medical professional. the abundance of advertisements for psychotropic medications in the general media may be contributing to this trend. future research should be focused on exploring the impact of such advertisements on the perceived usefulness of psychological interventions for treating psychological conditions given a medically-based alternative. the current study has several limitations that may have impacted the results and that should be addressed in future research. specifically, the small sample size and small number of participants per group limits the conclusions that can be drawn from the data, as there was low statistical power. also, the gender of the subject in the vignette was ambiguous, and it would be interesting to see how including the gender of the patient would influence results. as our respondents were generally in the age range of 18 to 20, and age of respondent could influence perceptions of the need for treatment, a follow-up study should not only replicate the current research, but seek to incorporate respondents of a more diverse age range. future research should also explore the idea that students in different fields (specifically those intending to work with elderly populations, such as psychology, social work, pre-medicine, nutrition) may be less likely to view symptoms of a major depressive episode as needing medical rather than psychological attention. ultimately, this research can serve as a starting point for future research impacting the care that the elderly population receives. references gatz, m., karel, m. j., & wolkenstein, b. (1991). survey of providers of mental health services to older adults. professional psychology: research and practice, 22, 413415. gatz, m., & pearson, c. g. (1988). ageism revised and the provision of psychological services. american psychologist, 43, 184-188. grant, l. d. (1996). effects of ageism on individual and health care providers’ responses to healthy aging. health & social work, 21, 9-16. james, j. w. & haley, w. e. (1995). age and health bias in practicing clinical psychologists. psychology & aging, 10, 610-616. kafer, k. a., rakowski, w., & lachman, m. (1980). aging opinion survey: a report on instrument development. international journal of aging & human development, 11, 319-333. kite, m, e. & johnson, b. t. (1988). attitudes towards older and younger adults: a meta-analysis. psychology and aging, 3, 233-244. lachs, m. s., & boyer, p. (2003). equal treatment for older adults. prevention, 55, 185-187. mcconatha, j. t., schnell, f., volkwein, k., riley, l., & leach, e. (2003). attitudes toward aging: a comparative analysis of young adults from the united states and germany. international journal of aging and human development, 57, 203-215. pasupathi, m., carstensen, l. l., & tsai, j. l. (1995). ageism in interpersonal settings. in b. lott & d. maulso blundon et al. 38 (eds.), social psychology of interpersonal discrimination (pp. 160-182). new york, ny: guilford press. praseedom, a., tube, p. a., vourdas, a., rafner, b., & woodfield, m. (1999). stereotypes of aging. british journal of psychiatry, 175, 190. schaie, k. w. (1993). ageist language in psychological research. american psychologist, 48, 49-51. schmidt, d. f. & boland, s. m. (1986). structure of perceptions of older adults: evidence for multiple stereotypes. psychology & aging, 1, 255-260. schwalb, s.j., & sedlacek, w. e. (1990). have college students attitudes towards older people changed? journal of college student development, 31, 127-132. slotterback, c. s. (1996). projections of aging: impact of generational differences and the aging processes on perceptions of adults. psychology & aging, 11, 552559. slotterback, c. s., & saarnio, d. a. (1996). attitudes towards older adults reported by young adults: variation based on attitudinal task and attribute categories. psychology & aging, 11, 563-571. uncapher, h., & arean, p.a. (2000). physicians are less willing to treat suicidal ideation in older patients. journal of the american geriatrics society, 48, 188-192. ying, y., coombs, m., & lee, p. (1999). family intergenerational relationship of asian american adolescents. cultural diversity and ethnic minority psychology, 5, 350-363. young, g., jeong, h., knight, b., & benton, d. (1999). differences in familism values and caregiving outcomes among korean, korean american and white american dementia caregivers. psychology and aging, 14, 355-364. table 1 number of participants per condition results table 2 perceived importance of treatment, symptoms of major depressive episode table 3 perceived importance of treatment, symptoms of arthritis discussion gatz, m., & pearson, c. g. (1988). ageism revised and the provision of psychological services. american psychologist, 43, 184-188. ethical and legal issues in assessments with children in school settings graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 ethical issues in assessments with infants and children margarita m. posada fordham university when conducting assessments with infants and children it important for psychologists to be mindful of the ethical issues that may arise. ethical issues may arise when proper procedures for performing assessments are not carried out. the present review will focus on the following ethical issues as they pertain to assessments with infants and children: obtaining parental consent, respecting children's autonomy, maintaining confidentiality, separating children and parents during assessments, and using multiple sources of information and appropriate measures. guidelines for ensuring the competent evaluation of children are then offered, with attention to the dynamic nature of the assessment process and the critical role of parents. home. once an assessment is deemed necessary, the process begins with the parents’ consultation with the assessment professional. the child's strengths and challenges, as well as the concerns and questions of the parents, are discussed. it is then decided which type of assessment (developmental, family, multidisciplinary, or play-based) is most appropriate for the child. depending on the type of assessment implemented, the child's parents, physician, schoolteacher, or counselor may assist in the process either directly or indirectly (the zero to three: new visions for parents, 1997). a number of ethical issues may arise when psychologists provide assessments to infants and young children. these issues can occur due to the differing needs of children, their parents, and professionals. the present review will examine some of these issues with regard to parental consent, children's rights, confidentiality, separation of parent and child during assessment, and the use of multiple sources of information and appropriate measures. first, a brief discussion of the assessment process will be presented as a framework for conceptualizing these issues. the assessment process assessing a child's functioning during the first three years of life is especially important, since it is a period of constant growth and development (meisels & fenichel, 1996). the zero to three: national center for infants, toddlers, and families (1996) focuses on providing support, education, training, and policies for parents, caregivers, and professionals to help advance the healthy development of infants and young children. in 1996, zero to three assembled a multidisciplinary work group on developmental assessment to "identify both problems and approaches in current assessment paradigms, policies, and practices" (meisels & fenichel, 1996, p. 5). this group also formulated a list of appropriate principles pertaining to assessments as well as practices to avoid in assessments; these will be utilized as a general framework for the present review. an assessment is an "ongoing process by which qualified professionals, together with families, through standardized tests and observation, look at all areas of a child's development: motor, language, intellectual, social/emotional and self-help skills" (zero to three: new visions for parents, 1997). an assessment may be performed to determine if infants and children are meeting developmental norms, to identify children with disabilities and those who may be at risk, to diagnose or confirm the presence and extent of a disability, to plan a program or appropriate intervention, or to demonstrate a child's knowledge of certain skills and accomplishments (meisels & fenichel, 1996). most often the assessment process is initiated by either a parent or a professional. it is quite common for a child's teacher or physician to notice a child behaving or developing out of the ordinary and to then consult with the child's parents about performing an assessment to learn more about the problem area. likewise, parents often contact teachers, physicians, or other professionals out of concern for their child’s development or atypical behaviors observed in the obtaining parental consent the american psychological association (2002) defines informed consent as a decision made by an individual that is informed, voluntary, and rational. in the case of parents providing consent for their child to be assessed, they are considered “informed” when they have been given substantial information about the assessment and its procedures, including the potential consequences, risks, and benefits. parents should be provided with information concerning their child's assessment in a language that is understandable correspondence concerning this article should be addressed to margarita m. posada, department of psychology, fordham university, 441 east fordham road, bronx, ny 10458. e-mail: posada@fordham.edu 42 ethical issues in assessment to them, and their decision must be voluntary and free from coercion from professionals or family members. finally, parents must have the ability to make a rational decision concerning their child's participation in the assessment procedure, which means they must be able to weigh the possible risks and benefits and to make an informed decision whether to allow their child to be assessed (ambuel & rappaport, 1992; kaser-boyd, adelman, & taylor, 1985). parents serve as the decision-making guides for children who have not yet reached the age of majority, which is 18 years (department of health and human services, 1991). parents or guardians are entitled to provide permission because they have legal responsibility and, in the absence of abuse or neglect, are assumed to act in the best interests of the child (krener & mancina, 1994). it is important that parents provide their child with the best possible care while ensuring that they are learning and developing appropriately, and as such it is often necessary for them to have their child evaluated in different domains so that they can learn more about their performance and developmental progress. various states and child centers recommend that children of certain ages be assessed as an effort to ensure that the child's development is being nurtured to the fullest extent possible (meisels & fenichel, 1996). obtaining parental consent is one of the most frequent challenges faced by psychologists and other professionals in the school system. ethical issues can arise when proper procedures for performing the assessment are not carried out, when parents do not agree with the requirement for assessments, or when parental priorities are ignored or underestimated by professionals (greenspan & meisels, 1996). the following case example provided by knauss (2001) illustrates how easily problems in this area can arise: shortly after being hired by a school district, a new school psychologist was given a long list of children who needed psychological testing. the new psychologist's supervisor explained the purpose of the testing, which was to obtain needed services for the children. she then mentioned that she had already scheduled the children for testing. the supervisor then implied that since the testing was part of their educational program, parental consent was not necessary. (p.2). in thinking about this example, was the newly hired psychologist's supervisor correct in not obtaining parental consent? if professionals from the school say it is appropriate to proceed without parental consent, should these guidelines be followed? finally, what ethical principle was violated or ignored? ethical codes require that informed consent be obtained from the appropriate individual before services are provided. since infants and young children do not yet have the ability to make their own decisions, parents are required to provide informed consent as the first step in beginning the assessment process. therefore, it is incorrect to assume that school professionals can substitute the decisions of the children's parents. however, an exception to this case would be if the parents voluntarily agreed to allow routine assessments for their child at the time of enrollment in the school (apa, 2002). the apa (2002) does not require psychologists to obtain informed consent when "informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity" (p.13). nevertheless, communicating with parents is often essential in establishing a basis for an effective home-school relationship (knauss, 2001). respect for children's rights although infants and young children do not yet have the decision-making abilities to provide informed consent, they do have several rights. by the ethical principles of autonomy, beneficence, and justice, children have the right to be treated with respect and be given proper care (knauss, 2001). the principle of autonomy refers to the duty of professionals to protect and encourage an individual's choices. studies have found that parental support of autonomy leads to positive outcomes for children across different developmental periods (allen et al., 1994; mattanah, 2001) and that by actively encouraging children to make independent decisions and to express themselves, parents can begin to foster a sense of autonomy (shaffer, 2002). but regardless of whether autonomy has been optimally fostered by parents, professionals should be mindful of the child’s needs as well as those expressed by the parents. beneficence refers to the responsibility to respect and make choices that are in the best interest of the individual. the well being of the child takes precedence over any needs of society to conduct the assessment (e.g., providing public statistics or conforming to state requirements). in the case of assessments, professionals should protect the health and safety of children by choosing assessments that are deemed necessary and sensitive to their specific needs. finally, the principle of justice expects that those working with others behave in ways that are fair and honest (blustein, dubler, & levine, 1999; fisher et al., 1996), and that any applicable benefits are distributed equally among individuals (national commission, 1979). when conducting assessments, examiners must be mindful of treating children as equals. for example, if assessment results indicate that a child might benefit from a special education program, the decision of whether to place him or her in such a program should be based on need, regardless of background or other criteria (national commission, 1979). overall, these ethical principles serve to remind professionals of the appropriate ways in which individuals, including children, should be treated. the most common of these issues to arise in the assessment of infants and young children is neglect of autonomy. because young children are not developmentally capable of voicing their own opinions and desires, their capacities can often be overlooked. this is especially relevant when a child has a developmental delay or other issue that has led to difficulty interacting socially and communicating needs. some assessment procedures may not adequately break 43 posada through these developmental barriers to uncover the child's specific strengths and weaknesses (greenspan & meisels, 1996). for this reason it is important that professionals engage in discussions with the child's parents about the child’s developmental history and capacities in order to gain a better understanding of the child's behavior. children's right to confidentiality at present, clear guidelines do not exist as to when children of certain developmental capacities have the right to confidentiality. in most areas, the law does not provide children with this right (mitchell, disque, & robertson, 2002). this position stems mainly from the notion that parents serve as the custodians and decision-making voices for children. since minors cannot legally provide informed consent, researchers are encouraged to respect their preferences by seeking their assent to participate in the assessment process when developmentally appropriate (american psychological association, 2002; dhhs, 1991). assent is the means of involving minors, typically seven years of age or older, in decisions affecting them, “an interactive process between a minor and researcher that involves developmentally appropriate disclosure about the procedures, and solicitation of the minor’s willingness and preferences regarding participation" (committee on bioethics, 1995, p. 316). it is important to obtain assent from children when it is developmentallyand age-appropriate because it includes children in the decision-making process. for this reason, assent is viewed as a benefit to the child. parents should nurture the moral growth and developing autonomy of their child by giving them the opportunity to provide assent. assent sets a lower standard of competence than informed consent in that it does not require the depth of understanding or reasoning ability required for the latter (weithorn, 1983). however, giving children the opportunity to provide assent, to the extent that they are able, allows them the chance to choose whether or not to participate in the assessment process. the separation of children and parents during assessments the zero to three: national center for infants, toddlers, and families (1996) has outlined several practices that should be avoided in the assessment procedure. one of these is "young children should never be challenged during assessment by separation from their parents or familiar caregivers" (p. 23). in other words, children should not be separated from their parents when the separation might pose a problem in conducting the assessment or affect the reliability of the evaluation. when professionals evaluate children without respect for this principle, conclusions may be unduly biased. for example, if a child has difficulty interacting with others and is separated from his or her parents for an assessment, he or she may be difficult to engage or may behave in a detached and unpredictable manner. clearly, such testing conditions are not optimal. the potential difficulties of separating a child from his or her parents are further illustrated by the following example, derived from a case offered by greenspan and meisels (1996): when a 3-year-old named sarah needed an assessment to evaluate her level of receptive and expressive language, the examiner requested that her mother wait outside the testing room. the mother explained that her daughter would be more cooperative if she were allowed to remain in the room. the examiner repeated the policy about having only the patient in the examination room. sarah's mother made it clear that she was hoping to test her daughter's language ability, not her readiness to leave her mother. the examiner told sarah's mother, with a patronizing show of patience, that the results of the test might not be the same if she were to stay in the room. she agreed with the examiner, but also wondered how the doctor expected to get any test results at all from a child who was nervous and withdrawn as a result of being separated from her mother. after completing the test, the examiner observed that sarah was not very cooperative for a 3-year-old child. the professional conducting this assessment may conclude that the child is uncooperative and has attachment issues. this may not have been the conclusion if the parent had been allowed to be present for the assessment (greenspan & meisels, 1996). if professionals acknowledge that children behave differently depending on whether their parents are present, they may choose to allow the parent to be present during the assessment until the child becomes comfortable enough to work with the examiner alone (morse, 2001). need for multiple sources of information during assessments another guideline for assessments provided by the zero to three: national center for infants, toddlers, and families (1996) is "assessment should involve multiple sources of information and multiple components" (p. 17). “multiple sources” can include direct observations of the child, interactions between the child and a caregiver, and the family system. in addition, it is important to obtain background information on the child's capacities in different areas of development, as well as assessments of specific areas of the child's functioning (greenspan & meisels, 1996). by using various types of information, psychologists can obtain a more complete picture and reach more comprehensive conclusions about the child's development (greenspan & meisels, 1996; national association of school psychologists, 2000). 44 ethical issues in assessment use of appropriate measures during assessments some of the assessments that have been widely tested and proven to be valid and reliable measures of infants’ and young children's abilities include the pediatric evaluation of disability inventory (pedi) (haley et al., 1992), the neonatal behavioral assessment scale (brazelton, 1973), and the bayley scales of infant development ii (bayley, 1993). the pedi, designed for use with children from the ages of six months to seven years, examines a child's ability to function independently while also observing what the child can do with assistance. since this measure has been developed with standardized scores that can be used to evaluate child's growth over time or a child's anticipated development, it is appropriate to use with children who have impairments (miller & robinson, 1996). the neonatal behavioral assessment scale is widely used by professionals who work with infants and families in hospitals, clinics, and educational settings and is designed to examine newborns and infants up to two months of age (brazelton, 1981). it provides the examiner with a behavioral description of the infant, which includes the infant's strengths, adaptive responses and possible vulnerabilities; this description is shared with parents by the examiner to develop appropriate care giving strategies aimed at enhancing the earliest relationship between infants and parents (brazelton, 1981). the bayley scales of infant development, second edition (bsid-ii) is an individually administered test that assesses the cognitive and motor development of infants and children from the ages of one month to 42 months. the main purpose of the test is to diagnose developmental delay and plan intervention strategies (bayley, 1993). using these and other age-appropriate assessments can help professionals design useful interventions and find appropriate special education placement and services when necessary. the national association of school psychologists (2000) mandates that "school psychologists be knowledgeable about the validity and reliability of their instruments and techniques, choosing those that have up-to-date standardization data and are applicable and appropriate for the benefit of the child" (p. 27). unfortunately, it is often the case that infants and young children are assessed using instruments and procedures developed for older children (greenspan & meisels, 1996). there exist very few assessment instruments that measure the specific developmental challenges and characteristics faced by young children and their families (demers, fiorello, & langer, 1992). this lack of appropriate measures for infants and young children can pose problems for professionals who are administering the assessments. although professionals may be aware of the limitations of the existing approaches for assessing young children, they may still often use procedures that are designed for school-aged children. not only is it unethical to use inappropriately normed and validated procedure, it is also unwise to draw conclusions from the obtained results, which may be misleading to parents (greenspan & meisels, 1996). professionals should make every effort possible to ensure that tests and procedures are used in ways that protect the rights and promote the well being of the children being assessed. the issue of using appropriate measures applies perhaps especially to professionals who assess children with significant disabilities. when choosing an assessment for a child with significant motor, sensory, or cognitive impairments, examiners should be mindful of the kinds of tests they use and the conclusions they draw from the results. examiners should ask themselves the following questions: can this test answer specific questions about the child's development? how do other children with this type of disability perform on the test? (miller & robinson, 1996). most tests that are norm-referenced assume that the child being assessed is similar to those included in the original sample. examiners who are testing children with motor and sensory impairments need to be aware of the fact that children these impairments are often excluded or not eligible to be included in the standardization of developmental instruments (miller & robinson, 1996). as noted by the national fair access coalition on testing (2002), “in choosing a particular test, the assessment professional…is responsible for reviewing test manuals or materials to ascertain the test’s applicability in measuring a certain trait or construct.” if examiners do not take these facts into account when assessing children with disabilities, they run the risk of violating one of the basic guidelines of administering assessments: that the examiner has knowledge of the validity, reliability, and standardization procedures of the test (national association of school psychologists, 2000). not only is violating this guideline unethical, but a child who is assessed using an inappropriate measure may be judged to lack certain abilities (miller & robinson, 1996). guidelines and recommendations for assessment procedures when conducting assessments, psychologists and other professionals should be aware of the issues raised in this review to ensure that they are evaluating infants and children with competence and care. by being responsive to the differing needs of children, their parents, and other professionals, examiners can ensure that proper procedures are being followed, that parents are being adequately informed about the procedures and results, and that parents’ concerns are being addressed and respected (greenspan & meisels, 1996). in order to ensure that the assessment process is being carried out appropriately, there are certain guidelines that can be followed and applied to the ethical issues discussed. the examiner should keep in mind the following questions highlighted by barrera (1996): "am i communicating with the child and family in a way that will elicit desired responses?" "do the child's and family's responses indicate their true abilities and potentials?" "is the child exhibiting age-expected behaviors and skills for his or her community and peer group?" "is the assessment doing an adequate job 45 posada of highlighting the child's strengths and weaknesses?" (p. 79). by viewing the assessment procedure as an active process and keeping in mind these questions, examiners can ensure that they are evaluating the child and his or her family with competence and care. brazelton, t. b. (1973). neonatal behavioral assessment scale. clinics in development medicine, no. 50. london: henneman. philadelphia: lippincott. committee on bioethics. (1995). informed consent, parental permission, and assent in pediatric practice. pediatrics, 95(2), 314-317. since parents serve as the voice and decision-making authority for their children in the assessment process, psychologists should work to prepare parents for their roles as participants in the assessment of their infant or young child (popper, 1996). examiners need to be aware that whether parents are having their child assessed for the first or second time, they will usually be protective yet cooperative with the examiner. professionals should be aware of parent's feelings and share information with them concerning the assessment (popper, 1996). demers, s. t., fiorello, c., & langer, k. l. (1992). legal and ethical issues in preschool assessment. in e. v. nutall, i. romero, & j. kalesnik (eds.). assessing and screening preschoolers: psychological and educational dimensions. allyn and bacon: boston. department of health and human services (1991). title 45: public welfare, code of federal regulations part 46: protection of human subjects. fisher, c. b., higgins-d’alessandro, a., rau, j. m. b., kuther, t. l., & belanger, s. (1996). referring and reporting research participants at risk: views from urban adolescents. child development, 67, 2086-2100. psychologists and other examiners should remind parents of the fundamental goals in the evaluation process. parents are there to "be the parent." (popper, 1996). their knowledge about their child makes them the expert; therefore, their input is important and should be acknowledged. in addition, parents should be reminded that they do not have to agree with all the information that results from the assessment. if parents feel that their child is being described in a manner that they do not agree with, they should be made to feel that they can voice their disagreement (popper, 1996). treating parents as active participants in the child assessment process can lead to more beneficial outcomes for the child, the parents, and the assessment professional. greenspan, s. i., & meisels, s. j. (1996). toward a new vision for the developmental assessment of infants and young children. in s. j. meisels and e. fenichel (eds.). new visions for the developmental assessments of infants and young children. zero to three: national center for infants, toddlers, and families: washington, d.c. haley, s.m., coster, w. j., ludlow, l. h., haltiwanger, j. t., & andrellos, p. j. (1992). pediatric evaluation of disability inventory: manual. boston, ma: pedi research group. references kaser-boyd, n., adelman, h. s., & taylor, l. (1985). minor’s ability to identify risks and benefits of therapy. professional psychology: research and practice, 169(30), 411-417. allen, j. p., hauser, s. t., eickholt, c., bell, k. l., & o’conner, t. c. (1994). autonomy and relatedness in family interactions as predictors of expressions of negative adolescent affect. journal of research on adolescence, 4, 535-552. knauss, l. k. (2001). ethical issues in psychological assessment in school settings. journal of personality assessment, 77(2), 231-241. krener, p. k., & mancina, r. a. (1994). informed consent or informed coercion? decision-making in pediatric psychopharmacology. journal of child and ambuel, b., & rappaport, j. (1992). developmental trends in adolescents’ psychological and legal competence to consent to abortion. law and human behavior, 16, 129154. adolescent psychopharmacology, 4(3), 183-200. mattanah, j. f. (2001). parental psychobiological autonomy and children’s academic competence and behavioral adjustment in late childhood: more than just limit setting and warmth. merrill-palmer quarterly, 47, 355376. american psychological association (2002). ethical principles of psychologists and code of conduct. washington, dc: author. barrera, i. (1996). thoughts on the assessment of young children whose sociocultural background is unfamiliar to the assessor. in s. j. meisels and e. fenichel (eds.). new visions for the developmental assessments of infants and young children. zero to three: national center for infants, toddlers, and families: washington, d.c. meisels, s. j. (1996). charting the continuum of assessment and intervention. in s. j.meisels and e. fenichel (eds.). new visions for the developmental assessments of infants and young children. zero to three: national center for infants, toddlers, and families: washington, d.c. bayley, n. (1993). manual for bayley scales of infant development (2nd ed). san antonio, tx: psychological corporation. meisels. s. j. & fenichel, e. (1996). preface. in s. j. meisels and e. fenichel (eds.). new visions for the developmental assessments of infants and young children. zero to three: national center for infants, toddlers, and families: washington, d.c. blustein, j., dubler, n., & levine, c. (1999). ethics guidelines for health care providers. in j. blustein, c. levine, & n. dubler (eds.), the adolescent alone: decision making in health care in the united states (pp. 251-269). new york: cambridge. 46 ethical issues in assessment miller, l. j., & robinson, c. c. (1996). strategies fro meaningful assessment of infants and toddlers with significant psychical and sensory disabilities. in s. j. meisels and e. fenichel (eds.). new visions for the developmental assessments of infants and young children. zero to three: national center for infants, toddlers, and families: washington, d.c. mitchell, c. w., disque, g. j., & robertson, p. (2002). when parents want to know: responding to parental demands for confidential information. professional school counseling, 6(2). morse, j. l. (2001). assessing children: negotiated transactions. review, 33, 8-15. national association of school psychologists (2000). professional conduct manual. principles for professional ethics: guidelines for the provision of school psychological services. nasp publications: bethesda, md. national commission (1979). belmont report: ethical principles and guidelines for the protection of human subjects of research, report of the national commission for the protection of human subjects of biomedical and behavioral research. schaffer, d. r. (2002). social and personality development. wadswoth/thomson learning. the national fair access coalition on testing (2002). model testing practices. retrieved from http://www.fairaccess.org/code_of_ethics.htm on january 23, 2004. weithorn, l. a. (1983). children’s capacities to decide about participation in research. irb: a review of human subjects research, 5, 1-5 zero to three: national center for infants, toddlers, and families (1996). new visions: a parent's guide to understanding developmental assessment. retrieved from http://www.zerotothree.org/ztt_journal.html on november 28, 2003. zero to three: new visions for parents (1997). new visions: a parent's guide to understanding developmental assessment. retrieved on january 21, 2004 from http://www.zerotothree.org/visions.html 47 posada 48 graduate students journal of psychology copyr graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 factors predicting maternal stress in mothers with infants hilary vidair, jennifer m. hoag, and wanda g. vargas hofstra university maternal stress has been linked to psychological well-being and a greater likelihood of poor adjustment for both mother and child. furthermore, higher levels of stress were predicted for mothers with a perception of limited partner support and/or low frustration tolerance. sixty-one mothers of infants that were contacted via mail completed the survey of personal beliefs (spb; kassinove, 1986), the parenting stress index (psi; abidin, 1983), and a measure of partner support. a simultaneous regression analysis found that limited partner support and low frustration tolerance, when taken together, significantly predict maternal stress, although low frustration tolerance accounted for most of the variance found in a stepwise prediction method. thus, these variables should be emphasized in cognitive-behavioral interventions aimed at reducing maternal stress in mothers of infants. parenting stress significantly impacts both a child’s emotional and behavioral development as well as the parent’s well-being, particularly during the early years, when young children spend the majority of time interacting with parents at home (abidin, 1995). specifically, research has shown that maternal stress has been linked to psychological health, potential for abuse, and a greater likelihood of poor adjustment for both parent and child (walker, 2002). previous research in the area of parental stress suggests that parents with more irrational beliefs and a perception of limited partner support have higher levels of emotional stress (e.g., joyce, 1995; ohr, vidair, hoag, and vargas, 2003a; ohr, vidair, hoag, and vargas, 2003b). blount, 1987). although the relationship between irrational beliefs and emotional stress has been studied within many types of samples, it has not been widely studied among parents. joyce (1990) proposed that ellis’ (1962) abc model might be used to understand how a parent’s irrational beliefs mediate the relationship between events the parent experiences and his or her feelings and behaviors. for example, a child’s behavior can be an antecedent (the “a”) or activating event for their parent’s negative feelings and behaviors, which are called the consequences (the “c”). the abc model emphasizes that the parent’s rational and irrational beliefs (the “b”), engender such consequences. according to this model, the parent can learn to dispute irrational thoughts in order to reduce emotional stress and improve their parenting skills, thus benefiting both themselves and his or her child. several researchers studying various populations have linked irrational beliefs and emotional stress (i.e., joyce, 1995; moller, rabe, & nortje, 2001; stebbins & pakenham, 2001; smith, 1982; smith, 1983). for example, irrational thoughts and stressful emotions have shown to be correlated (e.g., ranging from r = .23 to .87) among people ranging from those in nonclinical, community samples experiencing marital conflict (e.g. moller, rabe, & nortje, 2001), to caregivers of traumatic brain injury (stebbins & pakenham, 2001), to those in psychiatric settings (jacobsen, tamkin, & according to joyce (1990), rational emotive behavior therapy (rebt) proposes that parents’ irrational beliefs concerning both themselves and their parenting skills foster self-defeating and inappropriate stressful emotions, which can hinder parenting skills such as problem-solving and disciplinary strategies, influence negative emotions such as anxiety or anger in their child, and ultimately harm the parent-child relationship. based on these ideas, joyce (1995) studied a variety of irrational beliefs and emotional stressors in 48 parents of school-aged children and developed a parenting program aimed at reducing parental stress. hilary b. vidair, jennifer m. hoag, and wanda g. vargas, department of psychology, hofstra university. this research was supported in part by the hofstra college of liberal arts and sciences’ faculty research and development grant for 2003-04. the authors would like to acknowledge phyllis s. ohr for her continual assistance in conducting the study and critiquing the manuscript. we would also like to thank mary e. travers and dawn dugan for their dedication to this study, and john j. giuffo, jr. for reviewing the final draft of the manuscript. correspondence concerning this article should be addressed to hilary b. vidair, department of psychology, hauser room 204, hofstra university, hempstead, new york 11550. e-mail: hilsey79@aol.com. joyce (1995) studied low frustration tolerance, one of rebt’s core irrational beliefs. this belief can be characterized as, “the person’s perceived inability to withstand the discomfort of an activating event,” for example, “i can’t stand it” (walen et al., 1992, p. 129). low frustration tolerance is considered an “evaluative belief,” which rebt considers to be one of the main beliefs associated with emotional disturbances (p. 127). 36 factors predicting maternal stress joyce (1995) measured low frustration tolerance with a version of berger’s 1993 beliefs scale which she had revised, and found that parents reporting more low frustration tolerance specifically related to parenting expressed more stressful negative emotions, including anxiety, selfdowning, guilt, anger, discomfort, and lower well-being. joyce (1995) then demonstrated that a nine-week rational-emotive parenting program reduced parents’ irrationality as compared to a waitlist control group, with effects being strongest for low frustration tolerance irrationality. these results were maintained almost identically at a 10month follow-up period, lending some support to the theory that parents can be taught to reduce low frustration tolerance in order to feel less stressed, and, theoretically, improve their parenting ability. ohr, vidair, hoag, and vargas (2003a) sought to further establish a link between irrational beliefs and maternal stress in mothers of young children, as measured by the survey of personal beliefs (spb: kassinove, 1986) and the parent domain of the parenting stress inventory (psi; abidin, 1986), respectively. as other measures of irrational beliefs may have been confounded with emotional stress, the spb was utilized (e.g. smith, 1982; chang & bridewell, 1998). for example, irrational statements have included an affective word on some questionnaires claiming to only measure irrational beliefs (demaria, kassinove, & dill, 1989). the spb avoids this issue by focusing items on cognitions rather than emotions. in ohr et al.’s (2003a) study, mothers were contacted via mail using a mailing list of recent births in a northeastern suburb of a major metropolitan area. correlational analysis of data from 23 mothers with young children (newborn to three-years-old) indicated that mothers who engaged in low frustration tolerance had higher levels of maternal stress (r =-.58, p <.01). therefore, these results lend support to joyce’s (1995) findings that low frustration tolerance was related to more maternal stress. ohr et al. (2003a) also assessed the relationship between mothers’ perception of spousal support regarding childrearing and maternal spousal stress related to perceived dysfunction in the relationship. higher levels of maternal spousal stress were related to maternal perception of limited partner support for how mothers deal with the children (r = -.61, p = .01). in a similar study with a larger sample of 50 mothers, vidair, travers, hoag, vargas & ohr (2003) also found that a mother reporting a high level of spousal stress perceived her partners as being less supportive of her parenting (r = .60, p = < .001). in terms of maternal spousal stress and mothers’ perception of limited partner support regarding parenting, it seems that mothers unhappy in their current relationships are feeling a lack of partner support in the raising of their children. it remains a question whether or not this lack of support predicts an overall level of maternal stress. mulson, caldera, pursley, reifman & huston (2002) noted that further research needs to assess the relationship between parenting stress and mothers’ perception of partner support beyond intimacy. to the authors’ knowledge, no other information currently exists concerning the relationship between mothers’ perception of partner support specifically regarding childrearing and maternal stress. assessing this connection may later assist clinicians in knowing what to address during cognitive-behavioral, stressreduction interventions. ohr, vidair, hoag, & vargas (2003b) sought to extend research concerning irrational beliefs by determining which, if any, of the following variables would predict maternal stress: partner support (defined by maternal perception of degree of partner support regarding child rearing practices), involvement (defined by maternal perception of degree of partner daily involvement with children in the home), low frustration tolerance, and awfulizing, which is “a way of exaggerating the negative consequences of a situation to an extreme degree, so that an unfortunate occurrence becomes ‘terrible’” (walen et al., 1992, p. 18). the dependent variable was an overall measure of maternal stress. fifty mothers were utilized and the methodology followed ohr et al.’s prior study (2003a). a regression analysis using a stepwise prediction method revealed that mothers’ perception of limited partner support predicted 25.3% of the variance in maternal stress, with a statistically significant incremental change of .089 when low frustration tolerance was added to the model. thus, 34.2% of the variance in maternal stress was accounted for by these two variables, when taken together. therefore, mothers’ perception of her partner’s support and low frustration tolerance significantly predicted self-reported maternal stress, yet perception of partner involvement and awfulizing did not add significantly to this prediction. however, the measure of support in this study reflects the perception of the mother, and may or may not accurately reflect what may be objectively determined through observation. this does suggest, however, that perhaps regardless of the actual degree of support, it is the mother’s perception of it that is related to her perceived level of stress. in addition, these results lend some support to joyce’s (1995) findings that low frustration tolerance is an important factor in parental stress. outliers in ohr et al’s (2003b) study, however, were not eliminated, suggesting that the accuracy of the percentage of variance accounted for may have been inaccurate. the current study following cognitive-behavioral theory, it is plausible that the way parents think about certain events in their lives influences the way they feel. irrational beliefs and various types of emotional stress have previously been somewhat correlated, although work has been very limited among parents, especially those of young children. when a child is first born, and he or she is very dependent on the mother, it follows that stress has a large impact on mother and infant functioning, as well as on dyadic interactions (ohr et al., 2003b). if low frustration tolerance and/or mothers’ percep37 vidair, hoag, & vargas measures tion of limited partner support regarding parenting predicts maternal stress in mothers of infants, this would lend support for a cognitive-behavioral intervention aiming to reframe this type of thinking, thus reducing parental stress. furthermore, if mothers’ perception of limited partner support regarding parenting significantly predicted maternal stress, partner involvement in intervention may also contribute to a beneficial outcome. in order to create an effective intervention for mothers experiencing stress, however, we must determine if these variables contribute to such negative feelings. partner support. mothers’ perception of partner support regarding childrearing practices was assessed with the following question: "how supportive is your partner regarding the way you deal with the children (e.g., the type of discipline you use)?" mothers responded on a 5-point likert scale ranging from “much below average” to “much above average.” irrational beliefs. the low frustration tolerance subscale on the survey of personal beliefs (spb; demaria et al., 1989; kassinove, 1986) was completed to obtain a selfreport of low frustration tolerance, one of ellis’ (1962) core irrational beliefs. the pbs contains 50 self-report items on a 6-point likert scale, compartmentalized into five categories, one of which is low frustration tolerance. there are 10 items on this scale. for example, one low frustration tolerance item stated, “there are some things that i just can’t stand.” possible responses ranged from agree to disagree. lower scores indicated a higher level of irrationality. chang and bridewell (1998) found a coefficient alpha of .80 for the total scale of irrational beliefs. as in their study, this irrational beliefs scale was utilized as opposed to others available because the items focus on cognitions rather than emotions. by avoiding emotionally-loaded words, this measure reduces the possibility of an overlap between the level of irrational beliefs and emotional stress. this study sought to assess if mothers’ low frustration tolerance and perception of limited partner support significantly predict an overall level of maternal stress. a review of the literature indicates that an assessment of these two variables together has been limited, and has not evaluated these variables in relation to mothers of infants at all. if these factors predict maternal stress over and above others, they could become the focus of a cognitive-behavioral, stress-reduction intervention for mothers of infants. method participants participants were contacted via mail using a mailing list of 700 mothers with recent births in a northeastern suburb of a major metropolitan area. surveys were sent out along with an introductory letter stating the purpose of the research as well as benefits received from participating. these advantages included contributing to scientific knowledge in the area of parent-child relationships, a chance to enter a raffle for a $100 gift certificate to toys-‘r-us, a chance to receive a free parenting packet with parenting tips, and the opportunity to receive a free stress management intervention. seventy-five mothers responded, but only sixty-one mothers completed all of the questionnaires necessary for the statistical analyses. in terms of demographics, all mothers did not contribute data for every variable. first, the mean age of the mothers was 32.8 years-old (sd = 5.35, n = 59). second, the infants of these mothers ranged in age from seven weeks to 15 months old, and they were the only child in 45.9% of the cases (n = 61). as for how many siblings the others had, 42.6% had one, 6.6% had two, and 4.9% had three. thirty-one of these infants were female, whereas 26 were male. furthermore, 78.7% of the sample identified as caucasian, whereas 6.6% were latino, 4.9% were asian, 3.3% were african-american, 1.6% fit into a category of other, and 4.9% did not fill out this information. in addition, 63.9% of 59 mothers reported being married and 52.5% of 60 mothers reported that they work. parenting stress. the parent domain section of the parenting stress index (psi; abidin, 1983) was completed by mothers to obtain a self-report of level of overall maternal stress. this 54-item scale is composed of the following seven subscales: depression, attachment, role restriction, competence, isolation, spouse, and health. a 5-point likert scale from strongly agree to strongly disagree was utilized for most of the statements, and participants were instructed to choose a response that best represented their opinion. for example, an item assessing competence stated, “i feel capable and on top of things when i am caring for my child.” in the area of role restriction, one item stated, “i find myself giving up more of my life to meet my children’s need than i ever expected.” if they had more than one child, they were told to base their answers on the child they were most concerned about. a few of the statements had four or five multiple-choice answers. for example, in the health section, one item stated, “since i’ve had my child, a) i have been sick a great deal, b) i haven’t felt as good, c) i haven’t noticed any change in my health, d) i have been healthier.” higher scores indicated a higher level of maternal stress in that area. the total score, which is a composite of these subscales, was utilized. the reliability coefficient for the psi’s total parent domain was .93 when administered 1 to 3 months after the baseline, lending some support for the consistency of these scores over time (abidin, 1995). 38 factors predicting maternal stress results respectively). theses were based on the data of 59 participants. results of simultaneous regression analysis indicated that the two predictor variables were found to account for 23.6% of the variance predicted for in maternal stress. the stepwise regression analysis revealed that low frustration tolerance predicted 17.1% of the variance in maternal stress, with a statistically significant incremental change of .065 when mothers’ perception of partner support was added to the model. therefore, low frustration tolerance appears to be more important than mothers’ perception of limited partner support in predicting maternal stress in mothers of infants, yet both are important factors. betas and values of significance can be seen in table 2. a simultaneous regression analysis was performed to determine which variables of interest would predict an overall level of maternal stress. the predictor variables were mothers’ perception of partner support and low frustration tolerance. the dependent variable was an overall measure of maternal stress. descriptive statistics for the variables are presented in table 1. the scatterplots of residuals were examined to determine if the assumptions of multiple regression were met. the assumption of homoscedasticity was found to be questionable for partner support. regarding the assumption of linearity, a pattern of linearity was demonstrated when maternal stress was regressed on each of the predictor variables. to determine whether the presence of outliers table 2 stepwise prediction method of partner support and low frustration tolerance predicting maternal stress might have undue influence on the results, inspection of the casewise diagnostics indicated that there were two cases that were extreme on the criterion variable. an analysis of cook’s distance indicated that these cases were exerting undue influence. specifically, one case had an extremely high maternal stress score on the parent domain, whereas the other case had an extremely low score on this scale. thus, these two cases were excluded in the analyses. measure b r r2 p 1. lft -1.487 .171 .171 .001 2. lft -1.442 + partner support -7.206 .236 .065 .033 the zero-order correlation among the two predictor variables, low frustration tolerance and partner support, was almost nonexistent (r = .05, p = .712). low frustration tolerance and partner support were both moderately correlated with the criterion (r = -.41, p = .001 and r = -.28, p= .035 note. lft (low frustration tolerance); psi (parenting stress inventory). ). mothers’ perception of partner support, , low frustration tolerance, and maternal stress were assessed. n = 58 for the regression analysis, as some mothers neglected to fill out all the information necessary. table 1 discussion descriptive analysis the results of the current study confirm ohr, vidair, hoag, and vargas’ (2003b) findings that both mothers’ perception of limited partner support and low frustration tolerance significantly predict an overall level of self-reported maternal stress in mothers of infants. most of the variance found in maternal stress, however, was accounted for by mothers’ low frustration tolerance, such as thoughts that situations are unworkable and intolerable. joyce’s (1995) research showed that low frustration tolerance specifically related to parenting was moderately related to parental stress. the results of the current study advance her findings by demonstrating that even a tendency to have low frustration tolerance related to general situations at home, work, and other life events (not just related to parenting) significantly predict maternal stress. as ellis (1962, 1995) theorized, engaging in irrational beliefs seem to result in emotional and behavioral consequences (e.g. joyce, 1990; walen, digiuseppe, & dryden, 1992; abrams & ellis, 1994; gerbode & moore, 1994; chang & bridewell, 1998). m sd minimum maximum partner support a 4.10 .86 2.00 5.00 low frustration tolerance b 31.88 6.78 19.00 49.00 parent domain c 123.80 24.38 73.00 183.00 notes. n=59 a mothers’ perception of partner support regarding childrearing (i.e. discipline) was assessed using a 5-point likert scale ranging from 1= much below average to 5=very much above average. b low frustration tolerance is another subscale on the survey of personal beliefs (spb). the subscale contains 10 items, with each item scored a 6-point likert scale. scores could range from 10 to 60. lower scores indicate greater irrationality. c the parenting domain of the parenting stress index (psi) was completed by mothers to obtain a self-report of overall and specific parenting stress. this 54-item scale is composed of seven subscales. the scores could range from 54-269. higher scores indicate greater overall stress. joyce (1995) found a relationship between low frustration tolerance and parenting stress in parents of school-age children. this study looked at mothers of infants, indicating that low frustration tolerance is a factor for these mothers as 39 vidair, hoag, & vargas well. perhaps we can teach mothers of infants to reframe their beliefs of low frustration tolerance, thus reducing parenting stress, as joyce (1995) demonstrated for parents of school-age children, and ultimately improve parenting skills. mothers’ perception of limited partner support regarding childrearing also influences the level of maternal stress for mothers of infants. bonds, gondoli, sturge-apple, and salem (2002) found that parenting stress mediates the relationship between perceiving some type of support for maternal parenting strategies and optimal parenting. bonds et al. suggest that community-parenting interventions could increase such perceptions, either by providing informational and emotional support or by facilitating group connections. perhaps increasing mothers’ perception of partner support regarding childrearing would also reduce maternal stress, which theoretically, would improve parenting. this study only examined a limited number of factors that could possibly contribute to maternal stress. although many factors are probably responsible for such stress, it was not within the scope of this study to address every possibility. future studies should be implemented to try replicating and expanding the findings of this study, as well as to address the following limitations. first, is important to note that the measure of partner support in this study reflects the perception of the mother and may not accurately reflect what would be objectively determined through observation (ohr et al., 1993b, vidair et al., 2003). the findings do suggest, however, that regardless of the actual degree of partner support, it is the mother’s perception of this support that is related to her perceived level of stress. nevertheless, future research should include direct observations assessing parent-child interactions, as all variables in this study were based on self-report measures. another important issue is the way that partner support was assessed. the question asked for mothers to rate their perception of their partners’ support regarding the way she handles the children. a potential problem with this is that each mother may define the variable of partner support differently. in addition, the measure does not differentiate between quality and quantity of partner support she perceives or whether or not she is satisfied with this amount or type of support. future studies should utilize a clearly defined measure of partner support that assesses all of these variables. moreover, studying general partner supportiveness in addition to studying partner support related to child rearing may be beneficial. issues concerning the distribution of scores on the questionnaires utilized also exist. for example, the partner support scores were skewed, as the majority of mothers felt that their partner’s level of supportiveness was either somewhat or much above average. second, the mean score on the parent domain of the psi in this sample (m = 122.78, sd = 23.28) was almost identical to the normative mean for the parent domain in the standardized sample (m = 123.1, sd = 24.4), indicating that this sample of mothers did not appear very stressed. perhaps the low response rate found in this study is because stressed mothers did not need the added stress of completing and returning the surveys. a variety of factors may have contributed to our low response rate. for example, mothers may have had stressors that prevented them from completing the surveys, such as problems with mental or medical health. moreover, infant medical problems may be a factor contributing to the low response rate. in addition, perhaps cultural variables may have influenced who volunteered to participate, as our sample was mostly caucasian. these variables should be taken into consideration in future studies addressing maternal stress. a different method of recruitment may be necessary, as a study utilizing a more distributive sample would be beneficial in order to make stronger conclusions concerning a stress-reduction intervention. furthermore, while the overall stress score was used as the dependent measure, the parent domain is a composite of subdomains of stress. it may be good to explore predictive relations among stress subdomains, perceived partner support, and low frustration tolerance to get a more complex idea of their interactions. future studies may also want to focus on more clinical areas of psychopathology, such as maternal depression, anxiety, and anger in order to determine predictive factors in those areas. nevertheless, as beliefs about low frustration tolerance and limited partner support significantly predict maternal stress, a cognitive-behavioral intervention program focused on reframing dysfunctional thinking may be beneficial. much evidence has supported cognitive-behavioral therapy as a successful strategy in the reduction of emotional stress (e.g., smith, 1982; smith, 1983; joyce, 1990; joyce, 1995; clark, 1998). theoretically, this decrease in stress would influence a better mother-child relationship. intervening with the mother, however, is only part of what seems to be needed for stress reduction in mothers with young children. mothers’ perception of partner support, regardless of the objective level of support given, suggests that the partner may be a critical component of any intervention program (ohr et al., 2003b, vidair et al., 2003). intervening with the mother may have implications for reducing stress in the short-term, but including the partner may result in maximal long-term gains regarding the psychological and physical well-being of mothers, their partner, and their infants. references abidin (1983). parenting stress index (form 6). charlottesville, va: pediatric psychology press. abidin (1995). parenting stress index third edition: professional manual, florida; psychological assessment resources, inc. abrams, m,. & ellis, a. (1994). rational-emotive behavior therapy in the treatment of stress. british journal of guidance and counseling, 22, 39-51. 40 factors predicting maternal stress 41 bonds, d.d., gondoli, d.m., sturge-apple, m.l., & salem, m.n. (2002). parenting stress as a mediator of the relation between parenting support and optimal parenting. parenting: science and practice, 2, 409-435. chang, e.c., & bridewell, w.b. (1998). irrational beliefs, optimism, pessimism, and psychological stress: a preliminary examination of differential effects in a college population. journal of clinical psychology, 54, 137-142. clark, l. help for emotions. kentucky: parents press, 1998. demaria, t.p., kassinove, h., & dill, c.a. (1989). psychometric properties of the survey of personal beliefs: a rational-emotive measure of irrational thinking. journal of personality assessment, 53, 329-341. ellis, a. reason and emotion in psychotherapy. new york: lyle stuart, 1962. ellis, a. (1995). changing rational-emotive therapy (ret) to rational-emotive behavior therapy (rebt). journal of rational-emotive and cognitive behavior therapy, 13, 85-89. gerbode, f.a. & moore, r.h. (1994). beliefs and intentions in ret. journal of rational-emotive and cognitive behavior therapy, 12, 27-45. jacobsen, r.h., tamkin, a.s., & blount, j.b. (1987). the efficacy of rational-emotive group therapy in psychiatric patients. journal of rational-emotive therapy, 5, 22-31. joyce, m.r. (1990). rational-emotive parent consultation. school psychology review, 19, 304-314. joyce, m.r. (1995). emotional relief for parents: is rational-emotive parent education effective? journal of rational-emotive and cognitive behavior therapy, 13, 5575. kassinove, h. (1986). self-reported affect and core irrational thinking: a preliminary analysis. journal of rational-emotive therapy, 4, 119-130. moller, a.t., rabe, h.m., & nortje, c. (2001). dysfunctional beliefs and marital conflict in stressed and nonstressed married individuals. journal of rational-emotive and cognitive behavior therapy, 19, 259-270. ohr, p.s., vidair, h.b., hoag, j., & vargas, w.g. (2003a, august). intervention for dysfunctional mother-infantsibling triads using cognitive-behavioral techniques. poster session presented at the annual meeting of the american psychological association, toronto, canada. ohr, p.s., vidair, h.b., hoag, j.m., & vargas, w.g. (2003b, november). dysfunctional thinking and maternal parenting stress in families with young children. poster session presented at the annual meeting of the association for advancement of behavior therapy, boston, ma. smith, t.w. (1982). irrational beliefs in the cause and treatment of emotional stress: a critical review of the rational-emotive model. clinical psychology review, 2, 505-522. smith, t.w. (1983). change in irrational beliefs and the outcome of rational-emotive therapy. journal of consulting and clinical psychology, 51, 156-157. stebbins, p. & pakenham, k.i. (2001). irrational schematic beliefs and psychological distress in caregivers of people with traumatic brain injury. rehabilitation psychology, 46, 178-194. vernon, a. (1990). the school psychologist’s role in preventive education: applications of rational-emotive education. school psychology review, 19, 322-330. vidair, h.b., travers, m.e., hoag, j.m., vargas, w.g., & ohr, p.s. (2003, november). maternal spousal stress, perception of partner supportiveness, and perceived partner involvement in parents of young children. poster session presented at the annual meeting of the association for advancement of behavior therapy, boston, ma. walen, s.r., digiuseppe, r., & dryden, w. (2nd ed.) a practitioner’s guide to rational-emotive therapy. new york: oxford university press, 1992. walker, a.p. (2002). parenting stress: a comparison of mothers and fathers of disabled and non-disabled children. dissertation abstracts international: section b: the sciences & engineering, 62, 3393. participants graduate student journal of psychology copyright 2 graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 adolescent body mass index in relation to depression, self-esteem, and academic achievement mathew malter-cohen teachers college, columbia university the differences in school achievement, depression, and self-esteem among overweight and normal weight adolescents were investigated. body mass index (bmi), measured weight status, and group classification (overweight or normal weight) were determined by k-means cluster analysis. multivariate analyses of variance (manova) indicated significant effects across weight classifications. overweight adolescents had a significantly lower grade point average than their normal weight counterparts. however, differences between weight groups for depression and self-esteem were insignificant. the implications and possible causes for these differences and similarities are discussed. recent research has documented extensively the adverse effects of obesity on orthopedic, neurological, pulmonary, and gastroenterological health (must & strauss, 1999; zametkin, zoon, klein, & munson, 2004). overweight (body mass index ≥ 85th percentile for age and gender) and obese (body mass index ≥ 95th percentile for age and gender) individuals are at increased risk for a number of illnesses, including hypertension, hyperlipidemia, osteoarthritis, and type ii diabetes, to name a few (flegal, carroll, kuczmarski, & johnson, 1998). obese children between the ages of 10 and 13 have a 70% chance of being obese adults (the office of the surgeon general website, 2006). given these findings, it is quite alarming to see the rates of childhood and adolescent obesity nearly triple in the usa, from 5.7% to 15.3%, between 1980 and 2000 (ogden, 2002). these increases in childhood and adolescent obesity span age, gender, and ethnicity (dietz & gortmaker, 2001). while the health effects of the obesity epidemic in the united states have been examined in great detail (dietz & gortmaker, 2001; flegal et al., 1998; zametkin, zoon, klein, & munson, 2004), not much attention has been directed toward other important effects, such as decreased school performance in children and adolescents, and the ramifications for professional life in adults. obesity and school achievement while the research on the relationship between obesity and school achievement has been sparse, it has also been varied in its parameters. taras and potts-datema (2005) published a literature review examining 10 studies from the past 50 years coming from brazil, china, finland, thailand, the united kingdom and the united states of america (usa). only four of these studies originated from within correspondence concerning this article should be addressed to mathew malter-cohen; e-mail: mhm2108@columbia.edu. the usa (datar, sturm, & magnabosco, 2004; falkner et al., 2001; schwimmer, burwinkle, & varni, 2003; tershakovic, weller, & gallagher, 1994), even though the obesity problem in the usa is more pronounced than in other countries. in china, for example, li (1995) examined an evenly matched cohort (obese and normal weight) of 204 elementary school children and found that severely obese children had significantly lower intelligence quotient (iq) scores on the wechsler intelligence scale for children (wisc) than controls. campos, sigulem, moraes, escrivao and fisberg (1996) found that children ages 8-13 years with normal height/weight ratios had significantly better performance on the wisc than their obese counterparts. in thailand, mo-suwan, lebel, puetpaiboon and junjana (1999) found that being overweight during adolescence (grades seven to nine) was associated with poor school performance. furthermore, adolescents who were more overweight were at greater risk for low gpa. li (1995) found that obese children performed significantly lower in six of the eight categories examined: chinese, arithmetic, foreign language, general knowledge, art, and gym. defining obesity as greater than 120% of sex/height specific mean weight for age, mikkila, lahti-koski, pietinen, virtanen and rimpela (2003) found good school performance to be inversely associated with being obese for boys and girls in a cohort of over 60,000 finnish adolescents, ages 14-16. within the usa, datar, sturm and magnabosco (2004) analyzed data from a nationally representative cohort of 11,192 first-time kindergartners from the early childhood longitudinal study (ecls), a project funded by the united states department of education. the ecls began following these children in 1998 and will follow them through twelfth grade in order to test hypotheses about the effects of a wide range of family, school, community and individual variables on children's development, early learning, and early performance in school. the overweight kindergarteners enrolled in the ecls had significantly lower math and 10 obesity and school achievement 11 reading test scores compared with the non-overweight children. however, once they included socioeconomic and behavioral variables in their model, datar’s group concluded that overweight status is a marker, and not a causal factor, of poor test scores (datar et al. 2004). the affective component clinical reports and other qualitative data seem to indicate that weight is linked to both depression and selfesteem. however, recent studies on adolescents concerning emotional health indicate that the data are not so clear-cut. swallen, reither, haas and meier (2005) found that while overweight and obese adolescents (ages 15-17) had significantly worse self-reported health than normal weight adolescents, no difference existed between the groups on measures of depression, self-esteem, and school/social functioning. several other studies found no differences in self-esteem between obese children and adolescents and non-obese controls (gortmaker et al., 1993; renman, engstrom, silfverdal, & aman, 1999; rumpel & harris, 1994). other studies indicate that obese children and adolescents have somewhat lower self-esteem than their normal weight counterparts (manus & killeen, 1995; stradmeijer, bosch, koops, & seidell, 2000; strauss, 2000). still others found a difference in self-esteem between obese and normal weight children and adolescent girls that was rendered insignificant once body image was controlled for (french, perry, leon, & fulkerson, 1995; pesa, syre, & jones, 2000). similar problems of confounding variables arise when examining the relationship between obesity and depression. sjoberg, nilsson and leppert (2005) concluded that there is a significant statistical association between adolescent obesity and depression, although it disappeared when shaming experiences, parental employment, and parental separation were controlled for. these findings were similar to those of erickson, robinson, haydel and killen (2000), although they were studying a cohort of children in the third grade. in girls, they found a modest association (r = 0.14, p < .01) between depressive symptoms and body mass index (bmi), which dropped out after controlling for level of overweight concerns. erickson et al. (2000) found no association between depressive symptoms and bmi in boys. the objective of this study of eleventh graders, in the usa, was to build on prior evidence (datar et al., 2004; mikkila et al., 2003; mo-suwan et al., 1999) that has suggested that there exists a negative relationship between bmi and school achievement. as bmi increases, school achievement, measured here by grade point average (gpa) is expected to decrease. due to the conflicting evidence presented by the literature concerning the relationship between bmi and depression, we do not expect to see a relationship between bmi and depression (sjoberg et al., 2005; swallen et al., 2005; erickson et al., 2000). additionally, no relationship is expected between bmi and self-esteem (swallen et al., 2005; renman et al., 1999; rumpel & harris, 1994; gortmaker et al., 1993). current research efforts into the possible biological correlates of obesity that have an impact on cognition will be examined. method sample participants in this study consisted of students in eleventh grade attending a public high school in an affluent community in the northeast. during the year 2000, the median annual family income in this region was reported to be almost $102,000 (u.s. census bureau, 1999); the highest national median income ever recorded by the u.s. census is $43,318 (denavas-walt, proctor, & mills, 2004). the majority of students, 87.1%, were of european american background, 0.8% were african american, 5% were hispanic, 4.2% were asian american, and 2.9% were of other ethnic backgrounds. with regard to gender of the students, 46.7% were female and 53.3% were male. this study was implemented as part of a school-based initiative that targeted positive youth development, and inclusion of students in the sample was based on passive consent procedures (i.e. students are automatically included and given the opportunity to opt-out at any point, before, during, or after the study). given increasing anecdotal and media-based evidence of various problems in communities such as theirs, school administrators and parent representatives in this particular community had sought a rigorous assessment of the nature and extent of difficulties among their high school students. following the development of a collaborative relationship between the local school district and a columbia university researcher, dr. suniya luthar (which ensued from a series of talks she gave for the community), the survey was initiated. school administrators sent letters to the parents of all eleventh graders by u.s. mail that described the project, indicated that survey results would be presented only in aggregate form (with no information on individual children), and requested notification if they preferred that their children not participate. a second notice was mailed a few days before data collection, once again offering parents the option to refuse consent. on each of the two days of data collection, all students were also told that their participation was entirely voluntary. on completion of data collection, questionnaires were scored with only participant numbers as identifiers. most of these students had participated in similar data collections conducted by dr. luthar during the sixth through tenth grades. of the 252 eleventh graders who participated, bmi data was available for only 240 of the students; 12 students did not report their heights and weights. measures subjective reports of maladjustment depressive symptoms. malter-cohen 12 the children’s depression inventory is a widely used 27-item, three-choice scale designed to measure depression for school-age children and adolescents (kovacs, 1992). this measure has acceptable internal consistency as well as criterion and concurrent validity (kovacs, 1992). alpha coefficients of internal consistency in this sample were .82 and .84 for girls and boys, respectively. self-perception profile for adolescents. the global self-worth subscale from the selfperception profile for adolescents (harter, 1988) was administered to tap each participant’s overall perception of his or her worth as a person. item content examines the extent to which adolescents approve of themselves along four dimensions: (a) social competence, (b) physical competence, (c) romantic appeal, and (d) friendship. for each item, two sentence stems were presented side by side, for example, “some teenagers are often disappointed with themselves,” but “other teenagers are pretty pleased with themselves.” students were asked to decide which stem best described them and whether the statement was “sort of true” or “really true” for them. questions are written in a “structured alternative format” designed to reduce the tendency to give socially desirable responses (harter, 1982). harter (1988) reports good psychometric characteristics for these scales. alpha coefficients of internal consistency in this sample were .96 and .89 for girls and boys, respectively. objective reports of maladjustment body mass index. bmi is a measure of the weight of a person scaled according to height. a frequent use of bmi is to assess how much an individual's body weight departs from what is normal for a person of his or her height. the weight excess or deficiency may, in part, be accounted for by body fat (adipose tissue) although other factors, such as muscularity, also affect bmi. as a rough guideline for adults, a bmi of less than 20 implies underweight, over 25 is overweight, and over 30 is obese. bmi is calculated by taking the weight of the individual in kilograms and dividing by the square of the height in meters. bmi for children age 2 to 20 is calculated just as it is for adults, but it is classified differently. a bmi that is less than the 5th percentile is considered underweight and above the 95th percentile is overweight. children with a bmi between the 85th and 95th percentile are considered to be at risk of becoming overweight. bmi categories are generally regarded as a satisfactory tool for measuring whether sedentary individuals are "underweight," "overweight," or "obese." it has been used by the world health organization as the standard for recording obesity statistics since the early 1980s. additionally, piertobelli et al. (1998) tested the hypothesis that in a healthy pediatric population, bmi is a valid measure of fatness (total body fat and percent of body weight as fat were estimated by dual energy x-ray absorptiometry). the measure is also independent of age for both sexes (piertobelli et al., 1998). research thus supports the use of bmi as a fatness measure in groups of children and adolescents. goodman and strauss (2000) found self-report of bmi by adolescents to be a reliable indicator of actual bmi; 96.2% of teens were correctly classified as obese based on self-reported height and weight measures. procedure data for each student were collected during two 45minute class periods on two separate days, and testing of the adolescents was done in groups of 15 to 20. to guard against biases due to variability in reading proficiencies, a member of the research team read each questionnaire aloud, and students marked their responses accordingly. questionnaires were administered in the same order to all groups, with relatively structured, non-threatening measures administered at the beginning and end of each session. students reported height and weight data in the demographics section. on completion of data collection, money to support a pizza party was given to all participating classes. following the data collection, gpa was obtained directly from school administrators. results complete data were obtained for 238 of the eleventh graders who were attending the school sampled; the school withheld gpa for two of the students for reasons unknown to the investigators. means and standard deviations on all variables are presented in table 1. a k-means cluster analysis was performed on bmi to create two groups with maximum distance between group averages. multivariate analyses of variance (manova) indicated significant effects across weight classifications (wilks’s λ = .959, p < .05). individual t-tests showed a significant difference between table 1 descriptive data on all variables weight classification normal (bmi = 21.09) (n = 208) overweight (bmi = 29.48) (n = 28) m sd m sd f grade point averagea 9.10b 1.94 7.88 2.07 9.604** depression 7.51 5.45 8.03 5.63 0.225 global self esteem 3.18 0.52 3.05 0.40 1.625 a gpa measured on a 12 point scale, 12=a, 9=b, 6=c, 3=d b means are convertible to standard collegiate 4-point scale by dividing by 3; subsequent group means are 3.03 and 2.63, respectively. ** p < .01 obesity and school achievement 13 classifications for gpa (f = 9.604, p < .01), but not for depression (f = .225, p = .636), or global self-esteem (f = 1.625, p = .204). error variance of all dependent variables was equal across groups and homogeneity was not violated. discussion this study replicates findings of a strong association between bmi and gpa (mikkila et al., 2003; mo-suwan et al., 1999), while also furthering hypotheses that bmi is not associated with depression (erickson, 2000; swallen, 2005) or self-esteem (gortmaker, 1993; renman et al., 1999; rumpel & harris, 1994). normal weight adolescents had an average gpa of 3.03 (when grades were converted to a standard collegiate 4-point scale), in comparison to an average gpa of 2.63 for the overweight group. miller (1998) found that high school grades “have a strong and significant effect on earnings 9 years after high school for both men and women, with or without bachelor’s degrees,” even after controlling for ses, race/ethnicity, region of the country and public or private status of the high school. while it was beyond the scope of this study to examine why overweight students are performing worse in school than their normal weight counterparts, current research efforts in the field suggest that certain structural and chemical differences in the brain among overweight individuals adversely affect memory and cognitive functioning (jeong, nam, son, son and cho, 2004; pannacciulli et al, in press). pannacciulli et al. (in press) examined associations between excess body fat and regional alterations in brain structure using voxel-based morphometry. in comparison with the group of lean subjects, the group of obese individuals had significantly lower gray matter density in several regions in the brain. in general, gray matter can be understood as the parts of the brain responsible for information processing. pannacciulli et al. identified structural brain differences associated with obesity in several brain areas involved in the regulation of reward and behavioral control, two processes that, along with information processing, have a significant impact on learning. jeong, nam, son, son and cho (2004) used measurements of bmi and waistline circumference to study a korean sample of 467 adults over age 64. waistline circumference was included to better identify those adults who were overweight due to excess body fat and not due to other causes such as greater muscle mass or enlarged skeletal structure. poor cognition was strongly associated with obesity (bmi ≥ 25) in the presence of abdominal obesity. in korea, a bmi ≥ 25 is defined as obese while a bmi of 23-25 is defined as overweight. in individuals with normal waist circumference, poor cognition was negatively associated with being overweight. additionally, abdominal obesity interacted with bmi in its association with poorer cognition. in this elegant study, jeong, nam, son, son, and cho (2004) were able to isolate the effects of abdominal obesity (i.e. excessive body fat) on cognition above and beyond having elevated bmi. finally, several other studies have shown that insulin deficiency, acute hyperglycemia and poor glucose tolerance are associated with impaired memory and cognitive dysfunction in the elderly (craft, 2005; stockhorst, de fries, steingrueber, & scherbaum, 2004; sommerfield, deary, & frier, 2004; convit, wolf, tarshish, & de leon, 2003). these conditions are more prevalent in obese populations, and are a consequence of type ii diabetes, a weight-related disorder. in addition to the biological effects on learning, cognition and memory, there is a socio-cultural impact on student’s academic outcomes. unfortunately, at present, there is a dearth of quantitative research on this matter (puhl & brownell, 2001). the only examination of this topic known to this author found that obese adolescents were significantly less likely than their normal weight counterparts to gain college admission, despite equivalent academic records and application rates (canning & mayer, 1966). while there has been considerable attention directed towards the harassment of, and shame wrought upon, obese children and adolescents in the school setting (neumarksztainer, story, & harris, 1999; national education association, 1994; crandall, 1994), no attention has been paid to the direct or indirect effect this has upon their grades. while other studies have found mixed results when examining the relationship between obesity and depression in adolescents (sjoberg et al. 2005; erickson et al., 2000), this study did not (p=.636). richardson et al. (2003) conducted a study of new zealand adolescents that may explain why this is so, at least for girls. they found that girls with major depression in late adolescence were twice as likely to be obese at age 26. the heterogeneous etiology of depression and subsequent complex effects this disease has on an individual likely explains why this study found no relationship with obesity. while some depressed adolescents may be obese, others have not yet experienced the effects of depression on their bodies. in essence, they may be too young for depression to have had an effect on their weight. many researchers use the global self-worth subscale from the self-perception profile for adolescents (harter, 1988) as a valid measure of self-esteem (french et al, 1995; strauss, 2000; strodmeijer et al., 2000). while the four dimensions tapped by this instrument (social competence; physical competence; romantic appeal; and friendship), are areas in which obese adolescents experience difficulty (puhl & brownell, 2001; neumark-sztainer et al., 1999), normal weight adolescents also experience difficulty in these areas. put more succinctly, it is not surprising that in this study the relationship between self-esteem and obesity was not statistically significant (p=.204); self-esteem is an issue with which most, if not all, adolescents struggle. limitations and conclusion one limitation of this study is sample size. weight classification groups are of unequal size, and the size of the malter-cohen 14 overweight group (n=28) significantly impacts the power of this study to examine all possible risk factors of elevated bmi. in a study such as this one, power of .8 or greater is ideal (cohen, 1988). while the power of individual t-tests examining differences in depression (.076), and self-esteem (.246) between weight class groups in this study is less than ideal, this discrepancy is not significantly meaningful in this case. extrapolating to larger group samples, it is unlikely that greater power would alter statistical significance between weight group averages on the cdi because the distributions are homoscedastic. a similar pattern of insignificant group differences, homoscedasticity, and negligible clinical differences is observed when examining the group differences in self-esteem. sample size further limits the ability to examine path models that may indicate direction of causality. the devastating effects of obesity have gained national attention in the united states and articles are written weekly documenting these effects. studies examining the biological effects of obesity on cognition are a recent development. more work needs to be done in this area, especially replicating findings in younger populations and with samples that are a better representation of the population at large. the results reported here indicate that physical factors such as obesity are a good indicator to parents and school administrators that a child may be doing poorly in school. references campos, a. l., sigulem, d. m., moraes, d. e., escrivao, a. m., & fisberg, m. 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(2004). psychiatric aspects of child and adolescent obesity: a review of the past 10 years. journal of the american academy of child and adolescent psychiatry, 43(2), 134-150. graduate student journal of psychology copyright 2 graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 navigating a successful academic career in psychology: tips and recommendations for graduate students david n. miller university at albany, state university of new york jessica blom-hoffman northeastern university sandra m. chafouleas university of connecticut t. chris riley-tillman east carolina university robert j. volpe northeastern university graduate students in clinical, counseling, school, and other fields of psychology frequently are eligible for and interested in pursuing academic careers. many graduate students, however, may be unsure of, intimidated by, or lack information about this process. the purpose of this article is to provide useful and practical information to doctoral-level graduate students in psychology, who are considering or aspiring to possible academic careers. three areas were selected for review because in the view of the authors they represent three different phases in the life of a beginning assistant professor. tips and recommendations are provided for interviewing for academic positions, achieving early career success in academia, and balancing work and home/family obligations. graduate students in clinical, counseling, school, and other fields of psychology are frequently eligible for and interested in pursuing academic careers. many graduate students, however, may feel intimidated by the prospect of a career in academia, and/or lack information about the academic hiring process, as well as issues that typically confront those in academic careers. for example, research suggests that doctoral students in psychology often do not perceive themselves to be adequately prepared for the expectations and realities of academic life, such as navigating the tenure and promotion process (meyers, reid, & quina, 1998). although there is some information available on this topic in the professional literature (e.g., darley, zanna, & roediger, 2004; rheingold, 1994; sternberg, 2004), much of it is scattered among several sources and may not be readily available or within easy access to graduate students in psychology. the purpose of this article is to provide what we hope is useful and practical information for graduate students correspondence concerning this article should be addressed to david n. miller, university at albany, s.u.n.y., 1400 washington avenue, ed 240, albany, ny 12222; e-mail: dmiller@uamail.albany.edu. considering or aspiring to possible academic careers in psychology. as early-career academic psychologists ourselves, we were fortunate to receive useful career advice from a variety of friends, mentors, and colleagues. it has been our experience, however, that many graduate students have frequently not been the recipients of helpful and practical advice in this area. in an attempt to address this issue, we offer below tips and recommendations for those graduate students in doctoral psychology programs contemplating a possible career in academia. our recommendations reflect our collective experiences as academic psychologists, and we believe our experiences may be useful to others interested in pursuing academic careers. our recommendations may be particularly relevant to those doctoral students who are nearing completion of their graduate studies, who have at least to some degree crystallized their research directions and goals, and who have already begun their academic job search. in discussing recommendations for aspiring faculty, many different issues could be reviewed, including how to negotiate the decision process to pursue an academic career, how to develop a line of research, how to enhance one’s skills in teaching and grant writing, and many other relevant 49 miller, blom-hoffman, chafouleas, riley-tillman, and volpe 50 topics. due to space limitations, however, we focus specifically on providing tips and recommendations in three areas: (1) interviewing for academic positions; (2) achieving early career success in academia; and (3) balancing work and home/family obligations. these areas were selected because, in our view, they represent three different phases in the life of a beginning assistant professor. specifically, issues related to interviewing are paramount when one first begins the academic job search, achieving early career success becomes an important issue once one has received an academic appointment and is pursuing tenure and promotion, and balancing work and family represents an ongoing struggle that will occur both during and after the tenure process. we begin our discussion with tips on interviewing. interviewing tips for graduate students if you have received an invitation to interview for an academic position, you can be confident that your credentials are deemed acceptable by the search committee and that you are a legitimate contender for the job. your goals for the interview should be to present yourself as a good colleague with potential for excellence in teaching and independence in scholarship. by being cognizant of the issues below, you will likely enhance your chances of engaging in a successful interview and getting a job offer. think carefully about the kind of job you want some academic positions emphasize research whereas others emphasize teaching. a clear understanding of the different expectations at research-oriented vs. teachingoriented programs is critical. prior to interviewing, you should be clear in your own mind as to how much time and effort you want to expend on each of these activities. for example, if you have little interest in writing grants or publishing refereed journal articles, a faculty position in a doctoral program at a major research university would be a poor match. taking the time to seriously contemplate which type of faculty position best suits your career aspirations cannot be overstated. learn about the program before you interview each psychology program has a different mission. it is important that you take some time to learn about the program(s) you are considering. this information should be utilized throughout the interview to illustrate your “fit” with the program, the department, and the institution. for example, it is often desirable to be viewed as an individual who will “reach out” across programs in collaborative pursuits. keep in mind that frequently the entire department will vote on whom to make an offer. if the search committee believes you are not only qualified for a position in their program and department but also that you are the type of individual who will thrive in both, you are more likely to receive an offer. for example, chairs of search committees looking to hire psychology professors reported that the fit between a candidate’s background and the position requirements was critical in making hiring decisions (sheehan, mcdevitt, & ross, 1998). never interview for a job if you have no intention of accepting it if offered do not use interviews merely as opportunities for practice. if you have no intention of taking a particular job under any circumstances, interviewing for it is unethical, a waste of both your and the search committee’s time, and deprives other candidates of an opportunity to interview for it. talk candidly with advisors, current professors, and friends to solicit their views both before and after interviewing, it is useful to get as many opinions as possible about job openings from current professors, advisors, friends, and colleagues. although you do not always need to take their words to heart, gathering information about programs and potential colleagues can provide useful insights. if possible, contact former faculty members at the institution(s) where you are interviewing and ask them why they left. such information can be very enlightening. be sincere you may be tempted to try to present yourself in a way that makes you “fit” the wants and needs of the program(s) to which you are applying to a degree that is insincere. don’t. if you do, you (and the institution) will regret it, and probably sooner rather than later. be straightforward about who you are, what you believe, and why you believe it. realize you are never off stage during an interview visit, it is often customary for the job candidate and members of the search committee to go out for breakfast, lunch, and/or dinner. think you are off stage? think again – you are being watched at all times. as such, be cognizant of proper etiquette and ensure your behavior is appropriate at all times. do not overestimate flattery members of search committees may sometimes flatter you by telling you how wonderful you are and what a fine addition you would make to their department. show your appreciation, but don’t take it too seriously. they may well be making similar or identical statements to other candidates. it is in an institution’s best interest to keep as many applicants interested in them as possible during a faculty navigating a successful academic career 51 search; that way, in case someone turns them down they can always offer the position to someone else. that said, know how to take a compliment. do not underestimate the importance of the colloquium the performance of your colloquium is critical and one of the most important determinants of whether or not a job offer will be forthcoming. members of the search committee and other faculty members will be carefully observing your colloquium to evaluate your research potential, your style and manner of presenting information, and the degree to which your presentation is clear, coherent, and wellorganized. an excellent presentation does not guarantee an offer, but a poor performance often seriously jeopardizes one’s chances (iacono, 1981). if this is an area of weakness for you, practice your presentation repeatedly, especially in the presence of others who can provide you with constructive feedback. keep in mind that the manner in which you answer questions is an important component of the colloquium. the more open minded you are to suggestions, the better you will be perceived. you do not need to know the answer to every question, but you should clearly be able to answer most of them. also, clearly state the limitations of your study and any shortcomings in your data. above all, don’t get defensive. assume there will be technological problems during your colloquium if your colloquium requires any kind of technology (e.g., lcd projector, laptop computer, overhead projector, etc.), make your needs clear well in advance of your interview. plan for problems. the authors have been amazed at how often technological difficulties occur during colloquium presentations. if you plan on using an lcd projector, always have overheads available as a back-up in case problems with the projector or computer occur. also, consider burning your talk and vita onto a disk or storing them on a memory stick. you can never be over-prepared; having these backups ready reflects well on you. exhibit a friendly, collegial demeanor it is useful to remember that one area the search committee and other members of the faculty will be assessing is the degree to which you are someone they would like to work with and see every day. even the most accomplished scholar or teacher will not be welcome if he/she comes across as aloof or unfriendly. demonstrating that you have a sense of humor is always a plus, but make sure any attempts you make at humor are appropriate; an interview situation is not the time to make remarks that may be perceived as cutting or “politically incorrect.” remember that your goal is to ingratiate yourself with potential colleagues, not alienate them. ask many of the same questions to multiple individuals the purpose of this is to observe the degree of consistency of responses across multiple individuals. if everyone is saying basically the same things in response to your questions, that is a good sign. if they are not – or are contradicting each other – that is a potential red flag. if this occurs, point out the contradictory or inconsistent statements and ask for clarification. enquire about the relative “weight” given to research, teaching, and service in making tenure decisions each institution typically awards tenure based upon one’s performance in the areas of research, teaching, and service (defined as service to the profession, such as reviewing manuscript submissions to professional journals – and service to the college or university, such as serving on various school committees). service is typically third on the list, but the relative value and “weight” given to research and teaching can vary enormously depending on the institution. ask about this and make sure responses are consistent across individuals; if they are not, acknowledge the inconsistent responses and ask for clarification. it is critical that you ask about the requirements for advancement (tenure) from faculty, deans, and (if possible) upper level administrators. at the time of your eventual tenure review, each of these individuals is likely to have a say in your tenure decision, and it behooves the future faculty member to know what each expects. make sure you have the opportunity to talk, in private, with both current students and tenuretrack assistant professors current graduate students and assistant professors are most likely to give you “straight talk” at an institution. as any graduate student knows, students can give you a sense of the climate of a program in a way that faculty cannot. moreover, other assistant professors “are likely to give you the best idea of the expectations of the department and the reception you would receive if you accepted the job” (iacono, 1981, p. 222). do not underestimate the importance of location remember that you will not only be working in a particular location but will be living there as well. use internet and other sources to compare cost of living indexes across locations of programs where you are interviewing. when interviewing, do not be shy about asking people about acmiller, blom-hoffman, chafouleas, riley-tillman, and volpe 52 cess to recreational areas, what they do for fun, and other aspects of the area. for example, if you are a parent or plan to be, you will likely want to know about the quality of public schools in the area. realize that there is no perfect job each academic position has its own unique pros and cons, but even the best of jobs have disadvantages associated with them. if you don’t perceive any “negatives” at a particular institution, you are not looking hard enough. ask faculty to discuss not only what they like, but also what they don’t like about their positions and the department and institution in which they are employed. if faculty members identify problems or things they dislike about the program or department, ask them how the faculty or institution is attempting to solve these problems. realize that rejection is inevitable and should not be taken personally you will likely get rejected by at least some institutions and often not know the precise reason(s) why this occurred. as noted by iacono (1981): “rejection letters are inevitable, remarkably uninformative, and sometimes insincere” (p. 224). additionally, although rejection is never pleasant, try not to take it personally; often the reason you will not receive an offer has less to do with your competency than with a search committee’s belief that you simply weren’t as good a match as someone else for a particular position. know what you want and get everything in writing you will never have a better time to negotiate for things you want or need (e.g., summer salary; laboratory space; conference money) than when you receive an offer, so be clear in your mind as to what you want – and what you can live without. also, ensure that you get everything that was agreed upon in your negotiation in writing. you will want to do this not because of a suspicion that your hiring institution will try to swindle you, but because college and university budgets fluctuate and memories of promises made may fade over time. once you get an offer and accept it, celebrate! you have worked hard, and it has (hopefully) paid off in your being hired for a tenure-track position. you will now want to concentrate on getting tenure and promotion to associate professor, and the next section will describe suggestions for easing the transition to faculty life and setting yourself up for success in the pre-tenure years. tips for early career success in academia the first years of an academic job are often the most stressful. the following suggestions are provided to ease your transition during the probationary (i.e., pre-tenure) period of your academic career. seek out mentorship inside and outside the university many universities will have formal mentorship programs for untenured faculty members. this may include pairing the untenured faculty member with a tenured faculty member, workshops with topics on teaching, preparing the tenure dossier, and grant writing, and/or social gatherings. it is important to recognize that mentoring is critical during the transition to academia and continues to be important throughout the pre-tenure years. take advantage of university-sponsored mentoring programs for untenured faculty members. it is also important to recognize the value of multiple mentors and to be open to learning from their experiences. one mentor may be particularly good at helping you navigate departmental and broader institutional policies. another mentor may share your research interests and be a helpful collaborator as you launch your research program. a third mentor may be helpful in terms of teaching, providing guidance as you design syllabi, prepare classroom activities, and grade student work. a fourth mentor, who is able to achieve a healthy work-life balance (discussed below), can be a role model in learning when to turn down opportunities that are not in line with your professional goals. by setting regular meetings with your mentors and having an agenda for those meetings, you will be able to maximize learning opportunities for yourself. understand university expectations you should have a broad sense of university expectations related to research, teaching, and service from the interview process before you accept your faculty appointment. as described above, before accepting a position, it is important to determine if the university’s expectations are consistent with your professional strengths and goals. many universities have a new faculty orientation that will frequently provide valuable information regarding pre-tenure expectations. it is important to fully understand expectations regarding research productivity (including the procurement of external funding), teaching load, and service at the departmental, college, university, community, and professional levels, and to make sure that your range of responsibilities and the time allotted to each is reflective of and in balance with these expectations. for example, if your university places the greatest emphasis in their tenure decisions on research productivity with a secondary emphasis on teaching, you should allocate your time in each of these activities accordingly (i.e., spending most of your time engaged in research and publication). your university mentors can provide guidance in this process and help you to set boundaries. navigating a successful academic career 53 begin to assemble your tenure dossier during your first semester assembling the tenure dossier can be a daunting task. this task can be made less overwhelming if you are well organized and develop a working dossier that you continue to refine throughout the pre-tenure years. start off with a large binder divided into three sections for teaching, research, and service, and a package of clear plastic sheet protectors. as you develop teaching products such as syllabi, presentation slides, rubrics for grading student work, materials for class activities, and student evaluations, slide these materials into the sheet protectors in the teaching section of the binder. as you publish papers or write grant applications, slide these into the research section. save permanent products that document your service activities in the service section of the binder. over the pre-tenure years, these materials will begin to pile up, and it is good to have them all in one location. this type of organizational system will also enable you to consolidate information for your annual merit reviews and the dossier that you assemble for the third or fourth year review. it is also a good idea to scan these documents at the end of each semester so you have electronic copies of them. update your vita on a regular basis your vita is the single most important document for demonstrating your skills and accomplishments. update it regularly, particularly early in your career (i.e., pre-tenure). in the day-to-day business of academic life, it is easy to forget seemingly little things you did during the day. did you serve as a guest lecturer at another university? did you do a community service presentation? did you form a discussion group for graduate students interested in pursuing academic careers in psychology? make sure these and other items, which may be easily and quickly forgotten, are on your vita as soon as you do them. also, when documenting your publication accomplishments, do not simply report your refereed journal articles and book chapters. in addition to these, have separate sections for manuscripts in submission, manuscripts in preparation, and research in progress. that way, readers of your vita (e.g., reappointment and tenure committees) can clearly see the trajectory of your research development. choose projects carefully, but follow your bliss carefully consider any possible research projects before committing to them. reappointment and tenure committees not only examine a faculty member’s quantity and quality of research, but also its thematic consistency. develop expertise in a particular area and a research line that can potentially lead to a series of publications in that area. that said, if a particular topic excites you but you perceive it as being outside of your research area, consider doing it anyway. academic freedom is an earned luxury of the academic life, so take advantage of it. in the words of the late mythologist joseph campbell, “follow your bliss.” also, consider that an interest you wish to pursue but perceive as being outside your area may not be if you simply reframe it. for example, the psychologist who studies both sport psychology and addictions may see these as different interests, when, in fact, they could be viewed as two components of an overall interest in health psychology. approach research in a “pipeline” fashion while still in graduate school, one of the authors received some extremely helpful advice from one of his mentors, a widely published and highly respected scholar. this very productive academic described his “2-2-2 rule,” which essentially states that one’s goal as an academic (in a research institution) should be to simultaneously have two journal articles in submission, two articles in preparation, and two studies for which data is being collected at any one time. maintaining this level of performance on a consistent basis will ensure a continual “pipeline” of research productivity and greatly enhance one’s probability of receiving tenure. schedule an annual meeting with your dean or department chair to review your progress typically, new faculty are reviewed for promotion and tenure after completion of their fifth year. prior to their tenure review, faculty members also are typically twice reviewed for reappointment. although formal evaluation occurs at these times, there is no reason to wait until reappointment or tenure reviews to receive feedback on one’s performance. instead, get in the habit of meeting at the end of each academic year with your dean or department chair to discuss your progress and review your vita. deans and department chairs will be familiar with the norms and expectations for tenure at your college or university, and their feedback can be highly instructive. set ambitious yet realistic goals as you begin your first faculty appointment, you may find that you have no idea where to begin. you need to navigate a new college or university system, develop new relationships with colleagues and students, prepare new courses, and set up your research agenda. in addition, you may be asked to jump right into service at the department and/or university levels. it is important to recognize that it is normal to feel overwhelmed during this time and that your mentors can be of assistance. one of the best pieces of advice one of us received from an advisor was not to collect data during the first year. although getting one’s research off the ground as quickly as possible is always beneficial, miller, blom-hoffman, chafouleas, riley-tillman, and volpe 54 doing this the first year on the job may be unrealistic and frequently impractical. instead, consider focusing on projects such as writing up papers from pre-existing data (e.g., your dissertation), writing an internally funded grant, and/or setting up the research infrastructure necessary for conducing future studies. ambitious-yet-realistic goal setting is a critical skill for achieving success. when setting ambitious-yet-realistic goals, it is important to think both in the long term and the short term. after deciding on the long-term goals, break them into smaller semester-by-semester sub-goals to make sure they are realistic. these can be reviewed with mentors to determine if you are “on the right track” to achieving your tenure and promotion goals. set goals that take you well beyond tenure, and you will often find that tenure will take care of itself. one of the most important long-term goals is to try to balance both personal and professional commitments. the following section will offer some advice in this area. tips for balancing work and home life the ability to balance work and personal life is correlated with lower levels of stress and burnout, and higher levels of job satisfaction, engagement, and the intention to stay on the job (mickey-boggs, 2004). statements like this provide validation for the thoughts, feelings, and behaviors experienced when balance is missing. that is, even a brief period of unbalance can create seemingly unbearable, intense pressures. burnout and balancing difficulties have been reported as more prevalent among women (mickey-boggs, 2004), and this finding appears to have some relevance within academic psychology as well. for example, although survey findings about academic jobs in school psychology have suggested that many women faculty members perceive academic climates to be generally positive, gender disparities also were perceived (akin-little, bray, eckert, & kehle, 2004). in that study, women reported experiencing stress in balancing work and personal obligations. more specifically, women cited inadequate parental leave and inadequate and unaffordable child care as being major concerns. as such, it appears prudent – particularly for women – to attend early in your career to fostering strategies for creating and maintaining balance between work and home life. although the tips we present below are not necessarily new, each does serve as a useful reminder about the above. as noted by hopson (n. d.), you cannot expect life balance to come solely from your job. life balance includes additional factors, such as a sense of emotional support from friends, hobbies, and relationships. maintain a positive, flexible attitude throughout your life, it is highly unlikely that you will be rewarded simultaneously on all fronts. that is, it is a rare day when your child tells you that you are the best parent in the whole wide world, your students compliment your lecture as the best ever heard, and you get an acceptance letter to a top-tier journal after a first round of reviews of your manuscript. “balance” at all times is probably an illusion – in reality, you are more likely to find concurrent success to be a rarity. acknowledging this will help you maintain a positive, flexible attitude as you are faced with different challenges. for example, when you get that rejection letter, maintaining a positive and flexible attitude can make it easier to mentally note, “revisions will clearly need to be done, but right now i am heading home to work out and walk my dog.” accepting that “things happen” can thwart negative thoughts and feelings that can easily throw off your balance and allow you to handle situations that arise with a more positive, flexible perspective. plan ahead as noted in the previous sections, advance planning can be very helpful in facilitating a successful academic career. planning ahead not only creates a vision for your career path, but also can help maintain balance between work and home life. for example, if you have decided your research goals for the next three years, it becomes easier to say no to projects that come up in the interim. that is, if a project is not closely related to your goals and does not provide “gain” in another realm, then you should probably not agree to take on the project. planning ahead can also be of assistance in the short term as well. for example, we routinely list our common projects, note the current stage of each, and set timelines for completion. we are then able to prioritize and focus on those we need to complete within the month, semester, year, etc. routine re-evaluation of our “plan” facilitates better communication and efficiency with regard to our work – which, of course, makes us happier (i.e., more balanced) when we get home each night. stay organized related to planning ahead, getting and staying organized is another strategy for facilitating work and home balance. currently, one of the biggest organizational challenges can stem from technology. thus, investing time upfront to create efficient systems for organization and storage of all technology needs (e.g., computer files, email, calendars) can prevent disorganization down the road. specific advice will be at least partially dependent on the technology available in your workplace (e.g., server storage); thus, building connections with your instructional technology (it) staff can be important. also, thinking about how you will store your “paper” also becomes relevant to staying organized. one strategy that some of us have used for staying organized with regard to teaching is to set aside about a week per class prior to the beginning of each semester to sort through materials, prepare the lecture, group everything needed for each class together, and then file away or toss navigating a successful academic career 55 the things that won’t be used. this advance organizational strategy helps prevent running around 20 minutes before class trying to figure out what to do and where the needed materials might be. stay connected academic jobs can be lonely. hopefully you will find a position in which there is a wonderful, collegial atmosphere. even in that climate, however, you can expect that most of the work will be done by yourself. you will be developing an independent line of teaching and research, of which the responsibility for accomplishing the associated tasks (think lots of writing) will fall on you. it is easy to become caught up in completing the never-ending tasks, so it becomes important to take the time to connect with colleagues, both within and outside your university, to create a network of people who can understand the situations you are faced with and provide a needed “reality” check. one good place to find those people is within your graduate school cohort. although you may not necessarily have similar research interests or live in a similar geographic region, fostering and maintaining a network of supports that begins in graduate school is a good way to stay connected, and thus, keep balance. in fact, as our “network” has grown over the past few years, we eagerly await the time we can get together to socialize at annual conferences! conclusion academia can provide a stressful but highly rewarding career. we hope the tips and recommendations provided above will be helpful to those graduate students exploring and/or considering an academic career in psychology. graduate students interested in additional information are encouraged to review other sources, particularly bain (2004); boice (2000); clark, et al. (2006); darley, zanna, and roediger (2004); fernald (1995); iacono (1981); lang (2005); nickerson and gagnon (2003); rheingold (1994); and sternberg (2004). these texts and articles discuss a wide variety of issues in academia and are highly recommended. references akin-little, a., bray, m. a., eckert, t. l., & kehle, t. j. (2004). the perceptions of academic women in school psychology: a national survey. school psychology quarterly, 19, 327-341. bain, k. (2004). what the best college teachers do. cambridge, ma: harvard university press. boice, r. (2000). advice for new faculty members. needham heights, ma: allyn & bacon. clark, e., elias, m., harrison, p., kamphaus, r., noell, g., jimerson, s., & vanderheyden, a. (2006, winter). at least five important activities to complete early in one’s career: advice shared at the school psychology research collaboration conference. the school psychologist, 60, 11-16. darley, j. m., zanna, m. p., & roediger, h. l. (eds.). (2004). the compleat academic: a career guide (2nd edition). washington, dc: american psychological association. fernald, p. s. (1995). preparing psychology graduate students for the professoriate. american psychologist, 50, 421-427. hopson, j. l. (n.d.). work/life balance. retrieved july 25, 2005, from http://wlb.monster.com/articles/reverse/ iacono, w. g. (1981). the academic job search: the experiences of a new ph.d. on the job market. canadian psychology, 22, 217-227. lang, j. m. (2005). life on the tenure track: lessons from the first year. baltimore, md: the johns hopkins university press. meyers, s. a., reid, p. t., & quina, k. (1998). ready or not, here we come: preparing psychology graduate students for academic careers. teaching of psychology, 25, 124-126. mickey-boggs, s. (2004). osu work/life: commitment, performance, & community. retrieved july 25, 2005, from http://hr.osu.edu/worklife/wlactionplan.pdf nickerson, a. b., & gagnon, s. g. (2003, spring). preparing, applying, and navigating through life as a junior professor. the school psychologist, 53, 55-59. rheingold, h. l. (1994). the psychologist’s guide to an academic career. washington, dc: american psychological association. sheehan, e. p., mcdevitt, t. m., & ross, h. c. (1998). looking for a job as a psychology professor? factors affecting applicant success. teaching of psychology, 25, 811. sternberg, r. j. (2004). psychology 101 ½: the unspoken rules for success in academia. washington, dc: american psychological association. do not underestimate the importance of the assume there will be technological problems enquire about the relative “weight” given to make sure you have the opportunity to talk, in seek out mentorship inside and outside the schedule an annual meeting with your dean or department chair to review your progress graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 proposed standard for multiple relationships in the apa ethical principles of psychologists and the code of conduct veronica lee lestina capella university cynthia m. walljasper family medicine of mt. pleasant, pc this article provides a proposal for new language and a revised standard for multiple relationships to be considered for the apa ethics code. the current multiple relationships language in the apa (2002) ethical principles of psychologists and the code of conduct was updated in part due to rural american psychologists being involved in a variety of relationships with clients out of necessity. this article explores the differences between the previous apa (1992) ethics code and the current apa (2002) ethics code, addressing the strengths and weaknesses of the current code and the need for an updated version. the proposed language builds upon the 2002 ethics code’s strengths regarding the definition of multiple relationships and the idea that not all multiple relationships are ethical violations. it then provides a minimum standard for a strategy of assessing multiple relationships and informing the client of the dynamics of a multiple relationship. as providers practicing in a rural generalist setting, the authors propose a review of the current standard regarding multiple relationships for psychologists as it is written in apa (2002) ethical principles of psychologists and the code of conduct, standard 3.05. in reviewing this standard, one can determine areas for growth in the language and specificity to assist all psychologists in clarifying multiple relationships, including the rural american psychologist. this article provides a review of the apa (2002) and apa (1992) standards on multiple relationships as well as a proposal for updating this standard. these proposed updated standards aims to help betterfulfill the needs of the profession today in terms of safeguarding and enforcing against potentially harmful multiple relationships. current and past multiple relationship standards the current apa (2002) ethical principles of psychologists and code of conduct for multiple relationships is as follows: 3.05 multiple relationships. (a) a multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. correspondence concerning this article should be addressed to veronica lestina, family medicine of mt. pleasant, pc, 501 south white street, suite 1, mt. pleasant, iowa 52641; e-mail: veronickins@mchsi.com. a psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) if a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the ethics code. (c) when psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (see also standards 3.04, avoiding harm, and 3.07, thirdparty requests for services.) (apa, 2002, p.6). the previous apa (1992) ethical principles of psychologists and code of conduct standard as it pertains to multiple relationships was as follows: 1.17 multiple relationships. (a) in many communities and situations, it may not be feasible or reasonable for psychologists to avoid social or other nonprofessional contacts with persons such as patients, clients, students, supervisees, or research participants. psychologists must always be sensitive to the potential harmful effects of other contacts on their work and on those persons with whom they deal. a psychologist refrains from entering into or promising another personal, scien25 lestina and walljasper 26 tific, professional, financial, or other relationship with such persons if it appears likely that such a relationship reasonably might impair the psychologist's objectivity or otherwise interfere with the psychologist's effectively performing his or her functions as a psychologist, or might harm or exploit the other party. (b) likewise, whenever feasible, a psychologist refrains from taking on professional or scientific obligations when pre-existing relationships would create a risk of such harm. (c) if a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist attempts to resolve it with due regard for the best interests of the affected person and maximal compliance with the ethics code. (apa, 1992, p. 1601) changes in the multiple relationships standard from 1992 to 2002 the differences between the multiple relationships standards in the 1992 and 2002 ethical codes are outlined in table 1. the 2002 code change allowed for a more explicit definition of a multiple relationship for psychologists, and it stated that not all multiple relationships are unethical (smith, 2003b). multiple relationships are viewed as something that the psychologist should refrain from, if possible, especially if it is reasonably “expected to impair the psychologists’ professional performance or could exploit or harm the other individual” (smith, 2003b, p. 65). the changes in the apa (2002) ethics code were implemented due to a variety of problems in the interpretation and enforcement of the previous 1992 code. in a national survey, multiple relationships were found to be the second most frequent type of unethical conduct in which psychologists had difficulty maintaining clear, reasonable, and therapeutic boundaries with their clients (pope & vetter, 1992). this survey underscored the need to more clearly define multiple relationships and delineate when they are therapeutically relevant/acceptable and when they are harmful. based on the survey’s findings, pope and vetter (1992) suggested that the standard must be specific enough for all psychologists yet take into account the special circumstances of those professionals who practice in small towns, rural communities, and other remote locales. these authors requested that a revised code provide direction in terms of multiple relationships that were premeditated and purposeful versus accidental or incidental encounters. these suggestions were taken into consideration for the changes in the current version of the apa (2002) ethics code. the earlier apa (1992) ethics code was directed toward risk prevention. this is evidenced by the preamble stating the “psychologists’ primary goal is to provide for the welfare and protection of the individuals and groups with whom they work” (sonne, 1994, p. 339). bersoff (2003) indicates that the updated apa (2002) ethics code took an even greater risk reduction stance by defining a multiple relationship and indicating that not all dual relationships are potentially unethical. this was intended to further protect the welfare of the client and the professional, with the gained clarity of the language in the new code. table 1 comparison of the multiple relationships standards in 2002 and 1992 apa ethics codes 2002 apa ethics code 1992 apa ethics code • explicit definition of multiple relationships • no explicit definition of multiple relationships • not all multiple relationships are unethical • not all multiple relationships can be avoided • enhanced risk prevention stance • risk prevention stance • if a potentially harmful multiple relationship arises, psychologist will resolve in compliance with ethics code • same as 2002 ethics code • refrain from engaging in multiple relationships if expected to impair psychologists’ objectivity or performance, or harm the other individual in the relationship • same as 2002 ethics code • if required by laws, policy, or circumstances to serve in more than one role, then clarify role expectations and confidentiality limits at outset and over time as needed • not included in 1992 ethics code problems within the earlier apa (1992) ethics code called for more definitive language regarding multiple relationships, given that many psychologists were found “to be dealing with a variety of nonromantic, nonsexual relationships with former clients” (anderson & kitchener, 1996, p. 65). a problem with the 1992 edition of the code is that a clear definition of a multiple relationship was not provided, nor did the code comment on how one should determine that definition or decide when a multiple relationship might be unethical. with a large number of psychologists in blurry territory and no clear definition of unethical multiple relationships, the profession was at a high level of potential risk as a whole. therefore, the updated apa (2002) ethics code aimed to provide more insight and clarification into this matter. continued concerns that might suggest further change to the 2002 ethics code a number of potential complications necessitate reexamination of the current apa (2002) ethics code. namely, the application of the 2002 standard of multiple relationships in the profession may be inconsistently interpreted across licensing boards. with the current language, multiple relationships and ethics 27 each state may provide its own interpretation on a case-bycase basis. this type of interpretation and utilization allows for a significant amount of subjectivity and possible discrimination, which could be viewed as inconsistent, capricious, and arbitrary. the civil courts could also use the current multiple relationships standard in an inconsistent manner for malpractice cases. some boards continue to operate from the 1992 standard for multiple relationships, stating that the 2002 change is at odds with the 1992 standard (bersoff, 2003; schank, slater, banerjee-stevens, & skovholt, 2003). these applications and interpretations present risk management concerns for the profession of psychology. not only could this lead to poor and inconsistent handling of clinical matters, but the state licensing boards could set themselves up for lawsuits. there continues to be variable interpretation of the 2002 standard. the authors propose that the language and specificity be revised to encourage more consistent interpretation across all state boards; continue to provide for the best client welfare possible; ensure clear, sound, and just standards for psychologists; and reflect the ethical theory of the profession of psychology. pros and cons of the 2002 standard for multiple relationships pros the apa (2002) ethics code has come farther in clarifying multiple relationships than any other code of ethical conduct for psychology. it also has developed the professional standard that not all multiple relationships are unethical. this is a positive development given that there have been disagreements about whether certain types of multiple relationships are ethical. the clarification helps protect both the psychologist and the client (fisher, 2003; apa, 2002; apa, 1992). the improved definition of a multiple relationship provided a more realistic understanding of what may or may not be an ethical violation. in the 1992 ethics code, there was no explicit definition of a multiple relationship; therefore, the licensure bodies had the freedom to consider each case uniquely and thus did not provide consistent determinations on ethical violations. this, to some extent, left the psychologists involved in alleged unethical multiple relationships at the mercy of the subjective interpretations of the boards. the current apa (2002) ethics code is the first to indirectly support rural and small town psychologists by stating that not all multiple relationships are unethical. in a rural area (not limited to a small town), a psychologist may be called to be a “teacher, administrator, researcher, therapist, mediator, entrepreneur, crisis counselor, and referral source all in the course of a day, sometimes changing roles by the hour” (o’conner, 2001). due to this potential changing of hats, the psychologist, under the current code, has room to navigate and explore multiple relationships as long as they do not negatively impact client welfare. this more accurately reflects and supports the reality of daily life in rural america. schank and skovholt (1997) interviewed 16 psychologists in rural areas and small communities regarding ethical dilemmas the psychologists have dealt with in their practices. the authors found that all 16 psychologists identified significant concerns involving professional boundaries. the concerns included major themes of “overlapping business relationships, the effects of overlapping relationships on members of the psychologist’s own family, and the dilemmas of working with more than 1 family member as clients or with others who have friendships with individual clients” (schank & skovholt, 1997, p. 44). although all 16 psychologists understood the 1992 ethics code, each one struggled with how to best apply the multiple relationship standard since it did not allow for the possibility of an ethical multiple relationship. these findings support that rural psychologists in america have a significant interest in examining multiple relationship concerns. rural psychologists are asked to compartmentalize and deal with blurred boundaries of multiple relationships in day-to-day life (schank & skovholt, 1997). rural psychologists must be aware at all times whether or not to accept social invitations for themselves and their family members, as this may introduce even more difficulties with handling multiple relationships in rural practice. attendance at church, running errands, and shopping at the local grocery store become thoughtful encounters rather than the simple daily task that most professionals have the luxury of performing automatically. the effects of multiple relationship concerns for rural psychologists and clients are beginning to be explored in more depth; however, the effects this may or may not have on the rural psychologists’ families has yet to be explored (schank & skovholt, 1997). community acceptance and trust is of great value for the rural psychologist, so she or he must be aware that each decision she or he makes may impact oneself, one’s family, potential clients, and/or community (schank & skovholt, 1997). to elaborate, the following are true-to-life examples of the overlap that occurs daily for the rural psychologist. • imagine that during a session your client expresses frustration about the boy her daughter has begun dating. you realize that the new boyfriend is your client. • every time you go out for dinner with your family, you are likely to see at least one or two of your clients, either as other diners or as restaurant employees. you find yourself wondering if there are any guidelines about how much to tip the waiter if he is your therapy client. • you need someone to fix your garage door, and there is really only one business in town that does this kind of work. the business owner’s spouse happens to be a previous therapy client. • after developing a relationship with a client, he tells you he is suing his ex-girlfriend for custody of their child. lestina and walljasper 28 you learn the ex-girlfriend is a previous client of yours. your records could be subpoenaed by both parents. • your spouse wants to buy a vehicle and has worked out an initial deal with a salesperson who you previously evaluated for adhd. • your child wants to play at a friend’s house, and you have done therapy with that friend’s brother. which of these multiple relationships could be harmful? how does the psychologist know? the current code allows for the recognition of this reality for rural and small town psychologists. it does not state that all multiple relationships for rural psychologists are acceptable. it simply implies that all potential and ongoing multiple relationships need to be examined. if there is no foreseen harm to the client, the multiple relationship is likely not to be considered unethical. this does not mean that the decision to have a multiple relationship should be taken lightly nor should it be assumed to be a simple decision process, as the above examples indicate. in sum, the current code provides more leeway for the psychologist to determine if and when a multiple relationship is potentially unethical. assuming the psychologist goes through the determination process with integrity, the apa (2002) ethics code is helpful in giving the psychologist this room to operate effectively. cons as with any code, there are usually areas that can be further developed within the framework of the current standard. the profession is not stagnant. there continue to be changes, interpretations, ideals, and other variables that allow for the profession of psychology to evolve. these changes have led to revisions of the apa ethics code a number of times. in examining the current apa (2002) ethics code as it pertains to multiple relationships, one can find a number of potential pitfalls or areas of confusion. the added statement that not all multiple relationships are unethical is a positive development, yet it has its own set of drawbacks. schank and skovholt (1997) remind the reader that, “psychologists must maintain a balance of flexibility in overlapping relationships” (p. 48), yet the psychologist must also have clear expectations and boundaries in each relationship. this is a tricky area for the psychologist to navigate. the updated apa (2002) ethics code does not provide a clear step-by-step process of how the professional should determine whether or not the potential multiple relationship might be unethical. therefore, a psychologist can easily and unintentionally be led into poorly defined or overlapping relationships. it does not take much for an ethical multiple relationship to fall into an unethical one. holub and lee (1990) note that “blurring of boundaries may become problematic for the therapist who becomes a compassionate friend to a client or acts as professional for a friend” (p. 107). in most cases of multiple relationships that become unethical, “the relationships began insidiously” (hamilton & spruill, p. 318). another potential pitfall for the current ethics code is that regardless of the clear definition of a multiple relationship, there may still be difficulty in carrying out the standard. for instance, smith, mcguire, abbott, and blau (1991) note that there is “often a discrepancy between what clinicians know to be the ethically preferred course of action in dealing with professional-ethical dilemmas, and their stated willingness to implement this ideal” (p. 238). the idea that the professional can be aware of the problematic and potentially unethical situation and not be able to steer clear of this dangerous situation is frightening, especially considering that the psychologist has the responsibility to determine whether or not the multiple relationship could negatively impact the client’s welfare. the professional is responsible for judging conduct in relationships outside of therapy and how such conduct could potentially result in harm to the client (schank et al., 2003). if the psychologist who is responsible for examining the multiple relationship for potential harm to the client has impaired objectivity, then there is definitely a problem according to the current apa (2002) ethics code (schank et al., 2003). due to the complex and often ambiguous nature of multiple relationships, schank and colleagues (2003) caution the professional to stay away from developing multiple relationships at all. ultimately, the psychologist is responsible for making the judgment regarding the multiple relationship and puts him/herself on the line if something goes awry. since the apa (2002) ethics code does not describe in detail how to examine potential multiple relationships for harm, the psychologist has no basic template from which to operate a checks and balances system. the apa (2002) ethics code is assuming that the psychologist will have the integrity and capacity to make this determination professionally. given that we have the code for a reason (i.e., there have been problems with some psychologists’ integrity), outlining the process of evaluating multiple relationships more specifically may help to keep the professional accountable as well as provide some protection for the psychologist who does go through a specific evaluation process. there are three main areas that the psychologist must seriously consider when examining a potential multiple relationship, according to smith (2003a): issues of power, length of treatment, and termination. first, the psychologist needs to gain a clear awareness of how much power he or she has in the relationship (smith, 2003a), as this will help determine the likelihood for harm. in making an informed decision, the psychologist must also be aware of the vulnerability the client may experience (schank et al., 2003). “this power continues even after the therapy relationship ends” (schank et al., 2003, p. 183). typically, a client allows the psychologist to be in an elevated hierarchical position. the client looks to the therapist for advice, approval, and even worth, at times. furthermore, the client discloses very difficult personal matemultiple relationships and ethics 29 rial, widening the power differential between client and psychologist. the psychologist who does not handle oneself professionally and properly can harm the client psychologically. the impaired judgment of a professional may allow for a lingering problem that could potentially have lasting effects upon the client or other individual involved in the multiple relationship; this highlights the importance of being as specific as possible in the language that covers multiple relationships. it is not easy to accurately predict the potential risks and benefits of a multiple relationship even if the professional has unimpaired judgment (schank, slater, benerjee-stevens, & skovholt, 2003). second, what will be the duration of the contact or relationship? the longer the duration; the more concern. as mentioned by smith (2003a), it is important to examine the length of a professional relationship before making a decision on a dual role. this could seemingly apply to both short-term and long-term relationships, in either a positive or negative manner. a psychologist could have worked with an individual for a long time, developed substantial trust and rapport, and have significant risk of harm if a multiple relationship developed. on the other hand, some individuals may only work with a psychologist for a brief time and not be appropriate for a multiple relationship. if possible, multiple relationships should be avoided, as a general rule. if it is not possible, then the professional must implement a strategy to determine whether or not to engage in the multiple relationship. simply having a time frame of how long a client/therapist relationship has been established is not sufficient because each case is unique. all situations must be weighed as carefully and objectively as possible, with peer consultation periodically. additionally, the professional is urged to consider other consultations, such as with a supervisor, attorney, state psychological association, ethics panel, or state ethics board. third, in the case of a therapeutic relationship, has it been terminated? if so, how long ago and what was the outcome (i.e., positive or negative)? termination is the last area that smith (2003a) emphasizes as a key factor in evaluating multiple relationships. a client treated for mild depression 25 years ago, for example, is different from a client with borderline personality disorder who finished treatment (for now) three weeks ago. some clients who have terminated three or four years prior would not be appropriate for a multiple relationship, whereas others would be appropriate. the apa (2002) ethics code indicates that a sexual relationship (i.e., an intimate and physical relationship) should not occur prior to two years following termination. this is simply a minimum. some professionals believe that a sexual relationship should not occur with a previous, current, or future client—this is the easiest and perhaps best answer to the question of whether a sexual relationship between psychologist and client is ever ethical. once again, the power and hierarchical differences could be severely damaging to the client even if a few years have passed. the disclosure was one-sided, and it is difficult to transform that into a two-way relationship. it does not appear that a sexual relationship could be an equal two-way relationship between a psychologist and a previous, current, or future client. smith (2003a) reported that these three areas must be examined carefully to make an informed decision about the foreseeable risk of a multiple relationship. the more informed the psychologist is, the more likely he or she will be able to make an objective judgment about the multiple relationship. therefore, although there are many positive aspects of the current apa (2002) ethics code in regard to multiple relationships, continued concerns need to be addressed to better protect psychologists and the people with whom they work. new language proposed for the multiple relationships standard most of the apa (2002) ethics code standard 3.05 that covers multiple relationships is important to keep in the new proposed standard offered here. several clarifications and additions are recommended. the proposed revision is as follows: multiple relationships proposed standard. (a) a multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. a psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) if a psychologist finds that there is a possibility of a multiple relationship prior to the multiple relationship occurring, then the psychologist is obligated to go through a number of steps in order to assess objectively if the relationship could potentially impair his or her functions as a psychologist or otherwise risk harm or exploitation to the client or person with whom the professional relationship exists. the assessment process should begin by a selfassessment of the nature of the multiple relationship. the psychologist should outline the type of relationship and the actual or projected expectations, length, and roles (including power differences) for both the professional relationship and the other relationship. at this point, if the psychologist believes the multiple relationship is not ethical, lestina and walljasper 30 then s/he does not allow the multiple relationship to develop. however, if the psychologist believes that the multiple relationship is still potentially ethical, then the psychologist should consult with another psychological or legal professional with documentation of this consultation, at a minimum. the other professional should assist in an objective assessment and provide the psychologist with a documented opinion. the original psychologist ultimately makes the decision and would be held responsible for continuing or not continuing in the development of the multiple relationship. (c) if a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the ethics code. (d) an assessment process should also be done if the psychologist has found him/herself in the position of (c) as listed directly above. this should begin with the same selfassessment as listed in (b) above. the psychologist should outline the professional relationship, expectations, length, and roles and outline the type of multiple relationship, expectations, length to date, projected length, and current and future roles. the psychologist makes an initial assessment. if the psychologist deems that the multiple relationship should cease, then the psychologist should move forward with this making certain that the professional relationship is intact and did not suffer. if the professional relationship suffered, then the psychologist should provide appropriate referrals for the individual. if the psychologist deems that the current multiple relationship is not causing undue harm or exploitation to the individual with whom s/he is in the professional relationship, then the psychologist should receive written documented consultation for additional objective assessment by another psychologist or legal professional. the psychologist makes his/her decision and is responsible for his/her actions. (e) when psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (f) if a multiple relationship is occurring within a professional relationship, then the psychologist is obligated to discuss the dynamic of the multiple relationship with the individual who is also in the professional relationship with the psychologist. the psychologist must inform the individual that s/he has the right to inform the psychologist if an unforeseen harmful or exploitative event occurs. the psychologist must also inform the individual that s/he is agreeing to the multiple relationship under the assumption that there are no foreseen exploitative or harmful events that will come of the dual venture. the psychologist must also include in an informed consent the expectations and roles of himself/herself as well as the expectations and roles of the individual. this informed consent discussion of multiple roles should be documented within the client’s record. if, however, the situation or characteristics of the client lead the psychologist to believe that open discussions and informed consent of the multiple relationship would be harmful to the client’s welfare, then the psychologist should refrain from this discussion with the client and document the rationale. the above language in the proposed revised standard for multiple relationships in the apa ethics code better addresses the evolvement of the profession and current concerns in this area (see table 2). part a maintained the same definition of a multiple relationship. this definition is specific enough to include all possible multiple relationships, including those that are ethical violations and those that are not. making this definition any more specific or limiting it to only relationships that are ethical violations would not be taking into account the often necessary and viable multiple relationships that present in some situations, such as rural practice. part b of the proposed standard would be new to the ethics code. it specifies the process of assessment for the psychologist if a potential multiple relationship arises. the steps for risk-management provide a clear understanding of a minimum standard. this proposed section also makes it clear that consultation with another professional is needed in addition to one’s own assessment. an objective opinion should be sought, documented, and utilized in the decision of whether to engage in or continue a multiple relationship. this section will hopefully lead professionals to seek more input and hence reduce the risk of an ethical violation. this assessment process will provide a clear indication of a potential ethical violation if the consultant’s documented objective opinion was not in congruence with the decision the professional made about the relationship. if the consultant and psychologist cannot agree, a third opinion could be sought and documented. at that point, an ethics panel or licensing board may be the most appropriate consultation. one potential concern is what to do if the consulting psychologist or other professional is impaired, biased, or under-trained in the area of multiple relationships. for instance, an urban ethics board reviewer without experience in rural practice may not be the best consultant in some situations. in this case, the urban psychologist may have very different expectations regarding roles given his/her different cultural perspective. thus, the consultant needs to be chosen carefully. overall, the assessment procedure should provide a clearer evaluation of potential impairment or risk of harm. part b in the apa (2002) ethics code was not altered and as presented in part c of the proposed standard. part d is similar to the assessment process in part b of the proposed standard; however, part d is applied to situations in which the psychologist finds him/herself in a multi ple relationship without prior time to examine the potential harm of this relationship. because the multiple relationship multiple relationships and ethics 31 table 2 comparison of the proposed multiple relationships standard and current 2002 apa multiple relationships standard proposed multiple relationships standard 2002 apa ethics code standard • explicit definition of multiple relationships • same as proposed • not all multiple relationships are unethical • same as proposed • enhanced risk prevention stance • risk prevention • if a potentially harmful multiple relationship arises, psychologist will resolve in compliance with ethics code • same as proposed • refrain from engaging in multiple relationships if expected to impair psychologists’ objectivity or performance or harm the other individual in the relationship • same as proposed • if required by laws, policy, or circumstances to serve in more than one role, then clarify role expectations and confidentiality limits at outset and over time as needed • same as proposed • explicit assessment process to determine whether multiple relationship is potentially harmful • not addressed • explicit resolution process for ending multiple relationship • not addressed • explicit description of need for consultation • not addressed • explicit description of need for discussion and informed consent of multiple relationship with other individual • not addressed has occurred or is ongoing, the psychologist needs to do an assessment to determine if there are any unforeseen factors that could be harmful to the client as well as determine if the multiple relationship should continue or terminate. part e consists of the same language that was utilized in the apa (2002) ethics code in part c. finally, part f is a new addition that addresses the need to inform and discuss the ethical issues of the multiple relationship with the individual with whom the psychologist has the professional relationship. this informed consent and discussion will better safeguard the welfare of the client or other individual in the multiple relationship. the client can be made aware of the expectations and roles for himself/herself as well as the professional in each of the relationships. this allows for the client to be a part of the discussion in terms of potential consequences of the multiple relationship. it also provides a clear understanding from the beginning so that neither party is making assumptions about what the dual relationship means at present or in the future. risk management and protection for the client as well as the professional is an important piece of this new addition. having this informed consent discussion documented in the client’s file allows for more consistent interpretation and evaluation of potential ethical violations due to multiple relationships. this proposed standard allows for exceptions in which it may be harmful to the client to discuss and obtain informed consent regarding the multiple relationship. examples of this type of situation include a client who is psychotic, who is not competent to provide informed consent, or who is so low functioning that he or she may not understand the relevant issues. however, it is the authors’ belief that at least a simplistic acknowledgment of the multiple role is possible for most clients. the changes proposed to the apa ethics code offer a number of positive benefits. the first is that the process of assessment for potential and current multiple relationships is better defined and established. a standard allows for more consistent interpretation and evaluation of potential ethical violations with multiple relationships. better protection is offered to the client and the professional with a standardized minimum of assessing a potential problem or risk. the professional is required to document as well as consult with others in order to comply with ethical guidelines and standards. this allows for a better system of documentation and objectivity. the second area that is new in this revised language is the directive to engage the client in an informed consent discussion regarding the multiple relationship. this final section allows for the continued enhancement of client welfare as well as providing a better map for the psychologist for a clear, clinically sound, and minimum standard. conclusion the purpose of this article was to address the need to update the current standard for psychologists regarding potential multiple relationships. although the current apa (2002) ethics code provides a clearer definition and more leeway for the psychologist to make an objective decision regarding the ethical possibilities of a multiple relationship, there continues to be the potential for complications, particularly for rural and small-community psychologists. the proposed standard upholds the strengths of the apa (2002) ethics code in terms of the definition of a multiple relationship and the possibility that not all multiple relationships are ethical violations. building on those strengths, the proposed revisions to this standard provide a minimum guideline for evaluating potential and current multiple relationships to encourage more consistent interpretations. the new language also provides guidance to the psychologist that the client needs to be fully informed of the dynamics of a multiple relationship. the new language proposed is designed to meet the needs of the current profession as it has evolved to require a more specific multiple relationship standard. it is hoped that a more specific strategy for assessing multiple relationships lestina and walljasper 32 and the call to inform and discuss this issue with clients will provide a better platform to decrease the incidents of ethical violations with multiple relationships for psychologists. references american psychological association. 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(1994). multiple relationships: does the new ethics code answer the right questions? professional psychology: research and practice, 25, 336-343. http://www.apa.org/ethics 37 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 a case study illustration of grief therapy using culturally-sensitive, integrative techniques eavan s. miles-mason fordham university this article is a case study detailing a therapeutic intervention conducted with a 12-year-old african-american girl who experienced behavioral problems following the death of her mother from drug abuse and aids. the intervention integrated several modalities and techniques to facilitate behavior change and the healthy grieving process; these included cognitive-behavioral techniques, psychodynamically-oriented art, and culturally-sensitive grief-focused therapies. this article seeks to elucidate the ways in which developing integrative techniques for african-american children and adolescents is a significant and worthy goal. this article is a case study detailing a therapeutic intervention conducted with a 12-year-old african-american girl who experienced behavioral problems following the death of her mother from drug abuse and aids. the intervention integrated several modalities and techniques to facilitate behavior change and the healthy grieving process, including cognitive-behavioral techniques, psychodynamically-oriented art, and culturally-sensitive grief-focused therapies. cognitive-behavioral therapy was implemented to reduce behavioral problems such as lying and physical aggression, while art therapy, in the form of poetry, was used as a form of psychodynamically-oriented grief therapy. the client wrote powerful, moving poems about her life experiences, including her mother’s death, her grief, and feelings of isolation. this part of the intervention had a strengths-based orientation and recognized the importance and power of spirituality within the context of the client’s racial-ethnic cultural heritage. the client’s interest in creative and spiritual expression was used to fuel the intervention. the client demonstrated marked improvement at termination in academic achievement, prosocial behavior, and emotional well-being. the effectiveness of interventions with african americans that incorporate spiritual and religious elements into the therapeutic process has been demonstrated in recent research (davis-russell, 2002). this case study offers an illustration of the integration of spirituality and spiritual expression into a successful, culturallysensitive intervention. developing new therapeutic techniques that help african-american clients explore emotional problems and distress through their own spiritual and religious traditions should be an important pursuit for multicultural counseling practitioners. developing these types correspondence concerning this article should be addressed to eavan s. miles-mason; e-mail: milesmason@fordham.edu. of therapeutic interventions for african-american children and adolescents is an equally significant and worthy goal. background information amy,1 a 12-year-old african-american girl was r eferred to a private mental healthcare agency last year because of behavioral problems and academic underachievement. amy is originally from oklahoma and grew up there until she moved to new jersey in june 2003, soon after the death of her maternal grandmother. amy’s mother, a drugabuser (and most likely a prostitute, based on amy’s accounts of her mother’s behavior), died of aids 2 years ago in oklahoma. amy has never met her father, who is also a drug user, and she has no idea of his whereabouts. amy was born addicted to crack/cocaine, but her cognitive and physical development have followed a normal trajectory and appear to be unaffected by her mother’s drug use. an official evaluation of amy’s cognitive functioning was not available; however, her teachers have reported that her academic grades do not reflect her full intellectual abilities. as will be seen in the description of the intervention, amy is very articulate and demonstrates a great capacity for abstract thought. amy’s previous therapist reported that her mother had also taken amy with her to random hotels where she would have sex with unknown men in front of her daughter (who was 9 or 10 years old at the time.) amy did not explicitly say that her mother was a prostitute, but given the information presented, her previous therapist suspects that she was. not only was amy forced to witness her mother’s highly traumatizing, sexually deviant behavior, she was also made an unwitting accomplice to it; she was taught to lie to other family members and to keep her mother’s secret. amy’s previous therapist, who worked with amy for 8 months, 1 all names and identifying information have been changed to protect the privacy of the client. miles-mason 38 suspects that amy may have been sexually abused due to some of the behavior she has displayed at school and the highly sexualized content of poems she was writing in therapy with him. amy currently lives in new jersey with her aunt who is a police officer. amy and her aunt maintain close familial relationships with members of their extended family, who live in both new jersey and oklahoma. amy’s current oppositional behavior is primarily lying to her family and teachers in addition to exhibiting aggressive behavior towards some of her peers. teachers at amy’s school have reported that she has displayed “inappropriate,” sexually-suggestive behavior at school such as dancing provocatively and “grabbing at” boys in her class. (there have been no gross or serious instances of sexual assault or harassment.) amy’s aunt, annette who is employed as a police officer, is her primary caretaker. her aunt is a strict disciplinarian and often comes into conflict with amy over her inappropriate behavior at school and continual lying. in spite of the tempestuous nature of their relationship, her aunt is solicitous of amy’s welfare and, in amy’s own words, “loves her,” even though she may not be overly affectionate or demonstratively nurturing. when amy’s previous therapist initially evaluated her, she was diagnosed with adjustment disorder with anxiety. amy’s grandmother had been the powerful matriarch of their extended family and provided stability and continual care to amy, as her mother was unreliable and often unable to function successfully. until her death approximately one year after amy’s mother’s death, amy’s grandmother had been amy’s primary source of stability and love. not only was she grieving for her mother’s and grandmother’s deaths, but she was also forced to leave her home environment (where she had lived all her life) and relocate to a foreign one—new jersey. shortly after the move, amy began exhibiting oppositional behavior, primarily aggression towards other students and lying. amy currently lives in a mostly white middle-class community and it has been difficult for her to “fit in” with other students who have an entirely different cultural and socioeconomic background. in one of our initial sessions amy expressed her feelings of inferiority, saying that she was not “up to” the other students (e.g., she did not have the same amount of money, clothes, etc.) and that she was often taunted at school. amy did not admit this to her aunt because she was embarrassed by it and said she was trying to be “tough,” not letting anyone (including her family) see that she was hurt by the other students’ insults. i began working with amy as a student intern in january 2004. after having two sessions with amy, it was evident that she had not adjusted to her new environment and felt like an outsider at school. she expressed her desire to live in her old town in oklahoma in the “projects” where she felt like she fit. a few days before our second session, amy was sent home from school because she was wearing inappropriate clothing. amy had been wearing normal winter clothing to school, but then changing into tightfitting summer clothing when she got to school. she had also stolen her aunt’s boots and bracelet, but would not admit that she had done so to her aunt. her aunt, exasperated and deeply upset by amy’s behavior, felt that amy had no remorse about her wrongdoings. while it was difficult for amy to admit that she had stolen items and disobeyed her aunt, in truth, she felt terrible about what she had done. amy broke down in our session, saying that she wished she had not done those things and feels terrible when she lies. from amy’s perspective, she was changing her clothes because she thought that they were “cooler” and would help her fit in. during this session, we came to a core issue underlying her emotional distress and behavior; amy was able to verbalize that she missed her mom and felt misunderstood by her cousin. possibly, she was affection-starved. she told me she longed to live with one of her mother’s friends in oklahoma and “be one of her children” because she was “softer” and less strict. behavioral observations amy is an attractive, yet somewhat awkward and heavy-set girl. she is much taller and both physically and sexually more developed than most of her same-age peers. amy often came to sessions looking a little unkempt, but clean and in good health. amy was very receptive to the therapeutic process. her willingness to share her feelings and experiences with the therapist as well as her advanced verbal abilities facilitated the therapeutic process. conceptualization because of all the tragic events amy has experienced, she has several layers of psychological trauma that must be worked through. in an effort to prevent destabilizing any emotional well-being she had been able to sustain, it was important to work with one issue at a time, beginning with her mother’s death. amy was grieving the loss of her mother. however, it appeared that she was not able to fully engage in the grieving process because of the great value her family places on strength and stoicism; her grandmother, a devoutly religious woman, told amy that one should not cry at someone’s death because that person is going to heaven to be with god. her grandmother told her not to cry at the funeral and amy said she was able choke back her tears even though she really wanted to cry. her aunt espouses that same stoicism and consequently amy has not been able to grieve openly or share her sadness with an adult figure. amy was also experiencing complicated grief because of the nature of her mother’s lifestyle and subsequent death. children whose parents or loved ones die from socially “taboo” causes such as murder, suicide, or aids often experience what is known as complicated grief, wherein the natural process of grieving is inhibited because “the child is unable to express what happened” (goldman, 2002, p. 8). because of the social stigma and shame associated with case study illustration of integrative grief therapy techniques 39 aids, children coping with the loss of a loved one from aids are often denied the ability to grieve by other family members and are told not to discuss the death. these suppressed feelings can become self-destructive and “get projected outwardly in the form of rage or inwardly in the form of the self-hatred” (goldman, 2002, p. 8). multiple deaths can also create complicated grief and the death of her grandmother and mother within 2 years must certainly compound her sense of loss. validating amy’s grief and allowing her a safe place to openly mourn her loss became a primary therapeutic goal. helping amy reduce her lying behavior was equally important, as it was jeopardizing her ability to function in the home and educational setting and damaging her relationship with her aunt. her therapeutic intervention had to address both of these key issues. the main therapeutic goals became facilitating the grief process through psychodynamically-oriented therapy as well as employing cognitive-behavioral techniques to change amy’s self-destructive behavioral patterns. counseling before therapy began, informed consent was obtained from amy and from her aunt and the limits of confidentiality were explained. a therapeutic alliance between amy and the therapist was easily established because of amy’s willingness to share her feelings and experiences beginning in the first session. as stated before, amy was, in essence, taught to lie by obeying her mother’s wishes to conceal her sexual indiscretions. amy most likely (consciously or subconsciously) modeled her mother’s maladaptive lying behavior. from conversations with amy and her aunt, i hypothesized that after her mother’s death, lying gradually developed into a coping mechanism for her, as it allowed her to suppress distressing emotions or cognitions about her mother, her family, and herself. a cognitive-behavioral intervention with the following underlying principles was designed to reduce her lying behavior: lying is not “innately nor always morally wrong…[and should not be] stamped out at all cost to the child” (bernard, 1984, p. 250). however, if lying becomes pervasive, it is self-defeating because it serves as a means of avoiding reality and adopting maladaptive means of maintaining self-esteem (bernard, 1984). in amy’s case, the lying had become a maladaptive behavior that not only alienated her family members from her, but also threatened her development of a healthy self-concept. in order to help amy maintain some level of emotional stability throughout the therapeutic process, eliminating the lying behavior had to be done gradually because it was functioning as a major defense mechanism against emotional distress. the ultimate goal of therapy was to help amy achieve insight into the causes of her feelings and behavior, working through all of her emotionally traumatic experiences, to answer the question: why does she lie? achieving this objective will require extensive, longer-term psychotherapy (which has been initiated), but amy’s behavior also needed to be addressed and controlled in the short-term so that she could function successfully in her present environment. albert ellis, the founder of rational-emotive behavior therapy (rebt), would call this the “practical solution” as opposed to the more profound, “elegant” solution (ellis, 1983). cognitive-behavioral therapy techniques were employed with the client; the antecedents, behavior, and consequences (abcs) associated with her lying were identified (bernard, 1984). amy explained that she lied “to get out of trouble.” telling her aunt that she had finished her homework when she had not and saying that the bracelet she stole from her aunt belonged to a friend at school were both used as examples during discussion. when we discussed the consequences of her behavior, we concluded that while lying keeps her from being caught and punished in the moment, it almost always backfires because the lie is discovered and amy gets into even more trouble. in the past, this has led to amy being grounded and prohibited from using any “electricity” (i.e., tv, radio, or phone). because amy feels very guilty when she lies, it was important to remove any sense of moral judgment from the discussion. lying was presented as a “bad habit” in our sessions that was separate from her worth as a person or her “goodness” (bernard, 1984). as stated earlier, amy demonstrates a great capacity for abstract thought. this allowed for the use of the rebt/cbt technique of rational disputation to help her come to the conclusion that she was, in fact, a good person who had a problem that could be helped and hopefully changed. a complementary aim that was coupled with this pursuit was an effort to bolster her self-esteem, to emphasize her positive qualities rather than focusing exclusively on her maladaptive behavior. to this end, amy completed behavioral “worksheets,” adapted from bernard (1984; see figure 1).2 the format of the worksheets r equired her to list figure 1. amy’s behavioral worksheet. 2 materials containing the client’s own words, writings, and drawings have been used with permission. miles-mason 40 many positive aspects of her life—her good qualities, pleasing experiences, or things that make her happy—and contemplate behavior she has to be “careful of” in order to raise her awareness of her maladaptive behaviors while withholding moral judgment of her actions. frequent verbal praise was given during therapy sessions that emphasized the enormity of the losses she has experienced and the strength she has demonstrated in coping with them. amy was also taught how to use other cbt-based techniques such as self-statements, guided imagery, and relaxation exercises to provide her with adaptive behaviors to employ in stressful and upsetting situations. helping amy change negative cognitions about herself, build ego strength, and bolster resiliency were conceived of as essential parts of the intervention during this painful yet ultimately healthy process of grieving. amy’s previous therapist initially employed cbt in amy’s treatment by asking her to keep a journal and recount instances where she lied and how she felt about it. in my first session with amy, i asked her about her journal and she replied that she did not like writing about daily events and instead preferred creative writing such as poems and stories. it became apparent that asking her to make a record of her undesirable behavior or transgressions was not intrinsically motivating and was in fact negatively reinforcing. in order to scaffold off of her natural interests, the journaling activity was changed. amy was allowed to write poems about her life experiences, emphasizing that the poems had to specifically express how she felt. in addition, because amy perceived herself as a good poet, the activity served to highlight her natural ability and reinforce positive self-esteem. although the activity did not directly address the need for her to “tell the truth,” expressing how she felt accessed her emotional reality and required her to honestly confront her emotions. hence, art therapy was included in the intervention along with cognitive-behavioral techniques. amy embraced this therapeutic technique, which tapped into her artistic, creative passion for expression and fueled the intervention. i presented the process to amy as making a portfolio of artwork about her mother and her grieving process. at the end of the intervention, we would bind together all of the work, making a book that she could then have as a tangible creation born of her life experiences. the portfolio-making process served as an “autobibliotherapeutic” technique for grief therapy. the emotional reality reflected in amy’s poems and drawings dealt with her grief over losing her mother, the endeavor to interpret her traumatic life experiences, and consequently form her own identity. empirical studies have shown that using art therapy in the treatment of bereaved children can facilitate a child’s grieving process by allowing for the expression of strong feelings of pain, sorrow, and anger (fogarty, 1999; goldman, 2002). artwork created in therapy sessions also provides a medium or context for the dialogue between the therapist and the child (allan, 1988). the use of art was particularly suited to this intervention because of amy’s creativity and the “spiritual framework” through which she interprets life events. amy naturally conceptualizes and expresses her feelings through symbolic language (poetry) or other means of artistic creation, including drawing and music. amy’s perceptual processes and worldview are, in part, influenced by her cultural and familial experiences. recent multicultural counseling research and theory have espoused a conceptual shift from a focus on the individual to a “selfin-cultural context” where the ethnic customs, values, and beliefs of the client are recognized and utilized in the therapeutic process (frame & williams, 1996). studies on counseling african-american populations have emphasized the importance of strong, afrocentric spiritual and religious values that have existed since institutionalized slavery began in the united states (frame, williams, & green, 1999; frame & williams, 1996): “african spiritual and religious traditions form an enduring framework for expressions of spirituality in contemporary black culture” (frame & williams, 1996, p. 16). african spirituality has been expressed through numerous artistic endeavors throughout africanamerican cultural history, such as in negro spirituals, blues, soul, jazz, fiction, poetry, and more recently in rap, r&b, and hip-hop. a sense of communalism and collective identity among kinsmen, neighbors, and community members is also an important part of the african-american experience that must be acknowledged and can be incorporated into therapeutic interventions (frame, williams, & green, 1999; frame & williams, 1996). these issues of spirituality and culture were particularly relevant to amy’s experience, as her family has owned and maintained a small farm in oklahoma for many generations. amy not only discussed the religious baptist beliefs and experiences in her local church, she also described older customs and superstitions that she said went back to “the days of slavery.” even though amy may be at odds with other family members at the moment, she has a strong network of extended family relations and friends that lend her stability and a sense of identity. amy also shows interest in african-american history and literature. amy’s culturally-oriented values and beliefs, especially her passion for creative and (as will be shown) spiritual expressions, were incorporated into the intervention and served as powerful therapeutic tools. expressing oneself through symbolic language and metaphor is an essential component of afrocentric oral traditions and, for amy, is a means of interpreting and understanding her experience. amy’s use of a symbolic and spiritual framework to express herself is illustrated in the drawing in figure 2, which fostered important therapeutic dialogue in the therapy session. amy identified herself as the figure in the middle crying because she misses her mother. the hand and “sparkling light” stretching down from the sky represents god helping her through her sorrow and pain. the figure of the woman floating next to the 41 figure 2. amy’s use of a symbolic language. moon is her mother as an angel looking over her. the broken heart symbolizes her profound sadness, and finally, the devil hiding behind it represents the struggle between good and evil that claimed her mother. the devil speaks to her perception of the presence of evil or pernicious forces in the world that can do harm, such as drug use. the symbol of the devil could also refer to the manner in which she died (from drug abuse and prostitution). seen from this perspective, the drawing also speaks to the difficulty (and perhaps conflict) children have processing grief from a stigmatized death (goldman, 2000). the theme of the destructive power of drugs and violence manifest themselves in later pieces as well. the sequence of poems that will be presented here demonstrates amy’s progress through a healthy grieving process. the process of grief for adolescents is broken down into the following stages: “1) accepting the reality of the loss; 2) experiencing the pain; 3) adjusting to an environment in which the deceased is missing; 4) relocating the dead person within one’s life and finding ways to memorialize the person” (webb, 1999, p. 226). presumably the first stage was completed before therapy began because she had already had 2 years to come to terms with the reality of her mother’s death and when she began therapy, she was able to discuss the death and its impact upon her. the second stage, experiencing the pain, can be seen in figure 2, with amy in the middle of the composition with tears streaming down her face. it can also been seen in a poem she wrote with a friend, “angel in the sky.” angel in the sky i lie in bed sobbing hoping that my life won’t dred i slowly fall asleep in the night breeze i hear my mother with her jingling keys oh wait! i forgot, i don’t know why my mother is a miles-mason 42 beautiful angel in the sky i look at the stars from my bedroom wondering why she had to die. oh lord, i hope she is o.k. i think about her everyday. i wonder why she had to pay i can’t wait for my day to pay the cost and then i won’t feel so lost. here, her mother is once again “a beautiful angel” whom she misses dearly and with whom she wants to be reunited. amy explained in therapy that there was a time when she thought about killing herself right after her mother’s death—“pay[ing] the cost so [she doesn’t] feel so lost”—but that she no longer felt that way. the line in the poem expressed how she had felt at that moment in the past. through the poem, amy was able to express the desperation and sadness she felt over losing her mother. in a discussion of the piece, psychodynamically-oriented art therapy techniques were employed to generate insights into her feelings (allan, 1988). another positive aspect of this poem is that she wrote it with a friend who had also experienced a great deal of loss in her life. being able to share one’s grief with another who empathizes with one’s experience is extremely beneficial to the healing process (goldman, 2002). this is explained in reference to adult/child grieving; however, a friendship with a peer can also help the child feel supported and understood. the third stage, adjusting to the environment without the missing loved one, was very challenging for amy. amy felt that her aunt and the rest of her family did not understand her like her mother had. she was having difficulty successfully functioning in her environment, as demonstrated by poor academic performance, lying, and aggressive behavioral problems. at the beginning of the intervention, almost all of amy’s privileges to leisure activities had been suspended as means of disciplining her, including visiting with friends, watching tv, and listening to the radio. even though amy still has difficulty with these issues, her misbehavior has lessened in frequency, and, more importantly, she has established a secure attachment to her aunt annette. over the course of the 3-month-long intervention, amy and her aunt have become closer and currently express open affection for each other. while amy still gets in trouble on a weekly, if not daily, basis (for small infractions), amy has expressed her positive feelings about annette, saying that she not only “loves” her aunt, she “likes” her too. her adjustment to living in new jersey with annette is reflected in the poem “wings,” which she dedicated to her family. wings if i had wings…wow! my world would fly! i’ll feel free. if i had power…man! you would bet that those who died would live again. if i had a million dollars… goodness! i would ask god for my mommy back. but..if i had you… that’s all i need. dedicated to: my family amy still expresses her desire to be with her mother, to make her “live again,” but the poem does not contain the same sense of sorrow and loneliness, the willingness to give up her life just to be with her mother. when asked who she meant by “you” in the poem, she said her aunt annette, , and the rest of her family in oklahoma. while she still misses her mother, amy now feels that having her loved ones’ support and affection are all she “needs” to “live and be happy.” the title “wings” and the references to flying in the poem imply a new-found freedom and unburdening. she does not actually “have wings,” but she feels empowered by and connected to the loved ones in this world and to the ones who are in heaven watching over her who do, in fact, have wings.3 the final stage, memorializing her mother, has already begun to be reflected in amy’s poems. her mother appears in all her work as an “angel,” someone who has gone to heaven, achieved peace, and now watches over her as a benevolent spirit. in addition, when amy discusses her mother in therapy, it is emphasized that she will always have the memories and love of her mother in which she can take comfort and joy. outcome it should be mentioned that the intervention was cut short because amy was moving back to oklahoma to live with the rest of her family and there are many issues that will still need to be addressed. for example, amy has not yet begun to discuss the ways in which her mother was not 3 music was also used as means of expression during therapy. amy would sing songs that she felt had great significance to her life and then we discussed their meanings. the songs’ themes focused on the need for love and healing. case study illustration of integrative grief therapy techniques 43 a good caretaker and put amy in dangerous, inappropriate situations. in an effort not to overwhelm amy and derail her progress, exploration of this issue must wait until a stable sense of well-being has been achieved and sustained for a substantial period of time. it should be remembered as an important concern, however, as amy moves further into adolescence and confronts issues of sexuality and sexual identity. when i first began working with amy 4 months ago, she felt like she did not fit in at school and was taunted by other students. both amy and i have noticed a remarkable change in her confidence and self-esteem since that time. she has reported that she is now making some close friends, getting good grades in school, and getting along with her aunt annette better. amy has also slimmed down since the beginning of the year and seems to have more confidence in her body. amy completed two beck depression inventory (bdiii) forms, as a source of anecdotal evaluation of the efficacy of her treatment. (i did not use the manual to interpret results.) i asked her to fill out one form representing how she felt in january and then one corresponding to how she felt now. although this is not an objective measure of her psychological health, it is an indication of her selfperception, which is linked to her self-esteem. in comparing the two inventories, a global perceptual shift in her selfconcept and her state of mind is evident. while she rated all items negatively on the inventory representing how she felt in january, her ratings of her current emotional state were overwhelmingly positive. when i asked amy what had changed between then and now, she smiled and said “me,” noting that she had more self-confidence and was proud of the grades she was getting in school. although these results are not empirically validated, i believe they do represent clinical validation of her perceptual and emotional reality and the progress she has made in adjusting to her new environment. this also corresponds with the positive messages in her latest poems about her family and mother. amy completed the self-report form of the behavior assessment for children (basc). the report indicated that all of her indexes were in the “acceptable range.” each of the informal evaluations (i.e., positive theme progression of her poetry, her current self-observations, my observations of positive changes she has undergone, grades at school) indicate that her self-esteem, quality of life, and ability to cope with her mother’s death have improved significantly. while amy has made significant progress in her grieving process and adjusting to her new environment, she still occasionally lies and recently got into a serious physical fight with a boy at school. figure 3 shows another cbt worksheet that amy filled out just before treatment was discontinued. once again, the worksheet attempts to break down the abcs of her actions so that she may better understand and eventually create systemic changes in her behavior. as may be seen in the figure, she did not answer the “why” question regarding lying, saying that it was a “hard one” and didn’t want to do it now. coming to a full understanding of the faulty cognitions causing her lying behavior and adopting new, adaptive cognitions represent primary goals for future therapeutic treatment. figure 3. understanding cognitions. discussion cognitive-behavioral therapy was used in this intervention to help amy reduce lying and aggressive behaviors and gain insight into the underlying cognitions causing her maladaptive behavior. amy was taught how to use selfstatements, guided imagery, and relaxation techniques to help control impulses and maintain emotional well-being under stressful or emotionally charged situations. the longterm goal of rebt—to acquire a healthy belief system and a repertoire of adaptive behaviors (ellis, 1983)—was not fully achieved during this intervention and amy would benefit from further therapy that explores salient psychological/emotional themes in more detail. it should again be noted that amy has experienced highly traumatic events at a young and developmentally sensitive age and extensive therapy will be needed to fully address the impact of her life experiences. although therapy was prematurely terminated, amy felt comfortable ending therapy because she said was moving back “home” and would be with her family and could talk to them about any problems she was having. psychodynamically-oriented art therapy was used to facilitate amy’s healthy grieving process. through symbolic language, in the form of poetry, amy was able to work through many of her feelings of loss and sorrow. her use of poetry still continues to reflect her emotional and miles-mason 44 psychological development. the following is a poem she wrote about her identity as an african american. negroes negroes…negroes of the black history month of seasonal energy, those who do not know the black ways is not negro. negroes….negroes back then were whipped to the bone for us, yet, how do we repay these slaves of knowledge. negroes…negroes today, peace up a’s down, eastside, westside, down bottom. ya’ll don’t know the real way of black coolness, yet, you still go by today’s hottest clothings. ya minds are poisoned by the pimpness and gangastaness of rap and r&b singles. but i give you my props, for i am the same way. negroes…negroes in their cellas waitin’ foe their day to die, each day they’re slippin’ from the soils of earth and into the hands of god. negroes…negroes who abuse and then accuse, baby daddies lookin’ for some other girl to get pregnant, drug attics who are lookin’ foe moe money just to put them back into devil’s paradise… thug mansion, every thug waitin’ foe their time. negroes…negroes of the world! in “negroes,” one sees amy grappling with her relationship to the cultural and historical legacies of african americans. she explained to me that many african americans today do not appreciate the sacrifices made in past generations by people like harriet tubman, who fought for freedom and equality. amy’s poem also expresses scorn or frustration with the “baby daddies” and “drug addicts” who are also part of her cultural identity and her personal experiences. amy’s art therapy (in the form of poetry) was an effective therapeutic vehicle for emotional expression, as well as a means of generating insight. techniques drawn from several modalities—psychodynamic, cognitive-behavioral, art therapy, and grief-focused therapy—were all employed to create a more comprehensive, individualized, and effective intervention. in addition, crafting a culturally-sensitive intervention which drew upon amy’s natural interests and the spiritual traditions of her ethnic heritage allowed for the expression of profound emotion and psychological insight that facilitated her grieving and healing process. this case study illustrates the importance of conceptualizing the client as “the self-in-cultural context,” understanding the interplay of familial, cultural, and racial factors that contribute to the client’s psychological, cognitive, and emotional processes. recognizing and integrating spirituality into interventions with ethnically diverse clients who maintain their own religious and spiritual belief systems is essential to providing effective and appropriate counseling to these minority populations. while there is a substantial body of research regarding the use of religion, spirituality, and church organizations in interventions for adult african americans (frame & williams, 1996; frame, williams, & green, 1999; querimit, 2003) less research and fewer programs have been implemented for african-american children and adolescents. this represents an area for future growth and development of therapeutic techniques that could be applied in multiple contexts for multiple psychological problems (aggression, depression, low self-esteem, etc.). therapy using afrocentric spiritual traditions comes from a strengths perspective and emphasizes positive cultural attributes, customs, and artistic pursuits. therapeutic interventions designed to empower african-american adolescents—helping them form solvent cultural and personal identities—have been effectively implemented in small community-based programs (querimit, 2003). another program, assimilating into mainstream society economically (aimse), focuses on the spiritual and healing relationship of the therapist and has also been successfully implemented in interventions (querimit, 2003). further research and development of similar programs should be undertaken to both widen and refine the application of these techniques with africanamerican adolescents and children. references allan, j. (1988). inscapes of the child’s world: jungian counseling in schools and clinics. dallas, texas: spring publications. bernard, m. (1984). rational-emotive therapy with children and adolescents. new york: john wiley & sons. davis-russell, e. (2002). religiosity and racial attitudes: clinically relevant factors in psychotherapy with african americans. in e. davis-russell (ed.). california school of professional psychology handbook of multicultural education, research, intervention, and training (pp. 263276). san francisco: jossey-bass. ellis, a. (1983). rational-emotive approaches to the problems of childhood. new york: plenum press. fogarty, j. (1999). the magical thoughts of grieving children. new york: baywood publishing. frame, m. w., & williams, c. b. (1996). counseling african americans: integrating spirituality in therapy. counseling & values, 41, 16-28. case study illustration of integrative grief therapy techniques 45 frame, m. w., williams, c. b., & green, e. l. (1999). balm in gilead: spiritual dimensions of counseling african american women. journal of multicultural counseling & development, 27, 182-190. goldman, l. (2002). breaking the silence: a guide to complicated grief-suicide, homicide, and abuse. new york: brunner-routeledge. querimit, d. s. (2003). empowerment psychotherapy with adolescent females of color. journal of clinical psychology, 59, 1215-1224. webb, n. b. (1999). play therapy with children in crisis. new york: guilford. microsoft word barryletter_avk_bwjk.doc 2 on ten years of the graduate student journal of psychology “do the steps that you’ve been shown by everyone you’ve ever known until the dance becomes your own.” (jackson browne, for a dancer) among the best parts of being a faculty member in a top-notch psychology department is the opportunity of working with some extraordinarily talented students. however, being the faculty advisor to the graduate student journal of psychology hasn’t really afforded me this opportunity to any great extent, albeit for just the right reason: the exceptional students who have served as editors and reviewers for this peer-reviewed journal, doctoral students from the clinical and counseling psychology program at tc, have really done all the hard work themselves. it is they who started the journal, publicized it, solicited articles (from an ever-widening circle of doctoral programs), reviewed manuscripts, corresponded with studentauthors, designed covers, worked on layouts, negotiated printing costs and paper quality, collaborated with mailing rooms, and groomed their successors. but if i haven’t had the pleasure of working intensively with students on the journal, i have had another great pleasure: that of being extremely proud of their efforts. the journal provides psychology graduate students the opportunity, often their first opportunity, to publish their work. moreover, over the years, the journal has become increasingly diversified, increasing greatly the number of students outside of teachers college who publish in this peer-reviewed publication, and also increasing the range of articles published, from purely theoretical pieces, to more clinically-oriented papers, to traditional empirically-based research. the current issue is a fine example of this diversity. students from the university of british columbia, indiana university of pennsylvania, the university of hawaii at manoa, utah state university, and, of course, teachers college are represented here. their articles focus on research methodology, clinical disorders, parenting practices, empirically-supported treatments, attachment theory, and spanish language-training for psychologists and psychology trainees. five of these articles are based on original research and three are literature reviews; some have been written by doctoral students and some by ma students. notably, too, many of the articles in the journal reflect deeply-held interests of students. for example, in the current issue, the article “starving to win” was written by a masters degree student at teachers college, sarah bernstein, a former nationally-ranked figure skater and professional coach who is quite knowledgeable, and passionate, about eating disorders in athletes. congratulations, then, to jessica keith and anitha venkataramani-kothari, current editors, on the occasion of the tenth year of publication of the graduate student journal of psychology. they have continued to build upon the journal’s impressive tradition of excellence and opportunity. they, along with all the previous editors and all those students who have contributed their talents and time, continue to remind me and the rest of the faculty in the department of counseling and clinical psychology at teachers college why being a professor is so very rewarding. these students have made this dance, this journal, their own. barry a. farber, ph.d. professor and director of clinical training, clinical psychology 23 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 the comparison of violent video games to a virtual reality exposure therapy model noreen j. vail-gandolfo hofstra university as video games become increasingly realistic and aggressive there is growing concern over the possible generalization to real-life situations of learned aggressive behavior. to add to this concern, today’s video game technology is very similar to that of virtual reality, which has been found to effectively change behaviors in clinical settings. since many similarities exist between video games and virtual reality, it is possible that video games may elicit a similar change in behavior. three tenets necessary for effective virtual reality exposure therapy, including complete immersion in the virtual environment, emotional arousal, and the generalization of the learned behavior to real-life situations, will be discussed and applied to video games (krijn, emmelkamp, olafsson, & biemond, 2004). current literature and future research directions will be discussed. although video games have been available for over thirty years, the violent and realistic content of today’s best selling games, such as grand theft auto vice city™ and doom 3™, can be traced back to 1992 with the debut of mortal kombat™ (i.e., an interactive game of one-on-one fighting with human characters and gruesome graphics, herz, 1997). despite the fact that these violent games have been on the market for over a decade, it was not until the 1999 shooting at columbine high school in littleton, colorado that concerns of their possible negative effects were so strongly voiced (garbarino & bedard, 2001). this incident sparked a great deal of debate primarily because the shooters, dylan klebold and eric harris, were avid players of the violent and aggressive game doom™. it was reported that they had even gone so far as to make their own modified version of this particular game that they later reenacted during the massacre at their school (hubbard, 1999). given that approximately 67% of households with children own a video game system (subrahmanyam, kraut, greenfield, & gross, 2001), it is not surprising that the video game industry earns more than twenty billion dollars in worldwide annual sales (federal trade commission, 2000). in 2000, the federal trade commission reported that of 118 “m” (i.e., mature) rated video games, 70% were directed at adolescents under the age of 17, and children between the ages of 13 and 16 were able to purchase these mature rated games approximately 85% of the time without noreen j. vail-gandolfo, is a third level doctoral student in the combined ph.d. program in clinical and school psychology at hofstra university. correspondence concerning this article should be addressed to noreen j. vail-gandolfo, department of psychology, hofstra university, 135 hofstra university, hauser hall, room 222, hempstead, ny 11550; e-mail: nvail1@pride.hofstra.edu. an adult present. clearly, these statistics suggest that violent video games are not only being marketed to and sought after by children, but they are quite easily obtained. as recent evidence demonstrates that boys and girls spend 13 and 5 hours a week, respectively, playing video games— almost the equivalent of having a part-time job—(gentile, lynch, linder, & walsh, 2004), the question then becomes, what impact does playing violent video games have on individuals and their behavior? contextual factors of video game playing anderson and bushman (2001) have applied a general affective aggression model (gaam) to violent media including video games. in this model they suggest that repeated exposure to violent video games increases the probability that an individual will think, feel, and behave more aggressively. this increase in aggressive responding is mediated by several variables, including the characteristics of the individual person, the situation or game to which they are exposed, the cognitive and affective excitement of the person, and the way the person appraises the situation. in terms of the contextual factors of the game, it has been found that the most desirable games are those that have the most realistic graphics and are highly interactive (wood, griffiths, chappell, & davies, 2004). it would seem to follow, then, that the more involved in a game the person becomes, the greater the possible effect of the game on their behavior. moreover, games that require a player to take the first-person perspective may increase the level of interaction and lead to the possible priming of the player for aggressive thoughts and responses when handling real-life situations (anderson & bushman, 2001). the realistic graphics and high level of interaction sought after in video games calls to mind a similar technological invention—virtual reality (vr) (glantz, rizzo, & vail-gandolfo 24 graap, 2003). virtual reality allows the individual to be completely immersed in an alternate environment and experience situations they may not normally be exposed to (krijn et al., 2004). interestingly, virtual reality has most recently been demonstrated to elicit changes in patient’s behaviors in therapeutic settings (hoffman, 2004) for such problems as nicotine addiction (lee et al., 2004) and fear of flying (arbona, osma, garcia-palacios, quero, & banos, 2004) to name just a few. these findings suggest that behavior can be changed with the assistance of a device that is very similar to video game consoles. while some critics may argue that violent video games do not increase the probability of an individual acting in a violent or aggressive manner (olson, 2004), if the characteristics of video games and virtual reality are so similar, from the equipment used to the presentation of stimuli and virtual reality is found to facilitate therapeutic change, it seems only logical that video games may also have the ability to elicit a powerful change. exploring the influence of video games a meta-analysis of thirty-five research studies conducted by anderson and bushman (2001) supported the position that violent video games increase aggressive behavior not only in children, but also in many populations including male and female adults regardless of the experimental setting. in addition to an increase in aggressive behaviors, anderson and bushman also found a slight shortterm reduction in pro-social behaviors (i.e., behavior executed to help another person) as well as a temporary increase in aggressive thoughts and emotions. despite the limited availability of longitudinal data needed to provide evidence of more lasting effects, this research does support the position that playing violent video games can negatively impact an individual’s behavior. the increasing realism of video games leads one to return to the literature of virtual reality, specifically virtual reality exposure therapy (vret). vret combines the technology of virtual reality with the psychological technique of exposure therapy to provide individuals the opportunity to experience various stimuli in a controlled environment. it also affords clinicians the opportunity to submerge the patient in a controlled, anxiety-provoking situation without having to leave the office (garcia-palacious, hoffman, see, tsai, & botella, 2001). preliminary data on the use of vret with such phobias as fear of driving (walshe, lewis, kim, o’sullivan, & wiederhold, 2003) and fear of flying (wiederhold, 2003; arbona et al., 2004) have been optimistic in terms of creating a reduction in anxiety. according to krijn et al. (2004) several conditions must be met for vret to be effective, including complete immersion in the virtual environment, emotional arousal, and the application of the learned behavior to situations occurring in reality. similarities between vret and commercial video games the first condition that must be met is complete immersion of the participant in the virtual reality world which is accomplished through equipment such as a head mounted device (hmd), a goggle-like mask that sits on the head and provides visual stimuli through small video screens and audio stimuli via headphones. while the stimuli are presented the individual can become immersed and unaware of anything occurring externally. typically, a sensor is connected to the hmd so that all physical movements made by the client toward the stimuli are carried out in the virtual environment. through these and other mechanisms, various stimuli may be presented visually, aurally, and when possible tactilely (krijn et al., 2004). the equipment available in most video game consoles appears to provide the same type of stimulation as the vr design. for example, microsoft’s game system xbox™, like all game systems, has handheld controllers to manipulate the actions of the characters. thus, just as in the vr environment, the actions of the player can be carried out in the digital world. while audio effects are typically amplified through television speakers, xbox™ has capabilities for both headsets and surround-sound to enhance the intensity of the game. although these features are available on most, if not all, of the game consoles currently being sold, xbox™ is being highlighted because of its compatibility with some of the most violent games available including doom 3™ and halo 2™ (walsh, gentile, gieske, walsh, & chasco, 2004). not only are these games violent, but they are played from the first-person perspective which means the player is not seeing and reacting to the stimuli as a character, but rather as if he or she were in the environment, much like the vr stimuli. in addition, recent evidence demonstrates that highly engrossing graphics and game content are the most desirable characteristics in a video game (wood et al., 2004), presumably because they keep individuals occupied for hours at a time and may prevent them from engaging in other activities. not only is the video game and virtual reality hardware similar, but both provide a degree of distraction from the outside world. interestingly, playing video games has been found to successfully reduce the level of pain and other side effects experienced during various medical procedures, such as nausea associated with chemotherapy in young children (redd et al., 1987). in addition, vr has also been shown to decrease the pulse of pediatric cancer patients, as well as the level of pain they experience (gershon, zimand, pickering, rothbaum, & hodges, 2004). these findings indicate that amongst similarly aged children, both video games and virtual reality have provided a level of immersion that is even able to distract an individual from aversive stimuli. it is difficult to deny that this is a powerful effect. the second condition necessary for effective vret is the comparison of violent video games to a virtual 25 to elicit an emotional response from the individual so as to engage him or her on a personal level (krijn et al., 2004). to accomplish this, an environment that is salient to the person is employed. for example, when conducting vret with a person who has aviphobia, or fear of flying, vr would be used to simulate an airplane environment (maltby, kirsch, mayers, & allen, 2002). if the stimulus does not elicit an anxious feeling which the person can learn to work through, it would seem impossible for the individual to successfully face his or her fear(s) in real-life situations. to objectively determine the effect the vr environment has on an individual, physiological measures are often employed. in particular, heart rate has been used as a way of measuring a person’s reaction to the simulated environment and can be indicative of their affective response to the stimuli (jang et al., 2002). as in vret, violent video games are replete with visual and audio effects designed to arouse the player. from rock music to conversations with other characters, these video games are able to pull the individual into, and sustain him or her in an alternate world (wood et al., 2004). in light of the vret literature, it appears that the physiological arousal achieved through violent video games is similar to that achieved in vr. one author relates her experience of playing video games, stating, “during especially difficult levels of play, my palms would sweat. my heart would race. i’d have knots in my stomach from anxiety” (sohn, 2004, ¶2). to further support this author’s experience, anderson and bushman’s (2001) meta-analytic review found a significant elevation of diastolic (i.e., relaxed heart) and systolic (i.e., contracted heart) blood pressure, as well as heart rate when individuals were engaged in playing violent video games. anderson and bushman (2001) also found a significant increase in aggressive affect, which they proposed was related to a heightened sense of anger or hostility in the player. additional research by panee and ballard (2002) found this increase in hostile feelings, as well as physiological arousal, after participants played a violent video game. thirty-six undergraduate students played a violent video game after being primed to either high or low aggressive acts. the high aggression condition was referred to as the “gun-shoot training mode,” in which the participants were instructed to kill the guards in the video game with a gun. the low aggression condition was referred to as the “time attack training mode.” these participants were told that it was not necessary to kill the guards in the game although they could do so if they chose. after being trained, all participants then played the video game metal gear solid™. they found that those individuals in the high aggression group engaged in more violent acts during the video game than those in the low aggression group. in terms of physiological and affective arousal, participants in the high aggression group had a greater increase in heart rate than the low aggression group, and self-report measures found that this increase in heart rate was correlated with greater feelings of hostility. these findings are consistent with anderson and bushman’s evidence that exposure to a high aggressive game increased the participant’s physiological arousal. the self-reported feelings of increased hostility presents the possibility that violent behavior acted out in video games may increase the likelihood of an individual acting on these hostile feelings, which according to the gaam model mentioned previously, can influence an individual’s behavior in real-life situations (anderson & bushman, 2001). this leads to the third tenet of vret. the third condition necessary in vret is that the learned behaviors generalize to real-life situations. for example, in treating someone who has a fear of spiders, the vret is considered successful when the patient is able to control their anxiety in the presence of a spider outside of the therapeutic environment (wiederhold & wiederhold, 2005). in terms of violent video games, there is a great deal of controversy surrounding this issue of generalization (anderson, 2004; olson, 2004). however, there is research supporting the hypothesis that playing violent video games negatively influences the way a person thinks about and subsequently responds to an ambiguous situation. for example, kirsh (1998) compared fifty-two children in 3rd and 4th grade who played either a violent video game (mortal kombat ii™) or a non-violent video game (nba jam™). after playing the video game, the child was read a story in which a character of the same gender as him or her caused a negative event to occur, but where the intent was not clear. children who had played the violent video game were more likely to attribute the intent of the character to a negative, aggressive reason in half of the stories then their non-violent counterparts. in a sense, being shown the violent video game may have primed the children to respond in a negative manner; specifically, the violent content of the games may have put them in a negative frame of mind that led them to attribute the actions of the character to behaviors that were commensurate with these negative thoughts. from video games to ‘real-life’ to further understand how violent video games influence an individual’s behavior in real-life situations, anderson and dill (2000) reported their findings from two separate studies. in the first they collected self-report data from 227 undergraduate students and correlated it with violent video game playing. the areas addressed included frequency and type of aggressive behavior, delinquency, and level of academic achievement as measured by the participant’s grade point average. in addition, the individual’s worldview was obtained by asking questions regarding the likelihood of crime occurring and their feelings of safety in various situations. the caprara irritability scale (cis) was used to assess the individual’s impulsivity in responding to frustrating stimuli and the buss-perry aggression questionnaire was used to assess trait aggression in each participant. a video game questionnaire was created by the authors so that participants could identify their favorite vail-gandolfo 26 video games and rate the amount of violent content in each game on a scale of 1 (i.e., little to no violent content) to 7 (i.e., extremely graphic). participants also reported the overall frequency with which they played video games. results of this study revealed that playing violent video games was directly related to aggressive behavior as well as to non-aggressive (i.e., stealing) and aggressive (i.e., hitting) delinquency. it was also found that individuals who played violent video games had more aggressive personalities as per the cis and buss-perry aggression questionnaire. however, there are several limitations to the application of these findings to the larger population. first, the undergraduate sample used poses a threat to the external validity of this study by making it difficult to generalize these findings to other groups. in addition the self-report measure by which data was collected threatens the internal validity of this study by making it difficult to establish a true cause and effect relationship. as such, the question remains: do hostile individuals seek these games out, or are they hostile because they play these games? the results of this study do provide valuable insight into the playing habits, personality styles, and aggressive behaviors of young adults and are an important contribution to the video game literature. the second study anderson and dill (2000) conducted aimed to obtain a more accurate view of an individual’s response to a real-life situation after playing a violent video game. in this study, they compared individuals’ responses to a perceived opponent in a competitive computer game after playing either a non-violent or violent video game. two hundred ten undergraduate students participated in this study after being screened for trait irritability. in the first session, participants played either a violent or non-violent video game and were then asked to fill out the state hostility scale. they continued playing for another fifteen minutes after which they engaged in a cognitive assessment of aggression that required each participant to read a list of aggressive and control words as quickly as possible. one week later the participants returned to the lab and played the violent or non-violent game from the previous session for fifteen minutes. they were then told that another participant in a separate cubicle would be playing against them in a competitive reaction task. the person who won would be able to send the other player a noise blast of different lengths and volumes, however, the intensity and duration of the blast was to be determined by the participant prior to each round. in reality there was no other player and the noise blasts were set in a pattern so all participants received an equal number of wins and losses. results revealed that exposure to the violent video game was related to more aggressive behavior in the participant as evidenced by their delivery of longer lasting noise blasts to their “opponents” after they had lost the round prior to their winning. limitations of current research and future directions it is difficult to truly examine the effects of violent video games on real-life aggression through the use of laboratory experiments and/or retrospective self-report measures, which are not always the most generalizable sources of data. it is also important that sweeping generalizations not be made based on anecdotal evidence, such as blaming all acts of teen violence on violent video games or other sources of violent media these individuals may be exposed to. ultimately, not every individual exposed to these games reacts aggressively because individual differences always exist. anderson and bushman (2001) take the individual into account when applying the general affective aggression model suggesting that not every one who plays these games will react aggressively. an example of how individual differences may affect a person’s response can be found in the study by anderson and dill (2000) described previously. some of the participants may have been more hostile by nature than others causing them to respond more aggressively when they believed they were playing against another person. therefore, they may have responded aggressively regardless of what game they had been given prior to competing. however, it is important that we not overlook the impact these games may have on the cognitions and behaviors of their players. with the increasing availability of virtual reality hardware and software and the compatibility of such programs with desktop personal computers, this area of research may be more easily studied than in previous years (riva, 2003). for those who have access to such technology, future research may take several approaches to explore the similarities and differences of violent video games and virtual reality. following is an example of one possible study that could be applied in a laboratory setting and that would consider individual differences in the domain of hostile personality: in the first step, participants would be prescreened using a measure, such as the buss-perry aggression questionnaire, and those individuals who scored in the top and bottom 25th percentiles would be included in the study in order to evenly distribute individuals who are high and low in aggressive personality traits and control for individual differences. in the second step, participants would be assigned to one of six groups based on their scores on the buss-perry aggression questionnaire including: high or low aggression and violent video games, high or low aggression and virtual reality, and high or low aggression and a neutral task, such as putting together a puzzle. next, each participant would engage in the assigned activity for fifteen minutes after which time self-report data of aggressive feelings would be collected using a measure such as the state hostility scale. physiological arousal data would be obtained before, during, and after each participant engaged in the assigned activity via heart rate and blood pressure. finally, after participants completed the self-report questionnaire they would engage in a laboratory activity that would mimic a real-life situation, such as helping a confederate or another participant try to solve a posed problem, to determine whether or not there is an effect on their level of frustration and frequency of verbal and non-verbal aggressive behaviors. frustration would be measured by the numthe comparison of violent video games to a virtual 27 ber of attempts made at completing the task, verbal aggression would be measured by the frequency of negative utterances, and non-verbal aggression would be measured by the frequency of negative actions, such as slamming hands on a table. this data would be collected by a blind observer to reduce the probability of expectancy effects. if the proposed study were carried out it would be expected that significant differences would arise between the hostile and non-hostile groups in all three conditions in their scores on the state hostility scale. significant differences would also be expected between the low and high aggression neutral task group and the high aggression vr and high aggression video game groups in terms of physiological arousal, level of frustration, and verbal and non-verbal aggression. by prescreening individuals it would be possible to determine the differences that exist between the groups when given the various activities. based on the theoretical assumptions presented above, it is hypothesized that no significant differences would exist between the video game and virtual reality groups. although the proposed study is just an example of how future research might explore this area, it is important, from a clinical perspective, to further understand the mechanisms of change in behavior that playing video games may have on individuals. in considering the characteristics of vret and violent video games, it is interesting to note the similarities of the environment created and the effects of the stimuli on the participant. although there is a relatively small amount of literature available on both virtual reality and violent video games, it is possible to make the theoretical hypothesis that because vret can elicit changes in people’s behaviors and there are strong similarities between video games and virtual reality, violent video games may also elicit the same types of change in behavior. references anderson, c. a. 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(2004). the structural characteristics of video games: a psycho-structural analysis. cyberpsychology & behavior, 7(1), 1-10. microsoft word vol10_calepalmer_avk#2af7ad.doc 38 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 executive functioning in schizophrenia: the contributions of attention, working memory, processing speed, and general intelligence cale d. palmer university of hawaii at manoa elaine heiby university of hawaii at manoa daryl fujii university of hawaii at manoa velma kameoka university of hawaii at manoa the purpose of this study was to assess the degree to which executive functioning performance may be associated with indices of attention, working memory, processing speed, and general intelligence in 45 individuals with schizophrenia from a multicultural sample. it was hypothesized that relatively higher performances on measures of these cognitive processes would be positively associated with higher executive functioning performance, as measured by the wisconsin card sorting test (wcst). contrary to expectations, results indicated that attention, working memory, and processing speed did not significantly correlate with executive functioning performance. however, wechsler adult intelligence scale, third edition (wais-iii) full-scale iq scores did significantly correlate with wcst performance, suggesting that general intellectual deficits may underlie executive functioning impairments in schizophrenia. schizophrenia is a psychotic disorder often characterized by delusions and hallucinations (american psychiatric association, 2000). schizophrenia may also be conceptualized as a chronic neurocognitive disorder with varied levels of functioning and symptom presentations, including deficits in attention, memory, processing speed, and executive functioning. such cognitive deficits appear to predate clinical symptoms (murray, 1994), remain relatively stable after the onset of schizophrenia (heaton et al., 2001; hoff et al., 1999; rund, 1998), and remain stable regardless of baseline and changes in clinical state (heaton et al., 2001). deficits in cognitive functioning may be considered core symptoms of schizophrenia (weickert et al., 2000) and have been associated with relapse and functional outcome (chen et al., 2005; green, kern, braff, & mintz, 2000; sergi, kern, mintz, & green, 2005; woonings, appelo, kluiter, slooff, & van den bosch, 2002). in addition, functional outcome may be more reliably related to cognitive impairment than positive symptomatic variables (axelrod, goldman, tompkins, & jiron, 1994). one such cognitive deficit that has been widely studied in individuals with schizophrenia is executive functioning, a broad term comprised of several components, including correspondence and reprint requests to cale palmer at department of psychology, university of hawaii at manoa, 2430 campus rd., honolulu, hi 96822. e-mail: cale@hawaii.edu. determining what one wants or needs, conceptualizing the future realization of that want or need, identifying and organizing the steps and resources required to achieve the goal, weighing alternatives and making choices, and the translation of a plan into action via sequences of complex behavior in an orderly fashion (lezak, 1995). executive functioning has also been described as involving volition, planning, purposive action, and self-monitoring of behavior (green et al., 2000; lezak, 1995), which enable the performance of complex and high-level tasks. lezak (1995) has characterized executive abilities as “those capacities that enable a person to engage successfully in independent, purposive, self-serving behavior” (p. 42). maintaining or shifting mental sets, establishing goals, and planning are crucial aspects of executive functioning (stuss & benson, 1986) and can be measured by neuropsychological tests specifically designed to assess executive functioning. one of the most established and widely used measures of executive functioning is the wisconsin card sorting test (wcst; berg, 1948; grant & berg, 1948; heaton, chelune, talley, kay, & curtiss, 1993), a complex task designed to assess the ability to shift cognitive strategies in response to changing environmental contingencies. the test requires subjects to perceive and abstract relevant attributes and ignore irrelevant ones, to engage in hypothesis generation and testing, and to abandon irrelevant hypotheses or principles when necessary (king & snow, 1981). successful wcst performance is thought to involve strategic planning, organized searching, goal-oriented behavior, modulation of impulsive responding, and the ability to use executive functioning in schizophrenia 39 environmental feedback to shift cognitive sets (spreen & strauss, 1998). in individuals with schizophrenia, performances on the wcst are often impaired relative to normal and psychiatric controls (beatty, jocic, monson, & katzung, 1994; everett, lavoie, gagnon, & gosselin, 2001; ilonen et al., 2000; johnson-selfridge & zalewski, 2001; metz, johnson, pliskin, & luchins, 1994; reed, harrow, herbener, & martin, 2002), and some of the research seeking to explain the wcst performance impairment associated with schizophrenia has centered on correlations with intellectual or cognitive abilities, such as attention and working memory, measured by tests commonly used in neuropsychological batteries. results from these studies, however, have often been unclear or conflicting, and much remains to be known about the specific cognitive processes involved in wcst performance and what processes contribute to the relatively impaired wcst performance associated with schizophrenia. some researchers, for example, have suggested that attention may underlie wcst performance (perry, potterat, & braff, 2001; stratta, mancini, mattei, casacchia, & rossi, 1994). differences between individuals with schizophrenia in an inpatient setting and controls on wcst performance may be eliminated after controlling for attention using analysis of covariance (kenny & meltzer, 1991), and attention training may remediate wcst deficits (lopezluengo & vazquez, 2003). other studies, however, suggest that attention may be insufficient in explaining wcst performance or have found no significant correlation between wcst performance and attention (chen et al., 1997; delahunty, morice, & frost, 1993; frost et al., 1991; goldberg, weinberger, berman, pliskin, & podd, 1987; greve, ingram, & bianchini, 1998). similarly, while some studies have found evidence of an association between working memory and executive functioning in schizophrenia (glahn, cannon, gur, ragland, & gur, 2000; gold, carpenter, randolph, goldberg, & weinberger, 1997; gooding & tallent, 2002; morice & delahunty, 1996; stone, gabrieli, stebbins, & sullivan, 1998), others have not (bellack, mueser, morrison, tierney, & podell, 1990; goldman, axelrod, & tompkins, 1992; greve et al., 1998; stratta et al., 1997; vollema, geurtsen, & van voorst, 1995). thus, while attention and working memory have yet to fully explain wcst performance impairments, many studies do suggest some degree of impairment, and differences in sample composition and instruments across studies likely contribute to inconsistent findings. in addition, few studies have directly assessed the association between attention and executive functioning, and of those that have, many studies relied on visual rather than auditory stimuli when measuring attention. as individuals with schizophrenia may be relatively more impaired on auditory measures of attention (borgaro et al., 2003; mirsky, yardley, jones, walsh, & kendler, 1995; mussgay & hertwig, 1990), a more sensitive measure of impairment may yield more consistent, significant results. research appears relatively more limited with regard to assessing processing speed in schizophrenia and its potential contribution to impaired wcst performance. individuals with schizophrenia have been found to have impaired processing speed (egeland et al., 2003; hong et al., 2002; saccuzzo & braff, 1981), and this impairment may result in a disrupted flow of information as new stimuli enter before other stimuli have transferred (felsten & wasserman, 1980; saccuzzo & braff, 1981). this slowed processing speed may cause individuals with schizophrenia to lose information before being able to use it (brebion et al., 2000; hartman, steketee, silva, lanning, & andersson, 2003), and thus may contribute to impaired wcst performance. however, this hypothetical association has yet to be directly assessed. finally, it is also possible that wcst performance impairments associated with schizophrenia may be due to deficits in generalized intelligence (laws, 1999). while some argue that wcst performance may not be fully accounted for by iq scores (elliott, mckenna, robbins, & sahakian, 1995; morice, 1990), many studies have demonstrated significant associations between wcst and iq scores (dieci et al., 1997; gold et al., 1997; goldberg, kelsoe, & weinberger, 1988; ilonen et al., 2000; laws, 1999; seidman et al., 1991), as well as iq estimates (koren et al., 1998; sweeney, kelip, haas, hill, & weiden, 1991) in individuals with schizophrenia. one study reported that iq scores account for approximately 40% of the variance in wcst performance (gold et al., 1997). additional support for a possible association between iq and wcst performance has been found in several studies that compared groups of individuals with different levels of iq or wcst performance impairment. for example, in a study by goldstein, beers, and shemansky (1996), individuals with poor wcst performance had significantly lower iq subtest scores compared to those individuals that did not exhibit wcst performance impairment. weickert et al. (2000), also found relatively impaired wcst performance in individuals with schizophrenia with lower iq estimates. in the same study, a minority of patients with schizophrenia demonstrated an average level iq, and, to a lesser degree, they too demonstrated some wcst performance impairment compared to normal controls (weickert et al., 2000). similarly, kremen, seidman, faraone, and tsuang (2001), found that based on wcst and visual-verbal test scores (feldman & drasgow, 1981), abstractionexecutive function was relatively more impaired in individuals with schizophrenia who had an estimated lowaverage iq compared to those with average iq, although both groups demonstrated impaired abstraction-executive function compared to iq-matched normal controls. finally, in a study by dieci et al. (1997), wcst performance was not able to better discriminate healthy controls from individuals with schizophrenia when compared to iq scores, suggesting that wcst may not represent a pronounced deficit separate from a general intellectual deficit. not all studies, though, have found a significant palmer, heiby, fujii & kameoka 40 association; in a study by morice and delahunty (1996), the correlation between wcst perseverative errors and iq was not statistically significant (r = -0.34), and wcst performance impairments appeared to be present independent of any apparent deterioration in general intelligence from premorbid levels. however, this study used a small sample size (n = 17) and may also have been unusual in that while iq scores were relatively lower compared to normal controls, the mean iq for the schizophrenia group was still in the average range. furthermore, as schizophrenia is a heterogeneous disorder, patterns of cognitive impairment may differ when looking at different levels of iq (weickert et al., 2000). overall, a review of the literature indicates some equivocal and contradictory findings, and not much is known about the actual processes that contribute to the poor wcst performance by persons with schizophrenia. as current research has yet to fully explain wcst performance impairments, the purpose of this study was to examine some of the hypothesized underlying cognitive processes that may contribute to the relatively impaired executive functioning of individuals with schizophrenia in a multicultural sample. to this end, measures of attention, working memory, processing speed, and general intelligence were correlated with executive functioning performance, as measured by the wisconsin card sorting test. it was hypothesized that relatively higher performances on measures of these cognitive processes would be positively associated with higher executive functioning performance. method participants participant data was obtained from archived neuropsychological reports from hawaii state hospital, a state forensic and psychiatric hospital serving a multicultural population. subjects had been referred for neuropsychological testing, were found to have adequate vision and hearing, and completed a neuropsychological battery. a review of reports from april 1998 to august 2002 yielded 54 subjects. after excluding 9 subjects due to missing data, a total of 45 subjects remained in the study. at the time of their evaluation, individuals were either currently in an inpatient setting at hawaii state hospital (n = 43), in an outpatient setting (n = 1), or in community placement awaiting trial (n = 1). there were 37 (82.2%) males and 8 (17.8%) females. the average age was 36.42 (sd = 8.25), and the average number of years of education was 10.76 (sd = 2.10). approximately half of the sample was of mixed ethnicity (n = 23, 51.1%). other represented ethnicities included caucasian (n = 8, 17.8%), pacific islander (n = 7, 15.6%), asian american (n = 5, 11.1%), and african american (n = 2, 4.4%). of those of mixed ethnicity, common ethnic combinations included individuals classified as “part hawaiian” (n = 8, 17.8% of total sample), caucasian and pacific islander (n = 3, 6.7%), and asian american and caucasian (n = 2, 4.4%). within the sample, 33 (73.3%) individuals had a primary diagnosis of schizophrenia, and 12 (26.7%) had a diagnosis of schizoaffective disorder. a comorbid substance abuse or dependence diagnosis was found in a majority (n = 29, 64.4%) of the participants. drug use included alcohol (n = 18, 40%), marijuana (n = 12, 26.7%), cocaine (n = 7, 15.6%), methamphetamine (n = 4, 8.9%), amphetamine (n = 1, 2.2%), inhalants (n = 2, 4.4%), heroin (n = 1, 2.2%), pcp (n = 1, 2.2%), sedatives (n = 1, 2.2%), and unspecified polysubstance use (n = 7, 15.6%). measures indicators of general intelligence, working memory, and processing speed were derived from wechsler adult intelligence scale – third edition (wais-iii; wechsler, 1997) full-scale iq, working memory index, and processing speed index scores, respectively. the working memory index consists of scores on the arithmetic, digit span, and letter-number sequencing subtests. the processing speed index consists of the symbol search and digit symbol-coding subtests. the indicator of the cognitive process of attention was derived from the total number of errors on the continuous performance test of attention (cpta-i), an auditory test of attentional vigilance (cicerone, 1997; nuechterlein, buchsbaum, & dawson, 1994). the wisconsin card sorting test (wcst) categories completed score yielded a measure of executive functioning. procedure data collection was based on an archived set of neuropsychological reports, which included demographic information, psychiatric diagnoses, and cognitive test scores. participants were administered standard versions of neuropsychological tests by trained hospital staff, from which scores of cognitive and intellectual functioning were derived. psychiatric diagnoses were determined from multidisciplinary group meetings, which routinely included hospital staff from psychiatry, psychology, nursing, and additional departments. statistical analyses correlational analyses assessed the degree to which scores of attention, working memory, processing speed, and general intellectual functioning were associated with executive functioning. statistical significance was set at the p 0.05 level. a data transformation was also conducted on cpta-i scores due to non-normal skewness and kurtosis; in accordance with tukey’s ladder of powers (1977), a square root transformation was able to successfully approximate normal skewness and kurtosis values for this executive functioning in schizophrenia 41 distribution. all other variables demonstrated normal distributions. the contribution of each wais-iii subtest to the variance of executive functioning was not computed due to the sample size. results individuals with schizophrenia demonstrated impairment on cognitive tests, including the cpta-i total number of errors (m = 33.93, sd = 22.53), wais-iii working memory index (m = 78.67, sd = 11.90), wais-iii processing speed index (m = 78.36, sd = 9.65), wais-iii fullscale iq (m = 78.69, sd = 10.18), and wcst categories completed (m = 2.91, sd = 1.84). zero-order correlations between executive functioning scores and measures of attention (r = -0.23, p = 0.135), working memory (r = 0.18, p = 0.245), and processing speed (r = 0.21, p = 0.177) yielded only non-significant associations, which did not support the hypothesis that measures of attention, working memory, and processing speed would help explain or account for deficits in wcst performance in schizophrenia. however, executive functioning was significantly correlated with general intellectual functioning (r = 0.39, p = 0.009). thus, the hypotheses of this study were partially supported. a post hoc analysis also found that even after controlling for attention, working memory, and processing speed, executive functioning was still significantly correlated with general intellectual functioning (r = 0.36, p = 0.020). discussion it was hypothesized that relatively higher performances on measures of attention, working memory, processing speed, and general intellectual functioning would be positively associated with higher executive functioning performance, as measured by the wisconsin card sorting test (wcst). contrary to expectations, results indicated that the specific cognitive processes of attention, working memory, and processing speed did not significantly correlate with executive functioning performance. however, scores of general intellectual functioning did significantly correlate with wcst performance, even after controlling for attention, working memory, and processing speed. these results suggest that general intellectual deficits may underlie executive functioning impairments in schizophrenia. the results of this study appear consistent with findings that iq often correlates with and can often be used to predict performance on a wide variety of neuropsychological tests (diaz-asper, schretlen, & pearlson, 2004). even in healthy, non-clinical samples, iq scores may be significantly associated with wcst performance in adults (diazasper et al., 2004; heaton, 1981) and children (arffa, lovell, podell, & goldberg, 1998; chelune, & baer, 1986), although correlations appear more modest than in clinical samples (heaton, 1981). however, while general intellectual functioning is often thought to be relatively stable, remediation studies indicate that the deficits associated with schizophrenia with respect to wcst performance do not appear wholly unremediable (bellack et al., 1990; delahunty et al., 1993; metz et al., 1994; perry et al., 2001; vollema et al., 1995; young & freyslinger, 1995). in addition, it has been shown that the skills measured on commonly used iq tests are trainable (staats, 1989; staats, 1990; staats & burns, 1981). thus, the results of this study may also suggest the importance of examining cognitive processes that are associated with each wais-iii (wechsler, 1997) subtest, particularly those not included in the computation of working memory and processing speed index scores. perceptual organization and verbal comprehension, for example, may contribute to wcst performance. scores from individual subtests that compose the wais-iii verbal comprehension and perceptual organization index scores were not able to be analyzed in this study due to a small sample size. however, the skills necessary for each of these subtests may also be important for wcst performance. for example, skills measured by wais-iii verbal subtests not directly analyzed in this study include distinguishing essential from non-essential detail, using abstract symbols, and abstract reasoning (groth-marnat, 2003). planning ability, attention to detail, accurate responding to visualspatial material, visual-spatial reasoning, and visual alertness and concentration are other skills measured by waisiii performance subtests (groth-marnat, 2003) not directly analyzed in this study. furthermore, additional wais-iii score configurations, such as horn’s (1985; kaufman & lichtenberger, 2002) broad visualization, as well as bannatyne’s (1974) spatial abilities, involve groupings of subtests not included in the working memory and processing speed index scores. as wcst performance also involves the use of visual cues, reasoning, and planning, these skills may prove to be significant contributors to understanding wcst performance impairment. it is also possible that cognitive processes not as explicitly measured by the wais-iii may be impaired in schizophrenia and factor into impaired wcst performance. cognitive processes, for example, such as concept formation and attribute identification (perrine, 1993) or insight and metacognition (koren et al., 2004) may better account for wcst performance impairments in individuals with schizophrenia. in terms of treatment implications, the identification of these potentially important cognitive processes may translate into improved wcst performance and executive functioning in individuals with schizophrenia. however, based on the results of this study, it would appear that a specific focus on improving attention, working memory, and processing speed may not carry over to improved wcst performance within this population of individuals with schizophrenia. the results of this study may be limited in their generalizability. first, the sample of the present study was drawn from a relatively understudied multicultural population palmer, heiby, fujii & kameoka 42 (leong, 1989) living in the hawaiian islands and thus consisted of a relatively large proportion of individuals of asian pacific islander descent. as such, related factors that were not included in the archived data used in this study (e.g., language proficiency, acculturation, familiarity with cognitive testing, etc.) may have impacted the statistical findings of this study. a review of the literature indicates that few studies have examined wcst performance deficits in ethnic minorities, and, in general, there is a need for more psychological studies on ethnic minorities (sue, 1999). this appears particularly relevant as iq scores vary across ethnic groups (lynn, 1996; suzuki & valencia, 1997), and ethnic background may predict performance on neuropsychological tests (gladsjo et al., 1999). individuals from disadvantaged cultural groups may also have higher rates of schizophrenia (eaton & harrison, 2000) and thus be at more risk for cognitive impairment. a second characteristic of the sample that may have implications for generalization is the inclusion of subjects with dual diagnoses. individuals with dual diagnoses are often excluded from neuropsychological studies, which may not be justified given that significant differences in wcst performance between non-affective psychotic patients with and without a dual diagnosis of comorbid substance use may not exist (liraud & verdoux, 2002). in addition, the high degree of comorbid substance use in individuals with schizophrenia (regier et al., 1990) suggests that many studies to date have looked at only a small subset of the larger population of individuals with schizophrenia due to the exclusion of comorbid substance use. comorbid substance use in this population may also be of great importance due to its association with poorer functional outcomes, more frequent hospitalizations, treatment noncompliance, a more severe course of the disorder, more severe symptomatology, and increased risk of suicide (bartels et al., 1993; jackson, fein, essock, & mueser, 2001; mueser, bellack, & blanchard, 1992). however, the research practice of combining data from individuals with different diagnoses invariably results in an increase in heterogeneity and may interfere with targeting what cognitive processes may be important to consider for executive functioning performance and the impairment that may be associated with specific disorders. the interpretation of statistical findings and the role that various cognitive processes may play in executive functioning in schizophrenia may have been clouded by the inclusion of dual diagnosis subjects. further research examining potential differences between individuals with schizophrenia with and without substance abuse problems may help clarify this issue and whether similar research in the future would benefit from the inclusion or exclusion of such dual diagnosis subjects. several additional limitations of this study may be noted. due to the correlational nature of the study, significant findings should not be interpreted as evidence of causation. also, several potentially relevant factors were not able to be addressed adequately by the archived data set, such as diagnostic reliability, medication use, symptom severity, and the reason for referral for neuropsychological testing. executive functioning performance and its relationship to other cognitive processes may differ for individuals with schizophrenia who are stable and on medications compared to those with more active and severe symptoms. future research may help to address these limitations and clarify what cognitive processes may help explain wcst performance in schizophrenia. addressing potentially relevant factors such as medication use and symptom severity, as well as measuring cognitive processes not addressed in this study, may illustrate key aspects to understanding executive functioning impairment. a comparison of individuals with and without dual diagnoses may also shed light on the degree to which executive functioning impairment and its related cognitive processes may be affected by substance use and have to be taken into consideration. furthermore, remediation studies with individuals with schizophrenia may provide the clearest evidence of the best path to cognitive rehabilitation. references american psychiatric association (2000). diagnostic and statistical manual of mental disorders (4 th ed., text revision). washington, d. c.: american psychiatric association. arffa, s., lovell, m., podell, k., & goldberg, e. 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(1995). scaffolded instruction and the remediation of wisconsin card sorting test deficits in chronic schizophrenia. schizophrenia research, 16, 199-207. graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 interpersonal psychotherapy for adolescents with depression: what has the research taught us so far? sadia r. chaudhury and karen a. shoum teachers college, columbia university given the high prevalence of depression among adolescents, there is a dire need for efficacious, cost-effective, and accessible treatments for adolescent depression. one type of psychosocial treatment shown to be efficacious in the treatment of adolescents with depression is interpersonal psychotherapy (ipt-a). originally developed and tested for depressed adults and modified for work with adolescents, ipt-a is a time limited, brief psychotherapy based on the premise that depression occurs in the context of interpersonal relationships (weisman, markowitz, & klerman, 2000). both the time-limited nature and focus on the present, especially social relationships, seem particularly relevant to adolescents and their specific developmental issues, including major life choices in education, work, and the establishment of intimate relationships. efficacy and effectiveness trials of ipt-a have demonstrated its flexibility and applicability. nevertheless, more efficacy data is warranted, with larger sample sizes and more diverse populations. depression in adolescents is much more prevalent than was once believed, and is currently seen as comparable to adults. this has been demonstrated in epidemiological surveys both nationally (i.e. the national comorbidity study [ncs], kessler, 2006) and in smaller community surveys of adolescents (e.g., cohen, et al., 1993). it is estimated that the one-year prevalence rate of depression in adolescents is between 1.6% and 8.9% (angold & costello, 2001). these rates of depression in youth may reflect an increased prevalence over previous decades. recent survey results from the ncs also show evidence of increased prevalence of childhood or adolescent onset depression among those born in more recent decades (kessler, avenevoli, & merikangas, 2001). in fact, half of all individuals who have a mental illness during their lifetime report that the onset of disease occurred by age 14 and three fourths report onset by age 24 (keuhn, 2005). retrospective assessment among community adults typically indicates that middle to late adolescence is the most common age at onset of first major depression or significant symptoms (e.g., burke, burke, regier, & rae, 1990). this has also been demonstrated across diverse cultures (cross-national collaborative group, 1992). young people who have an untreated mental illness may suffer debilitating symptoms during their most productive years, including problems with educational attainment and career and family building (kessler, avenevoli, & merikangas, 2001). despite these detrimental consequences, depression in adolescence is largely untreated (flaherty, weist, & warner, 1996). depressed adolescents are a largely underserved population that faces multiple barriers to receiving treatment (mufson, dorta, olfson, correspondence concerning this article should be addressed to the authors; email: sadiac80@gmail.com or ks46@columbia.edu. weissman, & hoagwood, 2004). there is a pressing need for more efficacious, cost-effective, and accessible treatments for adolescent depression. this paper will address an attempt to alleviate this problem through the development of a modified interpersonal psychotherapy for depressed adolescents (ipt-a). description of interpersonal psychotherapy (ipt) interpersonal psychotherapy is a time-limited therapy based on the idea that depression can be treated by focusing on the patient’s key interpersonal relationships (weissman, markowitz, & klerman, 2000). unlike other types of psychotherapy, ipt does not delve into the patient’s past to try and determine the cause of the depression. rather, by focusing on current interpersonal conflicts and improving relationships, ipt alleviates depressive symptoms by reducing current stressors. one of the most important steps in ipt is identifying a primary interpersonal problem area. the four main interpersonal problem areas are grief, interpersonal disputes, role transitions, and interpersonal deficits. during the 16 sessions of ipt, the therapist and patient focus on one, or at most two, of these problem areas as the primary focus of the therapy. in recent years, there has been strong empirical support for ipt’s effectiveness in the treatment of depressed adults (de mello, de jesus, bacaltchuk, verdeli, & neugebauer, 2005; o’hara, stuart, gorman, & wenzel, 2000; talbot, et al., 2005; weissman, 2007; weissman, klerman, prusoff, sholomskas, & padian, 1981). the development of interpersonal psychotherapy for depressed adolescents (ipt-a) 33 chaudhury and shoum 34 because ipt is based on the premise that the onset and perpetuation of depressive episodes occurs in an interpersonal context, its adaptation for adolescents is relevant. ipt addresses issues important to the developmental context of adolescents, such as major life choices in education, work, and establishment of intimate relationships. furthermore, the time-limited nature of ipt may fit the adolescent’s reluctance to seek or stay in treatment. the rationale for an adolescent adaptation to ipt is that improving the adolescent’s interpersonal context will help change the course of the depressive episode and result in recovery (moreau, mufson, weissman, & klerman, 1991). the initial phase of treatment in ipt-a is very similar to that of ipt; however, there are some key modifications. for example, drug abuse and suicidal behavior, both of which are serious problems with depressed adolescents, are thoroughly evaluated during the initial sessions. furthermore, in ipt-a the responsible parent plays an integral role in the therapeutic process and is brought into the initial phase of treatment to participate in psychoeducation about depression along with the adolescent. the middle phase of ipt-a focuses on one of the four primary problem areas identified during the interpersonal inventory completed during the initial phase. the main purpose of this phase of therapy is to assist the patient in making the association between depressive symptoms and interpersonal difficulties. finally, throughout all of the sessions of ipt-a, the issue of termination is raised in order to ensure that the adolescent is aware that the therapy is indeed time-limited. patients are advised that it is not uncommon for a slight exacerbation of symptoms to occur as therapy comes to an end. the skills acquired during therapy are reviewed during the termination phase, and the availability of an external support system is reiterated. early signs of depression and possibilities for future treatment, as needed, are discussed in order to ensure that the adolescent knows how to cope if there is a recurrence of depression (moreau et al., 1991). do the modifications work? initial trials of ipt in depressed adolescents in order to test the efficacy of ipt-a, phase i and phase ii studies were conducted (mufson et al., 1994). during phase i, modifications to ipt-a were made to the original ipt-a manual based on findings from therapeutic work with five depressed adolescents. in phase-ii, 14 depressed adolescents were enrolled in a clinical trial of ipt-a. this study found that depressed adolescents who underwent ipta experienced a significant decrease in depressive symptoms along with a significant improvement in overall functioning. in fact, by the end of the study, not one of the adolescents met criteria for a dsm-iii-r depressive disorder. while the phase ii study indicated the promise of ipt-a as an effective treatment for adolescent depression, a larger randomized controlled study, which would allow ipt-a to be compared to either a control condition or another treatment condition, was needed in order to truly determine efficacy of the therapy. recognizing that relapse is common in adolescents with a history of depression (kovacs et al., 1984, as cited in mufson & fairbanks, 1996), the authors set out to determine the clinical status of adolescents one year after the completion of therapy, and attempted to recontact the 14 adolescents who participated in the phase-ii trial. of these adolescents, 10 (7 hispanic females and 3 africanamerican females, mean age 17.5) agreed to participate in the follow-up evaluation. at follow-up, 9 of the adolescents met recovery criteria for depression based on both subjective (beck depression inventory, bdi) and objective (hamilton rating scale of depression, hrsd) measures of depression. in the realm of social functioning, though a trend was found suggesting some difficulties in the “friends” and “dating” dimensions, the overall gains in social adjustment were maintained one year after termination. the results of this study demonstrated that the improvements made during the 12-week trial of ipt-a were maintained during the full year following completion of treatment, suggesting that ipt-a is an effective treatment option for adolescents suffering from depressive disorders. however, there are limitations that must be considered when interpreting these results: 1) by only enrolling hispanic and african-american females, the sample is not representative of the general population; 2) with such a small sample, there was not enough statistical power to detect potentially significant benefits of ipt; and 3) this trial, as well as the initial open trial, lacked control groups for comparison. despite these limitations, this study provides important information about ipt-a while stressing the importance of conducting larger clinical trials in depressed adolescents to confirm preliminary findings. efficacy of ipt-a based on the result of the open clinical trial (mufson et al., 1994) and the one-year follow-up study (mufson & fairbanks, 1996), a randomized clinical trial to test the efficacy of ipt-a was conducted (mufson, weissman, moreau, & garfinkel, 1999) with 48 clinic-referred adolescents (ages 12-18 years) randomly assigned to either weekly onehour ipt-a sessions (n=24) or biweekly clinical monitoring (cm) with a therapist (control group, n=24) for 12 weeks. participants were administered an assessment battery biweekly by a blind independent evaluator to monitor their progress throughout the study. eligibility criteria for the study included meeting dsm-iii-r criteria for a current major depressive episode and having a score of 15 or more on the hrsd. there were no significant baseline differences demographically or on any outcome measures. although the ipt-a group (in comparison to the control group) reported significantly fewer depressive symptoms at week 12 on the hrsd (clinician-report), bdi (self-report) results showed no significant differences at the end of the treatment. the investigators of this study defined rates of interpersonal psychotherapy for adolescents 35 recovery as less than or equal to 6 on the hrsd, and less than or equal to 9 on the bdi. with these criteria, significantly more ipt-a patients (75%) than control patients (46%) met recovery criteria on the hrsd, a result that was significant at the p=.04 level. the results of the randomized controlled trial conducted by mufson et al. (1999) support the findings of the previous studies of ipt-a (mufson et al., 1994; mufson & fairbanks, 1996), providing further evidence that ipt-a is an efficacious tool in the treatment of depression in adolescents. however, the relatively small sample (24 subjects in each condition) implies the need for replication studies with larger sample sizes in order to confirm these findings. there was also a large drop-out rate in the clinical monitoring group which may have led to skewed results. furthermore, the sample in this study was predominantly hispanic females, which is not representative of the general population of depressed adolescents as a whole. finally, a key limitation with this efficacy trial, as with all efficacy trials, is the fact that given the stringent inclusion and exclusion criteria for this study, the results are not necessarily generalizable. in order to remedy this problem, effectiveness trials of ipta were conducted. effectiveness trials of ipt-a mufson, dorta, wickramaratne, nomura, olfson, and weissman (2004) examined the effectiveness of ipt-a compared with treatment as usual (tau) in school-based mental health clinics in the new york city area. details of how ipt-a was adapted for the school-based mental health clinics have been published (mufson, dorta, olfson, weissman, & hoagwood, 2004). participants in this 16week randomized clinical trial were 63 adolescents ages 1218 (mean age 15) who were referred for mental health intake visits and met dsm-iv criteria for major depressive disorder, dysthymia, depressive disorder not otherwise specified, or adjustment disorder with depressed mood. patients were randomized to either ipt-a (n=34), consisting of 12 sessions during 12-16 weeks, or tau (n=29), defined as whatever psychological treatment the adolescents would have received in their school clinics if the study had not been in place. though tau may have varied between schools, it was comparable to supportive individual counseling. results showed that adolescents who received ipt-a compared with those who received tau had significantly greater decreases in depressive symptoms both on both the clinician-report (hrsd) and self-report (bdi) at week 12. overall functioning and social functioning also significantly improved in the ipt-a group at week 12 as compared with the tau group. in examining whether research therapy can be applied to community settings, the present study (mufson, et al., 2004) concluded that interpersonal psychotherapy delivered in school-based health clinics was an effective therapy for adolescent depression. it was also notable that depressed adolescents in the ipt-a group, when compared to the tau group, showed significantly more improvement at a faster rate after eight consecutive weekly sessions of ipt-a. because larger treatment effects occurred in older and more severely depressed adolescents, the authors suggest that this group may benefit more from structured, targeted treatments such as ipt-a. despite its application to a “real world” setting, this study was limited again by its largely hispanic female sample from low socioeconomic backgrounds. other groups must be studied in order to establish the generalizability of these benefits. many of the participants in the aforementioned trial had comorbid disorders, in particular, comorbid anxiety disorders. young, mufson, and davies (2006) examined how comorbid anxiety affected the effectiveness of ipt in depressed adolescents within this sample. they found that comorbid anxiety was often indicative of a more severe depression, as evidenced by higher depression scores at baseline. furthermore, the depressed adolescents with comorbid anxiety had higher depression scores at the end of the study, regardless of treatment group, implying that this combination of depression and anxiety is more difficult to treat. at the same time, a non-significant trend was found suggesting that ipt-a was more effective in treating depression in adolescents with comorbid anxiety compared to tau. these results suggest that though depressed adolescents with comorbid anxiety tend to have a more severe course of illness than those without comorbid anxiety, ipta shows promise as an effective treatment for this difficultto-treat combination of disorders. in another study of effectiveness, rosselló and bernal (1999) evaluated two treatments—cognitive behavior therapy (cbt) and ipt-a, comparing them with each other and with a wait-list control (wc). this trial consisted of 71 adolescents, ages 13-17, in school grades 5 through 12 who met dsm-iii-r criteria for major depressive disorder, dysthymia, or both and who were randomly assigned to either cbt, ipt-a, or wc conditions. cbt and ipt-a treatment conditions consisted of 12 one-hour weekly individual therapy sessions over 12 weeks. the investigators found that both ipt-a and cbt were more effective than the control condition in reducing adolescents’ reports of depressive symptoms. they also found that ipt-a, when compared to cbt, increased self-esteem and social adaptation. although both ipt-a and cbt were superior to the wait-list control group, participants in the ipt group only benefited in their self-concept and social adaptation significantly more than participants in the wait-list control condition. limitations again included a small, mostly hispanic female sample and the use of only self-report measures. novice therapists given the fact that most adolescents receive care in community settings such as schools (mufson et al, 2004) it is important to design a brief yet effective training protocol that is feasible within existing constraints (i.e. training less experienced therapists). santor and kusumakar (2001) conchaudhury and shoum 36 ducted a trial of ipt-a using “novice” therapists. these therapists were considered novice because they lacked prior experience with ipt, learning about its principles during a 3-day intensive training workshop, followed by weekly supervision sessions during the following year. in this trial, 25 adolescents (ages 12-19 years; 23 females, 2 males) with dsm-iv diagnoses of major depression were recruited via consecutive referrals from outside clinicians. unlike the samples in other studies (mufson et al., 1994; mufson & fairbanks, 1996; mufson et al., 1999), all of the participants in this study came from two-parent homes of middle socioeconomic status. sixty percent of patients also met criteria for a comorbid diagnosis (dysthymia, posttraumatic stress disorder, anorexia nervosa, generalized anxiety disorder, conduct disorder, and/or social phobia). depression severity was assessed via the bdi (recovery defined as 13 or less) and hrsd (recovery defined as 5 or less), and global functioning was assessed through the children’s assessment of global functioning (c-gas). results indicated no significant differences in outcome measures as a function of the therapist’s professional background. santor and kusumakar (2001) found that 84% of participants displayed a significant decrease in depression as measured by the bdi and hrsd. in fact, at termination, only one of the 25 participants met dsm-iv criteria for depression. furthermore, based on c-gas results at termination, over half of the participants displayed a significant improvement in overall functioning. the results of this study provide further evidence that ipt-a is a highly effective mode of treatment for depressed adolescents, while also demonstrating that ipt can easily be implemented in community settings with therapists who have little or no experience with this form of therapy, provided that they receive adequate training and supervision. however, there was no control group in this study and thus no way to tell whether the results could actually be attributed to therapist training and background. generalizability was again limited by patient demographics, as all patients were mostly females from two-parent, middle-income families. group adaptation group therapy is also believed to be an effective treatment for adolescents with depression (mufson, gallagher, dorta, & young, 2004). it provides immediate opportunities to practice new skills, and it offers adolescents a context to decrease their feelings of isolation. in a group setting, collaboration can also provide adolescents with feelings of empowerment. there are opportunities for role play of communication skills, and room for advice and validation from peers. thus, the adaptation of ipt-a to a group setting (ipt-ag) seems particularly promising. furthermore, ipt-ag appears cost-effective (requires less staff for the treatment of more patients) and feasible in various settings including school, community, and primary care clinics (mufson, dorta, wickramaratne, et al., 2004). however, these benefits are also potential limitations in that the individual member’s problems may be eclipsed by those of other group members. mufson, dorta, olfson, weissman & hoagwood (2004) addressed this potential risk by incorporating individual initial sessions prior to group meetings, at midpoint, and at completion of the group. during these individual sessions, therapists conducted interpersonal inventories and described to the adolescent how his or her issues would be addressed within the group. nevertheless, in the group setting, attention to each individual’s specific problem(s) is more limited than in individual treatment, as the focus becomes common interpersonal elements among them. three pilot groups of four to six adolescents each were conducted to aid in the development of ipt-ag. of these three groups, one involved a chart review of mostly latino female patients ages 13-17 of low socioeconomic status. though measures could not be collected during group meetings, chart reviews were conducted by an independent evaluator. investigators found that the average attendance for group therapy was 90% (comparable to individual ipta studies) and that c-gas scores increased from baseline to termination (mufson, dorta, olfson, weissman & hoagwood, 2004). future work is necessary to assess the efficacy of the group modality for ipt-a. conclusion the literature review presented in this paper provides evidence for the efficacy, feasibility, and applicability of the adolescent adaptation of ipt (ipt-a). both ipt-a’s time-limited nature and focus on the present, especially social relationships, seem particularly relevant to adolescents and their specific developmental issues. additional work has studied ipt-a adaptations in a group modality and with novice therapists, demonstrating the flexibility of ipt-a therapy and its applicability to “real-world” settings. nevertheless, more efficacy data is warranted, with larger sample sizes and more diverse populations. for example, given that most of the trials of ipt-a were conducted with predominantly hispanic females of low socioeconomic status, additional studies are required in order to ensure that the original findings can be generalized to the larger overall population of depressed adolescents. additionally, it would be interesting to see how ipt-a compares to other evidence-based psychotherapies, such as cbt, as well as medications such as selective serotonin reuptake inhibitors (ssris) in treating depression. studies of this nature have been conducted with depressed adults, and it seems appropriate to conduct similar trials with depressed adolescents. the research to date on interpersonal psychotherapy in depressed adolescents has led to many important findings; with further research, more questions regarding the treatment of adolescents with depression will undoubtedly be answered. interpersonal psychotherapy for adolescents 37 references angold, a., & costello, e. j. (2001). the epidemiology of depression in children and adolescents. in i. m. goodyear (ed.), the depressed child and adolescent. (2nd ed., pp. 143-178). new york, ny: cambridge university press. burke, k. c., burke, j. d., regier, a., & rae, d. s. (1990). age at onset of selected mental disorders in five community populations. archives of general psychiatry, 47(6), 511-517. cohen, p., cohen, j., kasen, s. velez, c. n., hartmark, c., johnson, j., rojas, m., brook, j., & streuning, e. l. (1993). an epidemiological study of disorders in late childhood and adolescence: i. ageand gender-specific prevalence. journal of child psychology and psychiatry, 34, 851-867. cross-national collaborative group. (1992). the changing rate of major depression: cross-national comparisons. journal of the american medical association, 268, 30983105. de mello, m. f., de jesus, m. j., bacaltchuk, j., verdeli, h., & neugebauer, r. (2005). a systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. european archives of psychiatry and clinical neuroscience, 255(2), 75-82. flaherty, l. t., weist, m. d., & warner, b. s. (1996). school-based mental health services in the united states. community mental health j., 32, 341-352. kessler, r. c. (2006). national comorbidity survey: replication (ncs-r), 2001-2003 [computer file]. conducted by harvard medical school, department of health care policy/university of michigan, survey research center. icpsr04438-v3. ann arbor, mi: inter-university consortium for political and social research [producer and distributor], 2006-12-08. kessler, r. c., avenevoli, s., & merikangas, k. r. (2001). mood disorders in children and adolescents: an epidemiologic perspective. biological psychiatry, 49, 1002-1014. moreau, d., mufson, l, weissman, m. m., & klerman, g. l. (1991). interpersonal psychotherapy for adolescent depression: description of modification and preliminary application. journal of american academy of child and adolescent psychiatry, 30(4), 642-651. mufson, l. h., dorta, k. p., olfson, m., weissman, m. m., & hoagwood, k. (2004). effectiveness research: transporting interpersonal psychotherapy for depressed adolescents (ipt-a) from the lab to school-based health clinics. clinical child and family psychology review, 7(4), 251-261. mufson, l., dorta, k. p., wickramaratne, p., nomura, y., olfson, m., & weissman, m. m. (2004). a randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. archives of general psychiatry, 61, 577-584. mufson, l., gallagher, t., dorta, k. p., & young, j. f. (2004). a group adaptation of interpersonal psychotherapy for depressed adolescents. american journal of psychotherapy, 58(2), 220-237. mufson, l. & fairbanks, j. 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(1999). the efficacy of cognitivebehavioral and interpersonal treatments for depression in puerto rican adolescents. journal of consulting and clinical psychology, 67(5), 734-745. santor, d. a., & kusumakar, v. (2001). open trial of interpersonal therapy in adolescents with moderate to severe major depression: effectiveness of novice ipt therapists. journal of the american academy of child and adolescent psychiatry, 40(2), 236-240. talbot, n. l., conwell, y., o’hara, m. w., scott, s., ward, e. a., gamble, s. a., watts, a., & tu, x. (2005). interpersonal psychotherapy for depressed women with sexual abuse histories: a pilot study in a community mental health center. journal of nervous and mental disease, 193(12), 847-850. weissman, m. m. (2007). recent non-medication trials of interpersonal psychotherapy for depression. international journal of neuropsychopharmacology, 10(1), 117-122. weissman, m. m., klerman, g. l., prusoff, b. a., sholomskas, d., & padian, n. (1981). depressed outpatients. results one year after treatment with drugs and/or interpersonal psychotherapy. archives of general psychiatry, 38(1), 51-55. weisman, m. m., markowitz, j. c., & klerman, g. l. (2000). a comprehensive guide to interpersonal psychotherapy. new york: basic books. young, j. f., mufson, l., & davies, m. (2006). impact of comborbid anxiety in an effectivness study of interpersonal psychotherapy for depressed adolescents. journal of the american academy of child and adolescent psychiatry, 45(8), 904-912. graduate student journal of psychology copyright 2 graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 critical evaluation and conceptual organization of marital functioning measures bonita schneider teachers college, columbia university the sheer quantity and diversity of measures of marital functioning reflect the complexity of marital relationships. this paper presents a conceptual/theoretical framework for organizing these measures according to the five core domains of marital functioning (marital quality, marital adjustment, marital satisfaction, sexual satisfaction and intimacy) and those factors that influence these domains (relational, individual and external). the paper defines each of these core domains and influencing factors and discusses their complex interrelationship. for each domain and influencing factor, examples of popular measures that tap the construct or variable are highlighted and critically evaluated. the researcher, clinician, and student should find the framework presented in the paper helpful in terms of making sense of and selecting from the current proliferation of measures. fifty-four percent of the american population (15 years and older) is currently married (u.s. bureau of the census, 2000). however, despite the popularity of this institution, marriage ultimately proves a source of disappointment for many individuals. social statistics indicate that: a) couple problems are one of the chief complaints from those presenting for individual psychotherapy (maling, gurtman & howard, 1995), b) union dissolution rates are high, ranging from 50% for first marriages to 70% for those who have remarried (statistics canada, 2002; us bureau of the census, 1999) and c) the rates of coercive behaviors indicating the presence of physical, sexual and psychological violence in close relationships range from 10% to 25% for both physical and sexual violence and up to 75% for psychological violence (archer, 2000). clearly, the need for clinicians and researchers to assess, study and understand close relationships is of paramount importance. indeed, researchers have devoted considerable attention to factors that make marriages fulfilling and likely to continue (e.g. gottman, 1994a; gottman, 1994b). however, given the complex nature of marital relationships, over the years a vast number of variables or constructs concerning them have been identified. this in turn has resulted in an extensive range of measures designed to assess these variables or constructs (bradbury, 1995). in fact, the number of instruments and procedures that currently exist is so great that they have been chronicled and analyzed in a number of books (e.g. fredman & sherman, dr. roni b. tower is gratefully acknowledged and thanked for her input throughout the writing of this article and her helpful comments on the various drafts. correspondence concerning this article should be addressed to bonita schneider; e-mail: bs2257@columbia.edu. 1987; grotevant & carlson, 1989; jacob & tennenbaum, 1988; o’leary, 1987; touliatos, permutter & strauss, 1990). furthermore, according to bradbury (1995), “…the marital and family assessment literature has become a victim of its own success. the number and range of instruments has proliferated to such a degree that practitioners cannot afford to evaluate and select them properly,” (p. 459). the purpose of this paper is to provide clinicians and researchers with a simple framework for “organizing” the various relationship measures that reflect the five core domains of marital functioning inspiring their creation: (a) marital quality, (b) satisfaction, (c) adjustment, (d) intimacy and (e) sexual satisfaction. in addition, there are a number of factors (e.g. commitment, dependence, dissolution, individual characteristics and life events) that influence these five domains; and use of their associated measures can facilitate a greater understanding of marital functioning. the remainder of this paper will define each of these domains and discuss their interrelatedness. according to sabatelli (1988), any attempt to evaluate a measure requires an elaboration and understanding of the domain on which it is based. however, in the case of marital measures this is particularly complicated as there is a great deal of heterogeneity within them. thus, the conceptual distinctions between domains have become blurred. the latter is particularly true of marital adjustment, satisfaction and quality. consequently, domains are likely to be interrelated in complex ways (bradbury, 1995; sabatelli, 1988). following a discussion of the conceptualization of each of the domains, examples of the more widely used self report measures associated with each one will be presented and critically evaluated. particular attention will be given to measures that have a solid empirical foundation. while the 38 evaluation and organization of marital functioning measures 39 nature of marital assessment can vary dramatically depending upon the population being served (bradbury, 1995), this paper focuses on measures that are broadly applicable to a number of research and clinical needs rather than those that have been developed for highly specific populations or problems. finally, an effort has been made to cover a relatively broad array of measures at the expense of providing a great deal of information on each of them. these parameters are in keeping with those employed by bradbury (1995) in his discussion of a model of marital functioning and associated measures. while reviewing this paper the reader may find it helpful to refer to figure 1 for a graphic representation of the relationship domains and their associated measures, the interaction between the domains, and the factors influencing them. domains of marital functioning marital satisfaction definitions of marital satisfaction are theoretically grounded in social exchange and equity theories (vaughn & matyastik baier, 1999). according to walster, walster and berscheild (1978), inequitable exchanges cause distress and detract from satisfaction with one’s relationships. giving more to a relationship than one receives leads to feelings of unfairness and resentment, whereas receiving more then one gives leads to feelings of guilt and shame. consequently, an imbalance of either type leads to dissatisfaction. indeed, kamo (1993) found that relationship satisfaction increases when the relationship is perceived as fair. satisfaction measures typically tap an individual’s attitudes toward his or her partner and the relationship (roach, frazier & bowden, 1981). the unit of analysis is the individual (i.e., the individual’s attitudes or feelings), and the object of analysis is the individual’s subjective impression rather than objective accounts of the relationship (vaughn & matyastik baier, 1999). measures of marital satisfaction the relationship assessment scale (ras). the ras (hendrick, 1988) is a unifactorial measure of global relationship satisfaction and focuses on: how well the partner meets the other’s needs, how well the relationship compares to others, regrets about the relationship, how well the individual’s expectations have been met, love for partner, and problems in the relationship (hendrick, dicke & hendrick, 1998). using the ras is advantageous due to its brevity and the fact that it does not confound attitudes and behaviors. also, the seven-point scale permits evaluation of subtle variations in satisfaction across a wide spectrum. in terms of shortcomings, the ras is unable to unearth specific areas of distress and cannot clearly distiguisbetween satisfied and dissatisfied individuals due to the absence of cut-off scores. marital satisfaction scale (mss). the mss (roach et al., 1981) was designed specifically to measure satisfaction. roach et al. (1981) wanted to develop a uni-dimensional measure of an individual’s subjective attitude toward the marriage relationship. initially, a 73-item likert-type scale was developed; content was derived from the marital literature and the author’s experiences as a therapist. several evaluative studies allowed the measure to be refined and reduced to a final 48-item version. the authors of the mss have been praised for developing a unidimensional assessment tool that captures an individual’s subjective evaluation of their relationship. however, the content of the scale has been criticized. not all items evoke affect or opinion related to satisfaction with the marriage for example “i’m afraid of losing my spouse to divorce,” “i feel competent and fully able to handle my marriage,” “my spouse and i agree on what is right and proper conduct” (sabatelli, 1988). kansas marital satisfaction scale (kmss). the kmss (schumm et al., 1986) consists of three items and was designed as a short and direct assessment of marital satisfaction, including both satisfaction with spouse and the marriage relationship. the scale is praised for its direct focus on relationships as a whole and its validity (sabatelli, 1988). it also appears able to accurately assess marital satisfaction while maintaining brevity (schumm et al., 1986). the authors of the test acknowledge its fallibility due to socially desirable responding and the tendency for distribution of responses to the scale to depart significantly from what is normal in terms of skewness and kurtosis. enrich inventory. the enrich marital satisfaction scale (ems) is made up of two of the subscales of the enrich (evaluation and nurturing relationship issues communication and happiness) inventory, which is a multidimensional measure of marital satisfaction (fowers & olson, 1993). the ems scale is a 15-item measure that includes the idealistic distortion (5 items) and marital satisfaction (10 items) subscales from the original enrich inventory. each of the 10 marital satisfaction items represents a marital relationship area that fournier et al. (1983) deemed important and that was assessed by the full enrich inventory. the idealistic distortion scale serves as a marital conventionalization scale, correcting the marital satisfaction scale score by capturing the extent to which the respondent portrays the marriage in an unrealistically positive light. the ems scale provides a score for each individual as well as a couple schneider 40 score. the ems scale provides a broad sampling of the important domains of marital satisfaction and appears to provide a psychometrically sound means of measuring marital satisfaction (fournier et al., 1983). it also includes an assessment of marital conventionalization, which can aid in the recognition of overly positive evaluations of marriage and/or denial of problems. lastly, there is a readily available couple consensus score. in short, the ems scale is a brief measure that reflects many of the strengths of the full length enrich inventory. marital adjustment marital adjustment measures were developed to provide a richer view of marriage than that which is provided by simple satisfaction measures (spanier, 1976). marital adjustment typically refers to those processes that are presumed necessary to achieve a harmonious and functional marital relationship (sabatelli, 1988). bradbury (1995) describes it as the ways in which individuals and couples deal with their differences of opinion and individual or marital difficulties and transitions. a well-adjusted relationship is typically described as involving frequent interaction between partners, open communication, infrequent disagreement on important marital issues, and the ability to resolve disagreement when they do occur (spanier, 1976). for adjustment measures, the unit of focus is the dyad. measures of marital adjustment target the individual’s account of the relationship in an effort to gain insight into marital functioning. unlike satisfaction measures, which are designed to illicit the individual’s subjective perspective, adjustment measures attempt to gain a more objective perspective. it is assumed that respondents, completing adjustment measures, are reporting on the types of behaviors that characterize their marital interactions without presumably passing judgment on them (sabatelli, 1988). however, it has been noted that the conceptualization and operationalization of marital adjustment is confounded by the fact that satisfaction with the relationship and/or partner can also be included as a component of marital adjustment (locke & wallace, 1959; spanier 1976; spanier & cole 1976). hence, when satisfaction is conceived of as a component of adjustment, the measure’s focus is on both the dyad and the individual, and the measure’s object of analysis becomes both the objective aspects of dyadic interaction and the subjective impressions of the relationship (sabatelli, 1988). measures of marital adjustment the locke-wallace short marital adjustment test (lwmat). the lwmat (locke & wallace, 1959) has been in use since 1959. it assesses marital adjustment, which locke (1951) defined as a couple’s ability to avoid and/or resolve conflict so that both partners feel satisfied with the marriage and each other. this 15-item measure assesses the spouses’ happiness with each other and marriage, the degree of agreement on marital issues (i.e., sex, affection, philosophy of life), the experience of companionship, and the ability to constructively resolve conflicts. (locke & wallace, 1959). despite being in use for several decades, however, the measure has limitations. first, there is a tendency for individuals’ to respond in socially desirable ways. second, the lwmat was calculated on the basis of a sample made up only of well or poorly adjusted couples, compromising its reliability. finally, the conceptualization of adjustment may be outdated, for example, in response to the item dealing with companionship and recreation, the highest level of adjustment is assigned to those individuals who report that both spouses generally prefer to “stay at home” rather then be “on the go. ” dyadic adjustment scale (das). the das was developed by spanier (1976) for use with married and cohabiting couples. spanier (1976) defined adjustment as a process, the outcome of which is reflected by problematic differences and tensions between the couple, as well as dyadic satisfaction, cohesion and consensus on important matters. the das measure consists of 32 items derived from an original pool of 200 items. arriving at the final version of the scale involved a content review by a panel of judges, an item analysis, and factor analysis. the das yields a total score and four sub-scores each reflecting a dimension of adjustment, namely, dyadic satisfaction, dyadic consensus, dyadic cohesion and affectional expression. the validity of the das has been questioned as it involved discriminating between couples in therapy and normal controls. the overall dyadic adjustment score might also be biased as the measure includes subscales of differing lengths and items of different response categories. finally, there is a tendency to elicit subjective and global impressions due to the inclusion of both evaluative and descriptive items (sabatelli, 1988). however, there are several factors that support the ongoing use of the das. first, the das has a massive database collected on it and has proved to be a useful, reliable and valid measure in a number of studies (heyman, sayers & bellack, 1994). second, because the das asks about specific content areas, it provides a useful indicator of areas that are causing particular difficulty (heyman et al., 1994). finally, sabourin and colleagues (2005) have recently developed an abbreviated form of the das called the das-4. this was psychometrically sound, as effective as the original das, less contaminated by socially desirable responding and less time-consuming to administer. marital satisfaction inventory. evaluation and organization of marital functioning measures 41 the marital satisfaction inventory (msi) was developed by snyder (1979). it is an objective self-report measure designed to assess an individual’s attitudes and beliefs regarding specific areas of his or her marriage. although the measure’s name implies that it taps satisfaction, it aims to provide insight into the adjustment quality of a relationship. the msi consists of 280 true/false items that fall into one of 11 subscales covering 10 different dimensions of marital and family life including: global distress, affective communication, problem solving communication, time together, disagreement about finances, sexual dissatisfaction, role orientation, family history of distress, dissatisfaction with children, and conflict over child rearing. the msi also contains a conventionalization scale. the items comprising this validity scale reflect the tendency of subjects to distort their appraisals of their marriages in socially desirable direction. no composite or total satisfaction score is derived. the test was designed so that nine of the scales can be given to couples who have no children. snyder (1979) created the measure by combining test items on an intuitive basis and refining them through deriving the scales’ internal consistencies, item-to-total scale correlations, and correlations of each subscale with the global measure of satisfaction. because snyder (1979) was concerned with creating an inventory useful for clinicians, the msi can provide therapists with a comprehensive picture of the problem areas experienced by the couple. however, sabatelli (1988) raises concerns about the content validity of the inventory. there is a tendency for some scales to correlate highly with the global distress measure and there is an absence of data on scale inter-correlations. marital quality there are two distinct approaches to the conceptualization and operationalization of marital quality (sabatelli, 1988). the first is to treat marital quality as a hybrid concept reflecting both marital adjustment (i.e., good communication and the absence of conflict) and marital satisfaction (i.e., a high degree of satisfaction with the relationship and the spouse) (lewis & spanier, 1979). this blends adjustment and satisfaction into a broader and more inclusive construct. when marital quality is conceived of in this way, measures assess both objective and subjective aspects of the relationship, and both the dyad and the individual are the foci of analysis. the above results in a measure of marital quality closely resembling what has historically been presented as a measure of adjustment (sabatelli, 1988). the second way in which marital quality is conceptualized and operationalized is as reflecting an individual’s global evaluation of the marriage relationship (fincham and bradbury, 1987; norton, 1983). this allows inferences to be drawn about how respondents view their relationships. however, this formulation of marital quality is highly similar to conceptualizations of marital satisfaction. according to sabatelli (1988), when some researchers refer to an individual’s global evaluations or attitudes toward their partner or relationship they mean marital satisfaction while others are describing marital quality. measures of marital quality the quality of marriage index (qmi). the qmi (norton, 1983) is a six item measure of marital quality defined as a person’s subjective evaluation of the relationship as a whole, specifically how good it is. the six items that comprise the scale were derived from a 20-item pilot questionnaire that was administered to 430 married couples and then subjected to item and factor analyses. one of the measure’s strengths is that it provides a direct way of evaluating an individual’s global assessment of their marital relationship. however, there is a lack of extensive data supporting the measure’s validity. marital intimacy gilbert (1976) defined intimacy as a deep verbal and nonverbal exchange between two individuals, which conveys both acceptance and commitment to the relationship. according to van den broucke and colleagues (1995), intimacy is a dyadic phenomenon and defines the degree of connectedness between two partners. intimacy includes affective, cognitive and behavioral aspects (van den broucke, vandereycken & vertommenand, 1995) and consequently, measures of intimacy can be grouped according to which concept they primarily reflect (prager, 2000). marital intimacy can be conceived of as a process (i.e., a characteristic way of relating between two partners that develops over time), and it can also refer to the relatively stable higher-order relationship qualities that emerge from this process (van den broucke et al., 1995). intimacy can be regarded as an important domain of marital functioning, has been cited as an important component in marital relationships (berman & lief, 1975), and is considered one of several interpersonal dimensions of close and prolonged relationships (waring, tillman, frelick, russel & weiz, 1980). furthermore, intimacy is dynamically related to the other four core domains of marital functioning (i.e., marital satisfaction, marital quality, marital adjustment and sexual satisfaction). research has found intimacy to be positively related to satisfaction and commitment in close relationships (prager, 1995). there is also evidence that intimacy is the primary dimension that determines marital adjustment (waring, mcelrath, mitchell & derry, 1981). in terms of sexual satisfaction, lawrence and beyers (1995) and oggins and colleagues (1993) found that relationship characteristics such as intimacy are related to level of sexual satisfaction. sexuality is regarded as a core composite of intimacy (hames & waring, 1980; waring, mcelrath, mitchell & deary, 1981). measures of marital intimacy schneider 42 marital intimacy questionnaire (miq). the miq (van de broucke et al., 1995) is a 56-item self-report questionnaire that measures five factoranalytically derived dimensions: intimacy problems, consensus (generally exemplifying cognitive and behavioral aspects of intimacy), openness (including authenticity), affection, and commitment. its strengths include a strong conceptual link with a marital intimacy theoretical model, high face validity, reasonable length, and the fact that it is easy to administer and score by hand. it also allows for identification of the current strengths and weaknesses with regard to the couple’s intimacy. however, the test authors acknowledge the need for additional validation studies as well as an assessment of the scales’ predictive validity (van de broucke, et al., 1995). miller social intimacy scale. the miller social intimacy scale (msis) aims to assess the level of social intimacy currently experienced in a marriage, dating relationship, or friendship (miller & lefcourt, 1982). despite the fact that intimacy is not operationally defined, item analysis indicates that intimacy is conceptualized as involving frequent self-disclosures and confiding, intense feelings of affection, closeness, and empathy (sabatelli, 1988). the 17 items that make up this self-report inventory were selected from an initial pool of 30 items that were subjected to inter-item and item-to-total correlations. sabatelli (1988) praises the measure for its thoughtful construction and the efforts made to demonstrate its validity. however, since items were derived from content analysis of interviews with students about intimate relationships the content validity of the scale may be compromised. personal assessment of intimacy in relationships. the personal assessment of intimacy in relationships (pair; schaefer & olson, 1981) distinguishes between intimate experiences and intimate relationships, and assesses the degree to which each partner experiences intimacy in five different relationship areas: emotional intimacy, social intimacy, sexual intimacy, intellectual intimacy, and recreational intimacy. individuals are asked to respond to a 5-point likert scale regarding how they currently experience the relationship and how they would like to experience the relationship. this is particularly helpful clinically as it highlights the gap between the current reality of the relationship and expectations, which may themselves be unrealistic. the scale was created through the item and factor analysis of a large pool of items reflecting various types of intimacy. this process resulted in six items for each of the five intimacy dimensions, as well as a conventionality subscale. the pair provides valuable information on how intimacy experiences differ from expectations. weaknesses of the measure include that there is a conceptual difference between expectations and ideals that the pair neglects to clarify. also, although the measure could be used for research purposes by computing total scores from the subscale scores, schaefer and olson (1981) do not advocate this. they regard the measure’s strength as its ability to provide a profile of intimacy experienced across various dimensions. it is therefore their contention that a total score would be meaningless. sexual satisfaction according to schwartz and rutter (1998), sex is one of the most intimate behaviors in which couples engage and one that can serve as a barometer for the entire relationship. sexual satisfaction impacts marital functioning because it is related to marital satisfaction. frequency, quality of sex, and sexual satisfaction have been found to be associated with general relationship satisfaction (blumstein & schwartz, 1977; call, sprecher & schwartz, 1995; donnelly, 1993; cupach & comstock, 1990; edwards and booth, 1976; greeley, 1991; lawrence & byers, 1995; oggins, leber & veroff, 1993). prospective studies reveal that sexual problems and/or sexual dissatisfaction predicts later relationship dissolution (edwards & booth, 1994; oggins et al., 1993; veroff, douvan & hatchett, 1995; white & keith, 1991). consequently, understanding and assessing a couple’s functioning may necessitate the use of one of the many measures of relationship and/or individuals’ sexual functioning. one of the challenges faced by measures of sexual satisfaction is how to tap both the psychological and physiological elements of sexuality (young, denny, luquis & young, 1998). measures of sexual satisfaction golombok-rust inventory of sexual satisfaction. the golombok-rust inventory of sexual satisfaction, also know as griss (rust & golombok, 1985, is a short measure of sexual dysfunction for heterosexual couples. it contains 28 items covering seven major areas: frequency, satisfaction, interest, dysfunctions, anxiety, communication and touching. there are two subscales for males (impotence and premature ejaculation) and two subscales for females (anorgasmia and vaginismus). it provides overall scores for the quality of sexual functioning within a relationship for men and women separately. the initial test items were generated by sex therapists at the maudsley hospital sexual dysfunction clinic. the final test items were selected following several statistical analyses. the griss is a highly reliable measure of sexual dysfunction, discriminates well between those with and without sexual problems and appears sensitive to changes that result from planned interventions. evaluation and organization of marital functioning measures 43 factors influencing marital functioning from the proceeding discussion it is clear that there is considerable overlap in the conceptualization and operationalization of the domains of marital functioning, particularly marital satisfaction, adjustment and quality. clinicians and researchers who wish to gain an even greater understanding as to the exact causes underlying poor marital functioning can turn to one of the various measures of marital complaints that have been developed, such as the areas of change questionnaire (birchler & webb, 1977), the lovesickness scale (ryder, 1973), or the marital comparison level index (sabatelli, 1984). they could also consider employing marital measures related to those factors that influence marital functioning (i.e., commitment, dependence, dissolution potential, individual characteristics, and life events). the remainder of this paper mentions briefly each of these factors and their associated measures. relational influencing factor – commitment commitment has not typically been included as a variable in the research examining marital functioning (dean & spanier, 1974), however, several studies have highlighted its association with pro-relationship maintenance acts. these include the tendency to accommodate rather then retaliate when a partner behaves badly (rusbult, verette, whitney, slovik & lipkus, 1991), willingness to sacrifice desirable activities when conflicting with a partner’s preferences (e.g., van lange et al., 1997), and tendencies toward relationship-enhancing illusions (e.g., martz et al., 1998). in addition, rusbult, martz and agnew (1999) found that both commitment and commitment-inspired maintenance behaviors have been shown to be associated with couple wellbeing (i.e., tendency to persist in the relationship and marital adjustment). given the above, level of commitment appears to be associated with healthy functioning in ongoing relationships. measures of marital commitment lund commitment scale. the lund commitment scale (1985) assesses respondents’ thoughts about the likelihood of their relationship continuing, the degree to which respondents pursue alternative relationships, respondents’ perceptions of the costs involved in terminating their relationship, and respondents’ feelings of desire and obligation for continuing the relationship. respondents are also asked how committed their partner is to the relationship and how likely their partner is to continue in it. the nine items in the scale were derived from item, factor and reliability analyses. the scale is unidimensional (item loadings range from .29 to .81). criticisms of the measure include the fact that items within the scale were derived from students’ responses to open-ended questions about commitment rather then being based on conceptualizations of commitment. indeed, the current conceptualization of commitment underlying the lund commitment scale confounds personal commitment with perceptions of partner commitment; the latter is not a reflection of an individual’s interest in maintaining the relationship despite being statistically related. broderick commitment scale. beach and broderick (1983) created a single item measure of commitment that involves the individual being read a definition of commitment and then rating his or her level of commitment on a scale from 0 to 100. the primary criticism of the bcs is that it is a single item measure and therefore cannot fully represent the theoretical concept of commitment or discriminate among its nuances. also, it is harder to deduce the measurement properties of a single item measure. relational influencing factor marital dependence the investment model suggests that dependence produces the psychological experience of commitment (rusbult, 1980; 1983). according to drigotas and colleagues (1999) dependence is a structural property and describes the extent to which an individual needs a relationship, whereas commitment is a subjective experience occurring on a daily basis. the degree to which a person is dependent on a relationship typically follows from the presence of distinct obstacles that increase the cost of terminating the relationship. examples include the quality of alternative relationships, the experienced degree of indebtedness to the partner, personal belief systems about divorce, and structural features (i.e., community pressures, economic considerations) (sabatelli, 1988). measure of marital dependence marital alternatives scale (mas). the mas (udry, 1981, 1983) assesses two factors contributing to dependence: respondents’ perceptions of how much better or worse off they would be without their present spouse and how easily the spouse could be replaced with one of comparable quality. the mas consists of 11 items focusing on individuals’ perceptions of their alternative relationships and their expectation about the quality of their general situation following dissolution. respondents are instructed to suppose that their spouse were to leave this year. with this in mind, they are to decide whether they think it would be impossible, possible, probable, or certain, to find another spouse as good as the existing one, to be able to take care of themselves, and to be better off economically. the measure may be confounded with a more global perception of the quality of the marital relationship. schneider 44 relational influencing factor dissolution potential measures of dissolution potential address the degree to which people are thinking about separation and are planning or acting on these thoughts. these measures can be thought of as providing insight into how uncommitted individuals are in their marriage and allow researchers to make inferences about the potential instability of a relationship (sabatelli, 1988). measures of dissolution potential marital status inventory (msi). the msi (weiss & cerreto, 1980) is based on the assumption that the termination of a marriage unfolds as a series of discrete acts. given its theoretical orientation, the msi employs a guttman scale, with the scale’s items reflecting a progression from simply thinking about separation or divorce to actively preparing by establishing financial independence from spouse. weiss and cerreto (1980) acknowledge that the measure does not address the dissolution potential of a relationship directly, since there could be discrepancies in spouses’ scores. what the measure does provide is an assessment of the degree to which an individual has thought about or acted on terminating his or her relationship. a limitation of the msi lies in its failure to take into account when and how often the divorce thoughts and behaviors occur. the outcome of this is that judgment about dissolution potential of an individual may be based upon thoughts or behaviors that have occurred several years in the past (sabatelli, 1988). the measure may be best suited to those research situations in which changes in relationships over time are being investigated. marital instability index (mii). the marital instability index (mii: booth, johnson and edwards, 1983; booth, johnson, white and edwards, 1985) is designed to assess a couple’s predisposition to dissolve an existing marriage. specifically, it measures the degree to which divorce is being contemplated and uncovers evidence of behavior that indicates a high probability of marital termination. initially constructed and refined via item and factor analyses, the measure consists of 14 items. individuals are asked questions about their own as well as their spouses’ thoughts and feelings. the mii is a carefully constructed measure based upon a firm conceptual and methodological foundation. rather then being a measure of an individual’s likelihood to terminate the marriage, the mii is clearly designed to assess the dissolution potential of a relationship. in terms of criticism, asking an individuals to report on one’s spouse’s thoughts and behaviors is problematic, as one may not know if one’s spouse thinks that the relationship is in trouble. individual influencing factors individual characteristics many longitudinal studies of marriage have examined the stable demographic, historical, personality and experiential factors that individuals bring to marriage and how these factors influence marital outcome. such characteristics include educational experiences and attainment, peer interactions, dating history, sexual development, medical history and experiences in the family of origin (e.g. parental separation and divorce, family conflict, sibling relationships and financial hardships). when assessing/investigating a marital dyad, the clinician and researcher should remain conscious of these factors and their associated measures. one of these is the relationship questionnaire (bartholomew & horowitz, 1991), which is based on bowlby’s theory of attachment and assumes that individuals’ very early experiences in close relationships will shape the nature and development of subsequent relationships in adulthood. another is the five-factor model of personality which can be helpful in assessing and understanding relationships since personality factors such as neuroticism, extraversion, openness to expression, agreeableness, and conscientiousness influence relationship satisfaction and intimacy (white, hendrick and hendrick, 2004). external influencing factors life events and circumstances stressful events, developmental transitions, and chronic or acute circumstances that couples encounter can impact on marital wellbeing. indeed, studies focusing on these variables highlight how the events and environmental conditions to which couples are exposed can affect the quality and stability of marriage (bradbury, 1995). the social readjustment rating scale (holmes & rahe, 1967) is an example of a measure that can be used to assess this. conclusion marriage remains a popular institution despite the likelihood of divorce and high rates of dissatisfaction among married individuals. consequently, there is a great need for clinicians and researchers to assess, study, and understand close relationships. however, due to the complex nature of marriage there are a vast and diverse number of measures of marital functioning. this paper has attempted to provide the researcher, clinician and student with a simple framework for conceptually organizing these measures and understanding their complex interconnectedness. five core domains of marital functioning were presented, namely; marital quality, satisfaction, adjustment, intimacy, and sexual satisfaction. in addition, a number of individual, relational, and external factors (i.e., commitment, dependence, dissolution, individual characteristics, and life events) that influence these five evaluation and organization of marital functioning measures 45 domains were considered. finally, a number of measures relating to the core domains and factors were presented and critically 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(1998). correlates of sexual satisfaction in marriage. the canadian journal of human sexuality, 7(2), 115-127. schneider 48 figure 1 domains of marital function and influencing factors – interrelationship and associated measures marital adjust ment lwmat das msi intimacy miq msis pair marital satisfact ion ras mss kmss enrich sexual satisfaction g-riss marital quality qmi core domains of marital functioning commitment lcs bcs marital dependence mas dissolution potential msi mii individual characteristics rq 5 factor model relational influencing factors external influencing factor individual influencing factor life events & circumstances srrs � relationship domains and associated measures (in rectangles), the interaction between them (hard and dotted lines), and factors influencing them (arrows). ras – relationship assessment scale mss – marital satisfaction scale kmss – kansas marital satisfaction scale enrich – evaluation and nurturing relationship issues communication and happiness lwmat – the lock-wallace short marital adjustment test das – dyadic adjustment scale msi – marital satisfaction inventory qmi – quality of marriage index miq – marital intimacy questionnaire msis – miller social intimacy scale pair – personal assessment of intimacy in relationships griss – golombok-rust inventory of sexual satisfaction lcs – lund commitment scale bcs broderick commitment scale mas – marital alternatives scale msi – marital status inventory mii – marital instability index rq – relationship questionnaire srrs – social readjustment rating scale relational influencing factor marital dependence individual influencing factors individual graduate student journal of psychology the graduate student journal of psychology is a publication of the department of counseling and clinical psychology, teachers college, columbia university. editors traci r. stein jesse a. metzger clinical psychology program teachers college, columbia university editorial board sadia r. chaudhury alethea 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on the psychosocial outcomes of children whose mothers have borderline personality disorder. in addition, the final article in this volume addresses the rarely discussed but inarguably important ethical issues associated with the unexpected death of the therapist. a great deal of work has gone into this year’s volume and we hope you enjoy the outcome. as always, we are grateful for the ongoing mentorship and support of professor barry farber, the financial support of the department of counseling and clinical psychology, as well as the encouragement of its chair, professor suniya luthar. we are also most grateful to the editorial staff, who, despite often overwhelming academic schedules, dedicated their time and considerable effort to this work. sincerely, traci r. stein jesse a. metzger editor editor editors editorial board department advisor 114 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university evaluating the sampling precision of social identity related published research �ȅljǔ�vǩǹșȅǿॹ���ƺκǩǐ�eȗƺйǿȅλॹ��ƺǿǐ��eȅǿρ�vƺǿǡॹ new mexico state university cong wang, university of nebraska omaha social identity theory states that a person’s sense of who they are is based largely on their group membership(s). we categorize ourselves, identify with groups, and compare our groups with others, in the hopes that our self-esteem is ǿƺǩǿƞƺǩǿǔǐ�ȅȗ�ljȅȅșƞǔǐ�ǟȗȅǿ�ƞǧǩș�ljȅǿȓƺȗǩșȅǿঀ���ȓȗǔȗǔȕȣǩșǩƞǔ�ȅǟ�șljǩǔǿƞǩйlj�ȗǔșǔƺȗljǧॹ�ǔκǔǿ�ȗǔǡƺȗǐǩǿǡ�șȅljǩƺǹ�ǩǐǔǿƞǩƞρॹ�ǩș� ƞǧƺƞ�ȗǔșǔƺȗljǧǔȗș�ǿǔǔǐ�ƞȅ�ljǔ�ljȅǿйǐǔǿƞ�ƞǧƺƞ�ƞǧǔ�ǔǿȓǩȗǩljƺǹ�ǟƺljƞș�ȗǔƺǹǹρ�ƺȗǔ�ǟƺljƞȣƺǹআ�ƞǧƺƞ�ǩșॹ�ƞǧƺƞ�ƞǧǔ�șƺǿȓǹǔ�șƞƺƞǩșƞǩljș�ȗǔȓȅȗƞǔǐ� accurately estimate corresponding population parameters; this is known as sampling precision, or how precisely our sample corresponds to our population. by employing the recently invented a priori procedure, the present research assesses the sampling precision with which published experimental and correlational social identity research statistics, across three time periods, estimate corresponding population parameters. we hypothesized 1: the precision of research in the social identity area should be hopefully below the 0.10 level or at least the 0.20 level for true experimental designs and 2: precision in the social identity area should be improving, with recent social identity research enjoying ƺ�ȓȗǔljǩșǩȅǿ�ƺǐκƺǿƞƺǡǔ�ȅκǔȗ� ǹǔșș� ȗǔljǔǿƞ� șȅljǩƺǹ� ǩǐǔǿƞǩƞρ� ȗǔșǔƺȗljǧঀ���șƺǿȓǹǔ�ȅǟࢶࢸ��ƺljƺǐǔǿǩlj�ȓƺȓǔȗșॹ� ƺljȗȅșșࢷࢵ��ǐǩаǔȗǔǿƞ� journals was collected for analysis. for experimental studies, the mean precision level was 0.51 and the median precision level was 0.50 (n = 39). for correlational studies, the mean precision level was 0.24 and the median precision ǹǔκǔǹ�λƺșࢱ�ঀࢱࢳ�শǿ�઀ࢶࢶ�ষঀ�eǧǔ�ǿƺǩǿ�йǿǐǩǿǡș�ƺȗǔ�ȓǔșșǩǿǩșƞǩljॹ�ljȣƞ�λǩƞǧ�ƞǧǔ�ǡǹǩǿǿǔȗ�ȅǟ�ǹǩǡǧƞ�ƞǧƺƞ�ȓȗǔljǩșǩȅǿ�ǩș�ǩǿȓȗȅκǩǿǡঀ� ?dzͧ͡ȥȵǯȸ࣒�ȱȵdzǩȉȸȉȥȟ࣓�ǩȥȟϫǯdzȟǩdz࣓�ȸȥǩȉǚș�ȉǯdzȟȿȉȿͧ�ȿȅdzȥȵ࣓ͧ�ǚ�ȱȵȉȥȵȉ�ȱȵȥǩdzǯɂȵdz࣓�dzȸȿȉȝǚȿȉȥȟ the overarching idea of social identity theory is that the individual and the group are intertwined. people are born into social societies, they develop ties to social groups, they classify themselves as members of those social groups, and the ȣǿǩȕȣǔ� ljȅǿljǩǿƺƞǩȅǿș� ȅǟ� ƞǧȅșǔ� șȅljǩƺǹ� ljǹƺșșǩйljƺƞǩȅǿș� create unique individuals. according to stets and �ȣȗƿǔ� শࢱࢱࢱࢳষॹ� ǩǐǔǿƞǩƞρ� ǩș� ȗǔмǔπǩκǔ� ǩǿ� ƞǧƺƞ� ǩƞ�ǿƺƿǔș� ǩƞșǔǹǟ� ƺǿ� ȅljǵǔljƞ� λǧǩljǧ� ljƺǿ� ljǔ� ljƺƞǔǡȅȗǩφǔǐॹ� ljǹƺșșǩйǔǐॹ� ƺǿǐ� ǿƺǿǔǐ� ǩǿ� ȗǔǹƺƞǩȅǿ� ƞȅ� ȅƞǧǔȗ� șȅljǩƺǹ� ljǹƺșșǩйljƺƞǩȅǿșঀ� social identity is a person’s knowledge that they belong to a social group or category (hogg & abrams, 1988). a social group consists of individuals who hold ƺ�șǔƞ�ȅǟ�ljȅǿǿȅǿ�șȅljǩƺǹ� ǩǐǔǿƞǩйljƺƞǩȅǿșঀ�eǧǔșǔ�ǡȗȅȣȓș� are further categorized as the ingroup, which consists of individuals who are like the self, and the outgroup, which consists of individuals who are unlike the self. this process of accentuating the similarities with the ǩǿǡȗȅȣȓ�ƺǿǐ�ǐǩаǔȗǔǿljǔș�λǩƞǧ�ƞǧǔ�ȅȣƞǡȗȅȣȓ�ǹǔƺǐș�ƞȅ�ƺ� second process called social comparison. the process of identifying and categorizing yourself is known as self-categorization. social identity researchers commonly assume that by classifying social identities through self-categorization (and by extension accentuating similarities with the ingroup, etc.), individuals will enhance their own positive self-esteem by promoting the ingroup and denigrating the outgroup. no matter what the theoretical criticisms of social identity happen to be, the theoretical basis of identity and social identity research is not the current ȕȣǔșƞǩȅǿঀ�eȗƺйǿȅλ� ƺǿǐ�eρȧφ� শࢺࢲࢱࢳষ� ǐǔǿȅǿșƞȗƺƞǔǐ� ǩǿȓȗǔljǩșǩȅǿ� λǩƞǧ� ȗǔșȓǔljƞ� ƞȅ� йκǔ� ƺȗǔƺș� ȅǟ� ȓșρljǧȅǹȅǡρ� (social, developmental, clinical, cognitive, and neuro) ƺǿǐ� eȗƺйǿȅλॹ� /ρǿƺǿॹ� ƺǿǐ� ?ȅșƞρƿ� শࢱࢳࢱࢳষ� ǐǔǿȅǿstrated imprecision with respect to marketing research șȓǔljǩйljƺǹǹρঀ� kȣȗ� ǡȅƺǹ� ǿȅλ� ǩș� ƞȅ� ǔπȓƺǿǐ� ƞǧƺƞ� ǹǩǿǔ� ȅǟ� inquiry and address a potential criticism that, to our ƿǿȅλǹǔǐǡǔॹ�ǧƺș�ǿȅƞ�ljǔǔǿ�ǿƺǐǔঀ�^ȓǔljǩйljƺǹǹρॹ�ȅȣȗ�ǡȅƺǹ� is to address the issue of the sampling precision of social identity research. sampling precision is a measure of how close a sample’s descriptive statistics are to the corresponding population parameters. usually, and in the present case, this is measured as a fraction of a standard deviation. if the sampling precision of that research is impressive, it would imply that, whatever the ȅƞǧǔȗ� ǐǔйljǩǔǿljǩǔș� ȅǟ� șȅljǩƺǹ� ǩǐǔǿƞǩƞρ� ȗǔșǔƺȗljǧॹ� ƺƞ� ǹǔƺșƞ� there would be good reason to trust that the sample statistics are a good estimate of the corresponding population parameters. in contrast, if the sampling precision of social identity research is poor, it would imply that the sample statistics are not good estimates of the corresponding population parameters. a further imȓǹǩljƺƞǩȅǿ�λȅȣǹǐ�ljǔ�ƞǧƺƞ�ƞǧǔ�йǿǐǩǿǡș�ljƺǿǿȅƞ�ljǔ�ƞȗȣșƞǔǐॹ� which would be a preliminary problem that future re115 social identity precision search would have to solve before addressing the more ljȅǿljǔȓƞȣƺǹ�ǩșșȣǔș�ǩǐǔǿƞǩйǔǐ�ǩǿ�ƞǧǔ�ǟȅȗǔǡȅǩǿǡ�ȓƺȗƺǡȗƺȓǧঀ to summarize the present thinking, we believe that getting the empirical facts straight is vital both for theorizing and for evaluating theories. if a theory is unable to explain human behavior reliably and validly, then it is not a strong psychological theory. by ensuring that sample statistics are good estimators of population parameters, the reliability and validity of theoretical conclusions related to social identity theory ljƺǿ�ǩǿșȓǩȗǔ�ǡȗǔƺƞǔȗ�ljȅǿйǐǔǿljǔঀ�'ȣȗƞǧǔȗॹ�ƞǧǔ�ǡǔǿǔȗƺǹǩφƺtion of these theories would also be improved. thus, for the purpose of this article, the actual content of social identity theory is unimportant. what is most important, is the sampling practices of that research. to examine this issue, we use the a priori procedure. the a priori procedure the a priori procedure (app) assumes the cruciality of obtaining sample statistics that are good estimators of corresponding population parameters শeȗƺйǿȅλ� ǔƞ� ƺǹঀॹ� �ষঀࢱࢳࢱࢳ @ǔșƞ� ƞǧǔ� ȗǔƺǐǔȗ� ǐȅȣljƞș� ƞǧǩșॹ� imagine a fanciful scenario where laplace’s omniscient demon appears and informs us that there is no relationship between sample statistics and corresponding population parameters. in that case, no empirical reports would be trusted, nor would sample statistics be taken to provide good tests of hypotheses. of course, there is no demon, but considering the fanciful scenario renders salient the importance of estimation. given that estimation is crucial, there are two related questions. first, there is the precision question: how close do we desire that sample statistics be to their corresponding population parameters? second, ƞǧǔȗǔ� ǩș� ƞǧǔ� ljȅǿйǐǔǿljǔ� ȕȣǔșƞǩȅǿॸ� vǧƺƞ� ȓȗȅljƺljǩǹǩƞρ� do we insist on of being that close? the basic idea of ƞǧǔ��xx�ǩș�ƞǧƺƞ�ƞǧǔ�ȗǔșǔƺȗljǧǔȗ�ǿƺƿǔș�șȓǔljǩйljƺƞǩȅǿș�ǟȅȗ� ȓȗǔljǩșǩȅǿ�ƺǿǐ�ljȅǿйǐǔǿljǔॹ�ƺǿǐ�ƞǧǔǿ�ƺǿ��xx�ǔȕȣƺƞǩȅǿ� ȓȗȅκǩǐǔș�ƞǧǔ�ǿǔljǔșșƺȗρ�șƺǿȓǹǔ�șǩφǔ�ƞȅ�ǿǔǔƞ�ƞǧǔ�șȓǔljǩйcations. if the researcher collects the necessary sample size, or a larger one, then the researcher can be assured ȅǟ�ǿǔǔƞǩǿǡ�ƞǧǔ�șȓǔljǩйljƺƞǩȅǿș�শeȗƺйǿȅλ�ǔƞ�ƺǹঀॹࢱࢳࢱࢳ�ষঀ consider an example. suppose that a researcher intends to collect a single sample and is interested in йǿǐǩǿǡ� ȅȣƞ� ƞǧǔ� șƺǿȓǹǔ� șǩφǔ� ǿǔǔǐǔǐ� ƞȅ� ljǔ� �ઔࢶࢺ ljȅǿйdent of obtaining a sample mean within one-tenth of a standard deviation of the population mean. usǩǿǡ�ƺǿ�ǔȕȣƺƞǩȅǿ�ljρ�eȗƺйǿȅλ�শࢸࢲࢱࢳআࢺࢲࢱࢳ�ষॹ�� � � � � � � � � � � � ॹ where n is the sample size, f is the desired precision, and z(1-c)/2 is the z-score that corresponds to the deșǩȗǔǐ� ǐǔǡȗǔǔ� ȅǟ� ljȅǿйǐǔǿljǔঀ� 2ǿșƞƺǿƞǩƺƞǩǿǡ� κƺǹȣǔș� ǩǿƞȅ� the equation indicates the following: n=(1.96/0.1)2 ઀ࢵࢹࢴঀࢷࢲઇࢶࢹࢴঀ�eǧȣșॹ�ƞǧǔ�ȗǔșǔƺȗljǧǔȗ�λȅȣǹǐ�ǧƺκǔ�ƞȅ�ljȅǹǹǔljƞ� ��ȓƺȗƞǩljǩȓƺǿƞșࢶࢹࢴ ƞȅ�ǿǔǔƞ� șȓǔljǩйljƺƞǩȅǿșঀ� 2ǿșǩșƞǩǿǡ� on 385 participants may seem extreme compared to the much smaller sample sizes in most research, however, this provides a much greater level of precision than in ƞρȓǩljƺǹ�ȓșρljǧȅǹȅǡρ�ȅȗ�ǿƺȗƿǔƞǩǿǡ�ȗǔșǔƺȗljǧ�শeȗƺйǿȅλ�૭� eρȧφॹࢺࢲࢱࢳ�আ�eȗƺйǿȅλॹ�/ρǿƺǿॹ�૭�?ȅșƞρƿॹࢱࢳࢱࢳ�ষঀ�2ǟ� the researcher is willing to settle for less precision, such as precision at the 0.3 or 0.4 level typical in much social psychology research, the necessary sample size would drop dramatically. this precision can be treated much ǹǩƿǔ�ljȅǿйǐǔǿljǔ�ǹǔκǔǹॹ�λǧǔȗǔ�λǔ�λƺǿƞ�ƞȅ�șǧȅȅƞ�ǟȅȗ�ƺࢶࢺ�ઔ� ljȅǿйǐǔǿljǔ�ǹǔκǔǹ�ljȣƞ�ǿƺρ�ǧƺκǔ�ƞȅ�șǔƞƞǹǔ�ǟȅȗࢱࢺ�ઔॹ�ǟȅȗ�ȓȗǔcision we can shoot for .1 but may have to settle for .3 or.4, depending on the circumstances of the research. although the app was designed to be used pre-data, it can be used post-data too, which is a necessary condition for the present work. remaining with the foregoing example, suppose the researcher wanted to collect 385 participants but only succeeded in obƞƺǩǿǩǿǡࢱࢱࢲ��ȅǟ�ƞǧǔǿঀ�hșǩǿǡࢶࢺ�ઔ�ljȅǿйǐǔǿljǔ�ƺș�ƺ�ljȅǿventional value, what is the precision entailed by 100 participants? to answer, the foregoing equation can be algebraically manipulated to yield f as opposed to thus, if the sample size is 100, rather than 385, the actual precision would be 0.196 rather than ƞǧǔ� ǐǔșǩȗǔǐ� κƺǹȣǔ� ȅǟ� �ࢱࢲঀࢱ শeȗƺйǿȅλ� ǔƞ� ƺǹঀॹ� ষঀࢹࢲࢱࢳ researchers are usually interested in more comȓǹǔπ� ljƺșǔș� șȣljǧ� ƺș� ǐǩаǔȗǔǿljǔș� ljǔƞλǔǔǿ� ǡȗȅȣȓșॹ� ljȅȗȗǔǹƺƞǩȅǿ� ljȅǔгljǩǔǿƞș� ȅȗ� ǟȣǿljƞǩȅǿș� ȅǟ� ƞǧǔǿ� শǔঀǡঀॹ� ȗǔǡȗǔșșǩȅǿ� λǔǩǡǧƞșষॹ� ƺǿǐ� șȅ� ȅǿ� শeȗƺйǿȅλॹ� �ষঀࢺࢲࢱࢳ 2ǿ� more complex cases, the mathematics can become extremely complex; but it is not necessary to address that complexity here because hui et al. (2020) published links to programs for rendering the computations and these are free and user-friendly. however, ƞǧȅșǔ�ǩǿƞǔȗǔșƞǔǐ�ǩǿ�ƞǧǔ�ǿƺƞǧǔǿƺƞǩljș�ljƺǿ�ljȅǿșȣǹƞ�eȗƺйmow and macdonald (2017) for multiple groups, eȗƺйǿȅλॹ�vƺǿǡॹ�ƺǿǐ�vƺǿǡ�শࢱࢳࢱࢳষ�ǟȅȗ�ǐǩаǔȗǔǿljǔș� ǩǿ� means for independent samples or dependent samples, ƺǿǐ� vƺǿǡ� ǔƞ� ƺǹঀ� শࢲࢳࢱࢳষ� ǟȅȗ� ljȅȗȗǔǹƺƞǩȅǿ� ljȅǔгljǩǔǿƞșঀ to place into perspective the importance of preci116 wilson, trafimow, wang, wang șǩȅǿ�κƺǹȣǔșॹ�λǔ�ƞȣȗǿ�ƞȅ�eȗƺйǿȅλ�ǔƞ�ƺǹ�শࢹࢲࢱࢳষঀ�vǩƞǧǩǿ� șljǩǔǿƞǩйlj�ǩǿȕȣǩȗρॹ�ȗǔȓǹǩljƺƞǩȅǿ�ǩș�ƺ�κǩƞƺǹ�ƞȅȅǹ�ǟȅȗ�ƞǧǔ�κƺlidity and reliability of a theory. if the results based on a theory cannot be replicated, then that theory lacks șȣгljǩǔǿƞ�șȣȓȓȅȗƞঀ�2ǿ�ƺ�șǩǿǡǹǔেșƺǿȓǹǔ�șƞȣǐρॹ� ǩǟ�λǔ�ǐǔsire a precision value of .1, and we only have a sample size of 10, then the probability of replicating would only be .06! however, with 111 participants, that probability becomes .5, and so on as the sample size increases. the bottom line, then, is that the app can be used, in a post-data fashion, to determine the sampling precision of varied published social identity research, where the sample sizes are reported. and this in turn can be used to draw conclusions about the possible replicability, validity, etc. of that published research. one question that often comes up is why samȓǹǩǿǡ�ȓȗǔljǩșǩȅǿ�ǿƺƞƞǔȗș�ƺƞ�ƺǹǹঁ�2ǟ�λǔ�ǧƺκǔ�ƺ�ǡȅȅǐ�ǔаǔljƞ� size, then what is the point of the app? well, think ƺljȅȣƞ�ǔаǔljƞ�șǩφǔঀ�2ǟ�λǔ�ƺȗǔ�ǹȅȅƿǩǿǡ�ǟȅȗ�ƺ�șȓǔljǩйlj�ǔπȓǔȗǩǿǔǿƞƺǹ�ǔаǔljƞॹ�ƺǿǐ�ȅȣȗ�ǔаǔljƞ�șǩφǔ� ǩș� ǹƺȗǡǔ�ǔǿȅȣǡǧॹ�ǿȅ� matter how small a sample we have, we will be able to șǔǔ�ƞǧǔ�ǔаǔljƞঀ�/ȅλǔκǔȗॹ�ǐȅǔș�ƞǧƺƞ�ǿǔƺǿ�ƞǧƺƞ�ƞǧǔ�λǧȅǹǔ� population of the world will also undergo that same ǔаǔljƞঁ�[ǔƺǹǩșƞǩljƺǹǹρ�ǿȅƞঀ�eǧƺƞ� ǩșॹ� ǿȅ�ǿƺƞƞǔȗ�λǧƺƞ� ƞǧǔ� ȅljƞƺǩǿǔǐ� ǔаǔljƞ� șǩφǔ� ǟȅȗ� ȅȣȗ� șƺǿȓǹǔॹ�λǔ� ǧƺκǔ� ǿȅ� ǩǐǔƺ� ǩǟ� ƞǧƺƞ�ǔаǔljƞ�șǩφǔ� ǩș�ljǹȅșǔ�ƞȅ�ƞǧǔ�ȓȅȓȣǹƺƞǩȅǿ�ǔаǔljƞ�șǩφǔ� unless there has been some sort of app calculation. therefore, there is no way to know how well the obƞƺǩǿǔǐ�ǔаǔljƞ�șȣȓȓȅȗƞș�ȅȗ�ǐǩșljȅǿйȗǿș�ƞǧǔ�ǧρȓȅƞǧǔșǩș�ȅȗ� theory from which the hypothesis was derived. this is the strength of the app and sampling precision. sampling precision values, and the app, can be used ƞȅ�ȓȗȅκǩǐǔ� ǩǿljȗǔƺșǔǐ�ljȅǿйǐǔǿljǔ� ǩǿ�ȅȣȗ� șƺǿȓǹǔ� șƞƺƞǩșƞǩljșॹ�ƺǿǐ�ƞǧȣș� ǩǿljȗǔƺșǔǐ�ljȅǿйǐǔǿljǔ�ƞǧƺƞ� ƞǧǔ�ǔаǔljƞ�λǔ� are seeing is representative of the overall population, ǿȅƞ�ǵȣșƞ�ƞǧƺƞ�ƞǧǔ�ǔаǔljƞ�ǩș�ȓȗǔșǔǿƞ�ǩǿ�ȅȣȗ�șƺǿȓǹǔঀ�kκǔȗall, the app sampling precision values can be viewed ƺș� ƺ� ljǹȅșǔǿǔșș� șƞƺƞǩșƞǩlj� șǩǿǩǹƺȗ� ƞȅ� ljȅǿйǐǔǿljǔ� ǹǔκǔǹș� ǩǿ� that the more stringent criteria we use, the more conйǐǔǿƞ� λǔ� ljƺǿ� ljǔ� ǩǿ� ȅȣȗ� ǩǿǟǔȗǔǿljǔș� ƺǿǐ� ljȅǿljǹȣșǩȅǿșঀ in this study, we tested competing hypotheses from optimistic versus pessimistic viewpoints. from an optimistic viewpoint, the expectations would be as follows. h1: the precision of research in the social identity area should be hopefully below the 0.10 level or at ǹǔƺșƞ�ƞǧǔࢱ�ঀࢱࢳ�ǹǔκǔǹ�ǟȅȗ�ƞȗȣǔ�ǔπȓǔȗǩǿǔǿƞƺǹ�ǐǔșǩǡǿș�শeȗƺйmow, 2018). h2: precision in the social identity area should be improving, with recent social identity research enjoying a precision advantage over less recent social identity research. of course, from a pessimistic perspective, the foregoing hypotheses should not be supported. if the precision of social identity research is worse than 0.30 শƞǧƺƞ� ǩș� ǹƺȗǡǔȗষॹ� ƞǧƺƞ�λȅȣǹǐ�șȣȓȓȅȗƞ�ȓǔșșǩǿǩșǿ�শeȗƺйǿȅλॹࢹࢲࢱࢳ�ষঀ�'ȣȗƞǧǔȗॹ�ǩƞ�λȅȣǹǐ�ljǔ�ȣǿǐǔșǩȗƺljǹǔ�ƞȅ�йǿǐ� that precision is not improving, as an increase in precision is related to an increase in replicability and stronger generalization of theory, and as research methods have supposedly improved as time passes, we should hope to see an improvement in sampling precision as well. finally, because the app has never been used systematically to analyze correlational research, the relevant correlational analyses to be presented can be ljȅǿșǩǐǔȗǔǐ�ǔπȓǹȅȗƺƞȅȗρ�ƺș� ƺ�йȗșƞ� șƞǔȓ� ƞȅλƺȗǐș�ƺ�ǿȅȗǔ� integral use of the app in sampling analysis. method the goal of this research was to investigate the precision (how close a sample statistic would be to its population parameter) of a sample of published social identity research. to investigate the question of whether șȅljǩƺǹ�ǩǐǔǿƞǩƞρ�ȗǔșǔƺȗljǧ�йǿǐǩǿǡș�ƺȗǔ�ȓȗǔljǩșǔ�ǔǿȅȣǡǧ�ƞȅ� be trusted, we applied the app programs presented by hui et al. (2020) to test the precision of the studies included in a sample of published social identity research. the present a posteriori use of the app has been sysƞǔǿƺƞǩljƺǹǹρ�ǔǿȓǹȅρǔǐ�ljρ�eȗƺйǿȅλ�ƺǿǐ�eρȧφ�শࢺࢲࢱࢳষ� ƺǿǐ�eȗƺйǿȅλॹ�/ρǿƺǿॹ�ƺǿǐ�?ȅșƞρƿ�শࢱࢳࢱࢳষ�ǟȅȗ�ǔπȓǔȗimental research but not for correlational research. procedure a total sample of 75 academic papers (see table 1) was collected, prior to data analysis, broken down into 25 papers per time period across three time periods: 2014 to 2021, 1995 to 2001, and 1975 to 1981. 2ƞ�λƺș� ǩǿȓȅȗƞƺǿƞ� ƞȅ� ǩǿljǹȣǐǔ� ƺ� șƺǿȓǹǔ� șȣгljǩǔǿƞǹρ� ǐǩverse to be representative of the existing literature, while also ensuring that the sample broke into equal portions. the sample included articles from 46 different journals, randomly selected from the set of articles that met our criteria, from multiple academic disciplines (i.e., psychology, advertising, business, sociology, etc.). the primary criteria for selection were: 1. must include social identity as a primary target of interest for investigation. this may be as 117 a theoretical concept, an applied concept, etc. this was checked via the mention of social identity in subject terms, titles, or the paper itself. 2. must directly specify the methodology (correlational, between-subjects, etc.). this is important, as determining the method of analysis is vital to understanding the precision of particular samples using the app equations. 3. must have a publication date within one of the three date ranges (1975-1981, 1995-2001, 2014-2021). these date ranges were chosen as an exploratory (not exhaustive) representation of research across time. the articles were picked using the institutionƺǹ� ǹǩljȗƺȗρ� șǔƺȗljǧ� ƞȅȅǹঀ�?ǔρλȅȗǐș�ȣșǔǐ� ƞȅ�йǹƞǔȗ� ȗǔșȣǹƞș� were as follows: social identity, social identity theory, sit, experimental, correlational, and research. articles were picked using a random method of 2 articles per results page starting from the top. if the article did not specify social identity, the research method, or was outside of the appropriate date ranges, then it was skipped, and the next article was picked. once two articles on the page were selected, we moved to the next results page and began selection again. all studies picked in this sample were quantitative leaning (i.e., analysis was done quantitatively). once the articles were collected, the relevant information was cataloged via an excel spreadsheet শǐƺƞƺ� ƺκƺǩǹƺljǹǔ� ǟȗȅǿ� vǩǹșȅǿॹ� eȗƺйǿȅλॹ� vƺǿǡॹ� ૭� wang, 2021 via the osf open-access database). the information cataloged included the citation for the paper, journal, publication year, number of studies included in the paper, sample sizes, and number of conditions. while some of this information is not pertinent for the actual precision analysis, examinǩǿǡ� ǐǩаǔȗǔǿljǔș� ǩǿ� ƞǧǔ� ǿǔƺǿș� ƺǿǐ� ǿǔǐǩƺǿș� ljρ� ȓȣljlication year and methodology type is of interest for potential broader investigations and conclusions. to determine the precision of each study, we used the app programs listed in hui et al. (2020). given sample sizes reported in the articles, and assuming a convenƞǩȅǿƺǹࢶࢺ�ઔ�ljȅǿйǐǔǿljǔ�ǹǔκǔǹॹ�ƞǧǔ�ȓȗȅǡȗƺǿș�ȓȗȅκǩǐǔ�ƞǧǔ� ȓȗǔljǩșǩȅǿ� ǹǔκǔǹॹ� ljȣƞ�λǩƞǧ� ƺ� ljȅǿȓǹǩljƺƞǩȅǿঀ� ^ȓǔljǩйljƺǹǹρॹ� because some studies were experimental whereas others were correlational, there are mathematical reasons why the precision of the correlational studies cannot be compared directly to the precision of the experimental studies (wang et al., 2021)1. consequently, results pertaining to experimental studies and results pertaining to correlational studies will be presented separately. results there were too few mixed designs for analysis and so we focused on between-participants experimental studies and correlational studies. for experimental studies, the mean precision level was 0.51 (sd = .25) and the median precision level was 0.50 (n = �ষঀ�eǧǔșǔ�йǿǐǩǿǡșࢺࢴ șȣȓȓȅȗƞ�ƺ�ȓǔșșǩǿǩșƞǩlj�κǩǔλ�ȅǟ�ǔπperimental social identity research. for correlational studies, the mean precision level was 0.24 (sd = .16) and the median precision level was 0.20 (n = 55). however, we reiterate that the precision of correlational research cannot be compared to the precision of experimental research. as correlations range from -1 to +1, and the precision value pertains to the fraction of a variance (not a fraction of a standard deviation), the degree to which this level of precision in correlational research is pessimistic or optimistic is a judgment call. certain theories and paradigms may require more șƞȗǩǿǡǔǿƞ�ljȣƞȅаș�ǟȅȗ�λǧƺƞ� ǩș�ljȅǿșǩǐǔȗǔǐ�ȅȓƞǩǿǩșƞǩlj�ȅȗ� pessimistic, and since correlational app equations use variance instead of standard deviation in analyșǩșॹ� ƞǧǔ� ljȣƞȅаș� ƺȗǔ� ƺ� ǵȣǐǡǿǔǿƞ� ljƺǹǹ� ȅǟ� ƞǧǔ� ȗǔșǔƺȗljǧǔȗঀ � eȅ�ǔκƺǹȣƺƞǔ�ƞǧǔ�ǔаǔljƞ�ȅǟ�ƞǧǔ�ρǔƺȗ�ȅǟ�ȓȣljǹǩljƺƞǩȅǿ�ȅǿ� precision, we performed multiple correlational analyses. first, we obtained mean and median precision levels across the three time periods for the experimental research. the mean precision levels were 0.59 (n = 17, sd = .20), 0.64 (n = 10, sd = .24), and 0.29 (n = 12, sd = .16) for the most distant to most recent time periods, respectively. the corresponding median precision levels were 0.59 (n = 17), 0.71 (n = 10), and 0.23 (n = 12). with respect to correlational research, the mean precision levels were 0.23 (n = 11, sd = .09), 0.27 (n = 24, sd = .19), and 0.21 (n = 20, sd = .15) for the most distant to most recent time periods, respectively. the corresponding median precision levels for correlational studies were 0.25 (n = 11), 0.23 (n = 24), and 0.18 (n = 20). overall, both correlational and experimental precisions have shown improvement over time, with experimental studies showing much more improvement than correlational studies. second, we correlated precision with the year of 1 1 these include that correlations are bounded (-1, +1) and that the precision level refers to a squared standard deviation (variance) as opposed to a stanthese include that correlations are bounded (-1, +1) and that the precision level refers to a squared standard deviation (variance) as opposed to a standard deviation. dard deviation. social identity precision 118118 publication. because smaller values indicate better precision, an optimistic perspective suggests a negative correlation whereas a pessimistic perspective suggests no correlation or a positive correlation. the correlation was -0.445 (n = 39, p = .004) for experimental research and -0.056 (n = 55, p = .687) for correlational research. figure 1 contains a scatterplot pertaining to experimental research and figure 2 contains a scatterplot pertaining to correlational research, both with the ljǔșƞ�йƞ�ƞȗǔǿǐǹǩǿǔ�ƞȅ�ǔπƺǿǩǿǔ�ƞǧǔ�ȓȗȅǡȗǔșșǩȅǿ�ȅǟ�ƞǧǔ�ǐƺƞƺঀ from the data presented in figure 1, we can see a clear negative trend across time. as the publication year becomes more recent, the precision level figure 1. scatterplot representing precision of experimental social identity research along the vertical axis as a function of year of publication along the horizontal axis. figure 1. scatterplot representing precision of correlational social identity research along the vertical axis as a function of year of publication along the horizontal axis. moves further towards zero, indicating a promising improvement in experimental precision. in contrast, 'ǩǡȣȗǔࢳ��ǐȅǔș�ǿȅƞ�șǧȅλ�ǿȣljǧ�ȅǟ�ƺǿ�ǔаǔljƞ�ȅǟ�ƞǩǿǔ�ȅǿ� correlational precision. these time-period correlations should be taken as exploratory however due to the small sample sizes within each time period. discussion social identity research composes an important domain within social psychology that is relevant to othǔȗ�йǔǹǐș�ƞȅȅ�șȣljǧ�ƺș�ǿƺȗƿǔƞǩǿǡॹ�șȅljǩȅǹȅǡρॹ�ƺǿǐ�ȅƞǧǔȗșঀ� hence, it is unsurprising that there is a large literature and many arguments both praising and criticizing social identity theory. the present work is agnostic about ƞǧǔ�ǹƺȗǡǔȗ�șȅljǩƺǹ�ǩǐǔǿƞǩƞρ�ǩșșȣǔș�ljȗǩǔмρ�ǿǔǿƞǩȅǿǔǐ�ǔƺȗǹǩer. this is not to say that these issues are unimportant; in contrast, we believe they are very important. however, we also believe that if empirical facts are going to be used either to test theories or to provide the foundation for theory formation, it is crucial to be clear that the empirical facts really are factual. that is, it is a prerequisite that researchers have good reason to believe that the sample statistics researchers report are reasonably good estimates of corresponding population parameters. our goal was to test whether this prerequisite has been met in a sample of published research. the picture is very clear with respect to experiǿǔǿƞƺǹ� ȗǔșǔƺȗljǧঀ� ^ƺǿȓǹǔ� șǩφǔș� ƺȗǔ� șǩǿȓǹρ� ǩǿșȣгljǩǔǿƞॹ� thereby resulting in precision levels that one would consider untrustworthy. it is true that there are many ǟƺljƞȅȗș�ƞǧƺƞ�ljƺǿ�ljȗǔƺƞǔ�ƞǧǔșǔ�ǩǿșȣгljǩǔǿƞ�ǿȣǿljǔȗș�șȣljǧ� as funding constraints, time, feasibility, and more. however, this does not disqualify the conclusion of ǩǿșȣгljǩǔǿƞ� șƺǿȓǹǔ� șǩφǔșॹ� ljȣƞ� ȅǿǹρ� ǩǿljȗǔƺșǔș� ƞǧǔ�ǿǔǔǐ� for more detailed and stringent research practices. it is important to note that quality research with smaller sample sizes is still very much alive and is in no way disȕȣƺǹǩйǔǐ�ǐȣǔ�ƞȅ�șƺǿȓǹǩǿǡ�ȓȗǔljǩșǩȅǿঀ�2ǿșƞǔƺǐॹ�șƺǿȓǹǩǿǡ� precision should be taken as an additional tool to assist researchers, in an a priori fashion, to determine a sample size needed for sample statistics that meet their corresponding population parameters, in essence giving researchers a goal for their eventual work to shoot for. there is some good news, which is that precision is improving, with research in the most recent period of research exhibiting more precision than research in previous periods. but even with the improvement, ǩƞ�λȅȣǹǐ�ljǔ� ǐǩгljȣǹƞ� ƞȅ� ƺȗǡȣǔ� ƞǧƺƞ� ƞǧǔ� ǹǔκǔǹ� ȅǟ� ȓȗǔljǩwilson, trafimow, wang, wang 119 social identity precision șǩȅǿ� ǩș� șȣгljǩǔǿƞঀ�/ȅλǔκǔȗॹ� �eȗƺйǿȅλ�ƺǿǐ�eρȧφ� শࢺࢲࢱࢳষ� ǐǔǿȅǿșƞȗƺƞǔǐ� ǩǿȓȗǔljǩșǩȅǿ� λǩƞǧ� ȗǔșȓǔljƞ� ƞȅ� йκǔ� ƺȗǔƺș� ȅǟ� psychology (social, developmental, clinical, cognitive, ƺǿǐ� ǿǔȣȗȅষॹ� ƺǿǐ� eȗƺйǿȅλॹ�/ρǿƺǿॹ� ƺǿǐ� ?ȅșƞρƿ� শࢱࢳࢱࢳষ� demonstrated imprecision with respect to marketing, there is no reason to be more pessimistic with respect to social identity research than other social science research. it is perhaps better to view social identity research as another domain in which researchers should devote increased ȗǔșǔƺȗljǧ� ǔаȅȗƞș� ǩǿ� ƞǧǔ� ǐǩȗǔljƞǩȅǿ� ȅǟ� ǩǿȓȗȅκǔǐ� ȓȗǔljǩșǩȅǿঀ � �ș� ƞǧǔ� ȓȗǔșǔǿƞ� λȅȗƿ� ljȅǿșƞǩƞȣƞǔș� ƞǧǔ� йȗșƞ� șρșƞǔǿƺƞic application of the app to correlational research, the correlational analyses are better considered exploratory ƞǧƺǿ�ǐǔйǿǩƞǩκǔঀ��ȅȗȗǔǹƺƞǩȅǿƺǹ� ȗǔșǔƺȗljǧ�ȅаǔȗș�ljȅƞǧ�ƺǐκƺǿtages and disadvantages relative to experimental research. from an app perspective, an advantage of correlational research is that there is only one group, thereby rendering precision easier to obtain. going beyond an app perspective, correlational research can be argued to be more representative of reality because of a lack of poƞǔǿƞǩƺǹǹρ� ƺȗƞǩйljǩƺǹ� ǹƺljȅȗƺƞȅȗρেǩǿǐȣljǔǐ� ǿƺǿǩȓȣǹƺƞǩȅǿঀ� 2ǿ� addition, it is easier to obtain diverse samples in correlational contexts, though the recent proliferation of λǔljেȓǔȗǟȅȗǿǔǐ� ǔπȓǔȗǩǿǔǿƞș� ǩș� ȗǔǐȣljǩǿǡ� ƞǧǩș� ǐǩаǔȗǔǿljǔঀ but there are disadvantages too. from an app perspective, a disadvantage is the lack of previous systematic app ƺȓȓǹǩljƺƞǩȅǿș�ƞȅ�ljȅȗȗǔǹƺƞǩȅǿ�ljȅǔгljǩǔǿƞșॹ�ƞǧǔȗǔljρ�ȗǔǿǐǔȗǩǿǡ� ljȅǿȓƺȗǩșȅǿ�ǐǩгljȣǹƞঀ�eǧǩș�ǩș�ǿȅƞ�ƺ�ǟƺȣǹƞ�ȅǟ�ƞǧǔ�ljȅȗȗǔǹƺƞǩȅǿƺǹ� research itself, but rather due to the historical fact that app equations applicable to experimental data were developed prior to app equations applicable to correlational data, and thus the basic assumptions underlying the equations cannot be directly compared on an “a = b” comparison. more generally, it is well-known that correlational research provides a less convincing case for causal mechanisms than experimental research. on the other hand, however, given the present demonstration of the lack of precision of experimental social identity research, it is not clear that even ƞǧǔ�ǔπȓǔȗǩǿǔǿƞƺǹ�йǿǐǩǿǡș�ȓȗȅκǩǐǔ�șƞȗȅǿǡ�ljƺȣșƺǹ�ǔκǩǐǔǿljǔঀ� 2ǟ�ƺ�șƺǿȓǹǔ�ǿǔƺǿ�ǐǩаǔȗǔǿljǔ�ljƺǿǿȅƞ�ljǔ�ƞȗȣșƞǔǐ�ƞȅ�ȗǔƺșȅǿƺljǹρ� ǔșƞǩǿƺƞǔ� ƞǧǔ�ȓȅȓȣǹƺƞǩȅǿ�ǿǔƺǿ�ǐǩаǔȗǔǿljǔॹ� ƺ� șƞȗȅǿǡ� ljƺȣșƺǹ� conclusion is contraindicated. therefore, the disadvantage of correlational research paradigms relative to experimental research paradigms might be considered decreased in the context of small sample experimental research. major implications can be discussed surrounding șƺǿȓǹǩǿǡ� ȓȗǔljǩșǩȅǿ� ƺǿǐ� ǧȅλ� ǩƞ� ǿǩǡǧƞ� ƺаǔljƞ� șȅljǩƺǹ� ǩǐǔǿƞǩƞρ� ȗǔșǔƺȗljǧ� ƺǿǐ� ƞǧǔȅȗǔƞǩljƺǹ� йǿǐǩǿǡș� ȅǟ� șȅljǩƺǹ� ǩǐǔǿƞǩƞρ� theory. it is important, as mentioned previously, to have sample statistics that are good estimates of corresponding population parameters. without this, basic assumptions of the applicability of theȅȗǩǔș� ƺǿǐ� șƺǿȓǹǔ�йǿǐǩǿǡș� ƺȗǔ�ǿȅƞ�ǿǔƞঀ� 2ǟ� șƺǿȓǹǩǿǡ� precision for research in social identity work is consistently low across the board, with no real attempt ƞȅ� ǩǿȓȗȅκǔॹ� ƞǧǔǿ� ƞǧǔ� ȗǔȓǹǩljƺljǩǹǩƞρ�ȅǟ� ƞǧȅșǔ�йǿǐǩǿǡș� ǩș� ǩǿ� ǵǔȅȓƺȗǐρঀ� (ǩκǔǿ� ƞǧǔ� ǿƺǵȅȗ� ȓȣșǧ� ljρ� șljǩǔǿƞǩйlj� ƺǐκȅljƺƞǔș� ǟȅȗ� ǡȗǔƺƞǔȗ� ȗǔȓǹǩljƺljǩǹǩƞρ� ǩǿ� șljǩǔǿƞǩйlj� ȗǔsearch, especially in social sciences, this means that sampling precision is a vital step towards a more ȅȓǔǿ� ƺǿǐ� ƞȗȣƞǧǟȣǹ� șljǩǔǿƞǩйlj�ǐǩșljǩȓǹǩǿǔঀ� 2ǟ� șƺǿȓǹǩǿǡ� ȓȗǔljǩșǩȅǿ�λǔȗǔ�ƞȅ�ȗǔǿƺǩǿ�ǹȅλॹ�ƞǧǔ�йǿǐǩǿǡș�ȅǟ�șȅljǩƺǹ� research and the applicability of theories developed ǟȗȅǿ�ƞǧȅșǔ�йǿǐǩǿǡș�λȅȣǹǐ�ljǔ�ȕȣǔșƞǩȅǿƺljǹǔ�ƺƞ�ljǔșƞঀ � �ș� ƺǹλƺρș� λǩƞǧ� șljǩǔǿƞǩйlj� ȗǔșǔƺȗljǧॹ� ƞǧǔȗǔ� ƺȗǔ� some limitations. one limitation is that we only tested three time periods. this of course was done due to time constraints as well as the exploratory শȗƺƞǧǔȗ�ƞǧƺǿ�йǿƺǹষ�ǿƺƞȣȗǔ�ȅǟ�ƞǧǔ�ȗǔșǔƺȗljǧঀ���șǔljȅǿǐ� limitation is that the sample size of the studies included was limited (again due to time constraints). thus, conclusions may be clear, but a more comprehensive analysis with a much larger sample size would provide a more detailed and stringent review of sampling precision in a posteriori fashion. unfortunately, no app techniques have yet been developed to estimate the number of studies that should be included in an analysis such as that conducted here, and so traditional app techniques are invalid to determine the sample size for a meta-style analysis of this kind. a third limitation is that, even within social identity research, there are research categories not addressed here. for example, there is social identity research with a basic or applied focus, a focus on integrating other literature, and many others. of course, one potential avenue for future research is to address the foregoing limitations. a second potential avenue is to expand to domains that are not precisely about social identity but are related. these could include work in attachment, aggression, or stereotyping. a third avenue is to pursue non normal distributions. because the researchers in the experimental papers all performed statistics based on the assumption of normality, we used that assumption too in the present analyses for the sake of consistency. however, this assumption is likely wrong, 120 wilson, trafimow, wang, wang as most distributions are skewed (blanca et al., 2013; ho & yu, 2015; micceri, 1989). the usual counter to skewness arguments is that the central limit theorem renders deviations from normality unimportant, but that depends on the goal of the research. for example, ǟȅȗ�ƞǧǔ�ǟƺǿǩǹρ�ȅǟ�șƿǔλ�ǿȅȗǿƺǹ�ǐǩșƞȗǩljȣƞǩȅǿșॹ�eȗƺйǿȅλॹ� wang, and wang (2019; 2021) have demonstrated that there are important precision gains to be had for analyses analogous to those conducted here, even under low levels of skewness, provided that the researcher focuses on locations as opposed to means. because locations are a parameter of skew normal distributions, whereas means are not, it makes sense to use locations rather than means anyway as locations are the more generally applicable parameter. and because the location equals the mean when there is normality, nothing is lost by including locations in app analyses, even in the rare cases where the normality assumption is true. it is also important to note again that this research is not an examination of the accuracy of social identity theory itself and is not limited to “social identity researchers’’ in the traditional sense (that is those who test the theory of sit). the goal of this research was to examine a broad and eclectic mix of social identity applications. in conclusion, the notion that theory should be checked against reality is a staple of science, including the social sciences. but the reality in the social sciences tends to be characterized by summary statistics such ƺș�ǿǔƺǿșॹ�șƞƺǿǐƺȗǐ�ǐǔκǩƺƞǩȅǿșॹ�ljȅȗȗǔǹƺƞǩȅǿ�ljȅǔгljǩǔǿƞșॹ� etcetera. social scientists do not obtain such sample summary statistics as ends in themselves. rather, social scientists obtain sample summary statistics because of the faith they have that these provide good estimates of corresponding 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(2018). the relation between social identity and test anxiety in university students. health psychology open, 5(2), doi: 10.1177/2055102918785415 126 wilson, trafimow, wang, wang 127 social identity precision 128 wilson, trafimow, wang, wang 49 graduate student journal of psychology 2022 vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university executive function in weight loss maintenance: the moderating role of socioeconomic status few individuals with overweight/obesity maintain weight loss. executive function (ef) and socioeconomic status (ses) contribute to weight loss maintenance (wlm). this study examined whether the relationship between ef ƺǿǐ�v@e�ǐǩаǔȗș�ƺljȗȅșș�^�^ঀ�'ȅȗƞρেǟȅȣȗ�ȓƺȗƞǩljǩȓƺǿƞș�ljǔƞλǔǔǿࢳࢴ�েࢹࢸ�ρǔƺȗș�ȅǟ�ƺǡǔ�λǔȗǔ�ƺșșǔșșǔǐ�઄ࢲ�েρǔƺȗ�ȓȅșƞে�ljǔǧƺκioral obesity intervention. those who achieved >5% weight loss during the program were recruited for the present study. participants (n = 44) previously lost >5% of initial body weight. hierarchical regressions tested the moderating role of ses in the relationship between performance-based ef [iowa gambling task (igt)] or self-report ef [behavior rating inventory of executive function (brief-a)] and %wlm. the relationship between performance-based ef and %wlm varied across ses (p < .05). for those with high ses, a 1-point t-score increase on 2(e�ljȅȗȗǔșȓȅǿǐǔǐ�λǩƞǧࢵ�ঀࢶઔ�ǡȗǔƺƞǔȗ�ઔv@e�শݾ�઀�ঀࢳࢶॹ�ȓ�઀�ঀࢴࢱষঀ�fȅ�ƺșșȅljǩƺƞǩȅǿ�λƺș�ȅljșǔȗκǔǐ�ǟȅȗ�ƞǧȅșǔ�λǩƞǧ�ǹȅλ�^�^� শݾ�઀�েঀࢳࢲॹ�ȓ�઀�ঀࢵࢶষঀ�'ȅȗ�ƞǧȅșǔ�λǩƞǧ�ǹȅλ�^�^ॹ�ǡȗǔƺƞǔȗ��'�ǿƺρ�ǿȅƞ�ljǔǿǔйƞ�v@eঀ�'ȅȗ�ƞǧȅșǔ�λǩƞǧ�ǧǩǡǧ�^�^ॹ�ǡȗǔƺƞǔȗ��'� ǿƺρ�ljǔǿǔйƞ�v@eঀ�xǔȗșȅǿƺǹǩφǔǐ�v@e�ǩǿƞǔȗκǔǿƞǩȅǿș�ƺljljȅȣǿƞǩǿǡ�ǟȅȗ�ǹǔκǔǹș�ȅǟ�^�^�ƺǿǐ��'�ǿƺρ�ljǔșƞ�ǟƺljǩǹǩƞƺƞǔ�v@eঀ� keywords: executive function, weight loss maintenance, socioeconomic status, obesity approximately one-third of u.s. adults have obesity, with prevalence estimates increasing each year (lundeen et al., 2018). behavioral treatment for obesity is the gold-standard approach (butryn et al., 2011). however, only half of the individuals achieve ljǹǩǿǩljƺǹǹρ� șǩǡǿǩйljƺǿƞ� λǔǩǡǧƞ� ǹȅșș� শǩঀǔঀॹ� �ઔষࢶં ƞǧȗȅȣǡǧ� these interventions (ball & crawford, 2002; christian et al., 2010; kraschnewski et al., 2010; montesi et al., 2016). further, only 20% of individuals maintain ljǹǩǿǩljƺǹǹρ� șǩǡǿǩйljƺǿƞ� λǔǩǡǧƞ� ǹȅșș� �েρǔƺȗࢲં ȓȅșƞেƞȗǔƺƞment (wing & phelan, 2005), highlighting the significant challenge of weight loss maintenance (wlm). a multitude of factors contribute to wlm, many of which relate to patients’ socioeconomic and demographic characteristics (fitzgibbon et al., 2012; goode et al., 2017). one review demonstrated that occupation, education, and income all predicted weight change over time, with more socioeconomically disadvantaged participants having a greater risk of weight gain (ball & crawford, 2005). because each of these constructs was related to poorer weight maintenance, it may be advantageous to utilize a measure of ses that captures the broader construct of ses related to weight maintenance (ball ૭��ȗƺλǟȅȗǐॹࢶࢱࢱࢳ�ষঀ�eǧǔșǔ�йǿǐǩǿǡș�ȓȅǩǿƞ�ƞȅλƺȗǐ�ƞǧǔ� ǩǿȓȅȗƞƺǿljǔ� ȅǟ� ǩǐǔǿƞǩǟρǩǿǡ� ƞǧǔ� ljȅǿljǩǿǔǐ� ǩǿмȣǔǿljǔ� of several measures of ses to understand the holistic ǩǿмȣǔǿljǔ� ȅǟ� ƺ� ǐǩșƺǐκƺǿƞƺǡǔǐ� ljƺljƿǡȗȅȣǿǐ� ȅǿ�v@eঀ additionally, several psychological variables, including executive function (ef), have been implicated in weight regain. ef refers to neuropsychological processing that controls and coordinates behaviors and cognitive abilities (diamond, 2013). this typically includes skills pertaining to organization and regulation such as problem solving, decision making, reasoning, attention, planning, and time manageǿǔǿƞঀ��ǔйljǩƞș� ǩǿ� ǩǿȓȣǹșǔ� ljȅǿƞȗȅǹ� শ(ǩǔǹ� ǔƞ� ƺǹঀॹ� �ষࢸࢲࢱࢳ and related ef constructs have been repeatedly assoljǩƺƞǔǐ� λǩƞǧ� ȗǔǐȣljǔǐ� ȅljǔșǩƞρ� ƞȗǔƺƞǿǔǿƞ� ǔгljƺljρ� ƺǿǐ� greater weight regain (montesi et al., 2016; wing & phelan, 2005; elfhag & rössner, 2005; varkevisser et al., 2019). further, constructs consistently related to executive dysfunction, such as binge eating (boggiano et al., 2014; striegel-moore et al., 1998), eating in the absence of hunger, and emotional eating, have been associated with a greater weight regain (giel et al., 2017; elfhag & rössner, 2005). together, these studies suggest that ef plays a critical role in wlm. � ^�^�ƺǿǐ��'�ǿƺρ�ǩǿƞǔȗƺljƞ�ƞȅ�ƺаǔljƞ�ǧǔƺǹƞǧ�ȅȣƞljȅǿǔș� as well. for example, in an intervention that trained ef skills, ses moderated improvement in ef skills, such that those from low ses families experienced greater improvement than those from high ses families, emphasizing the importance of including ses as a mod kathryn p. king,1,2 casie h. morgan,1 gareth r. dutton,3 sylvie mrug,1 alena c. borgatti,1,3 and marissa a. gowey, 2 1 department of psychology, university of alabama at birmingham 2 department of pediatrics, university of alabama at birmingham 3department of medicine, university of alabama at birmingham 50 erator, rather than simply a covariate when examining ƞǧǔ�ǔаǔljƞș�ȅǟ��'�ȅǿ�ƞȗǔƺƞǿǔǿƞ�শ^ljǧȣljǔȗƞॹࢷࢲࢱࢳ�ষঀ��κǩdence from qualitative research supports this notion as well. one study exploring factors associated with dietary behavior indicated that low and mid-ses womǔǿ�ǔǿȓǧƺșǩφǔǐ�ƞǧǔ�ǔаǔljƞ�ȅǟ�ǔǿȓǹȅρǿǔǿƞেȗǔǹƺƞǔǐ�ƞǩǿǔ� constraints on food preparation more than high-ses women (inglis et al., 2005). similarly, low-ses women, but not mid or high-ses women, named the cost of healthy food most frequently among food purchasing considerations (inglis et al., 2005). these emphases reмǔljƞ�ƺ�ǧǩǡǧ�ǐǔǿƺǿǐ�ǟȅȗ�ȗǔșȅȣȗljǔ�ǿƺǿƺǡǔǿǔǿƞ�κǩƺ�ȅȗǡƺnization and planning when preparing and purchasing foods (inglis et al., 2005). indeed, healthy food preparation can require a great deal of time and ef. those with greater ses resources may be able to compensate for ef constraints by utilizing higher cost strategies (e.g., eating healthier quickly prepared foods due to lack of cost barrier and endorsing more opportunities to cook from home; inglis et al., 2005) to accomplish ef-demanding health behaviors. thus, these individuals may not experience the same degree of negative ǔаǔljƞș� ȅǟ��'�ȅǿ� ƞǧǔǩȗ�v@eঀ��ȅǿκǔȗșǔǹρॹ� ƞǧȅșǔ�λǩƞǧ� low ses may not be able to employ more costly coping strategies (inglis et al., 2005) and subsequently experiǔǿljǔ�ǡȗǔƺƞǔȗ�ǿǔǡƺƞǩκǔ�ǔаǔljƞș�ȅǟ��'�ǐǩгljȣǹƞǩǔș�ȅǿ�v@eঀ although initial evidence suggests that ses may ǩǿƞǔȗƺljƞ� λǩƞǧ� �'� ƞȅ� ǩǿмȣǔǿljǔ� ǧǔƺǹƞǧ� ljǔǧƺκǩȅȗ� ȅȗ� wlm, the literature has yet to examine this moderƺƞǩȅǿ� ǔаǔljƞঀ� �κƺǹȣƺƞǩǿǡ� ƞǧǔ� ǩǿƞǔȗƺljƞǩȅǿ� ljǔƞλǔǔǿ� ^�^� and ef on wlm would elucidate risk and resilience factors in wlm and has the potential to inform precision medicine approaches to wlm (e.g. idenƞǩǟρǩǿǡ� λǧȅ� ǿƺρ� ljǔǿǔйƞ� ǟȗȅǿ� ǩǿƞǔȗκǔǿƞǩȅǿș� ƞƺȗǡǔƞing resources and/or ef skills). as such, the present paper aims to examine whether ses moderates the relationship between ef and wlm in a racially-diverse group of individuals who lost a clinically sigǿǩйljƺǿƞ� ƺǿȅȣǿƞ� ȅǟ�λǔǩǡǧƞ� κǩƺ� ǹǩǟǔșƞρǹǔ�ǿȅǐǩйljƺƞǩȅǿঀ� we hypothesized that higher ef will be associated with greater wlm among those with low ses, but be unrelated to wlm among those with high ses. method participants forty-four participants between 32-78 years of age (m = 57.43 years, sd = 11.71) were recruited from previous participants of a behavioral obesity intervention. the original intervention, improving weight loss maintenance through alternative schedules of treatment (imwel, nct02487121), consisted of weekly sessions involving evidence-based dietary ǿȅǐǩйljƺƞǩȅǿșॹ� ǩǿljȗǔƺșǔǐ�ȓǧρșǩljƺǹ� ƺljƞǩκǩƞρॹ� ƺǿǐ�ljǔǧƺκioral strategies designed to promote adherence to these lifestyle changes, delivered by trained interventionists (for more information, see gowey et al., 2021). for the original intervention, participants were recruited ƞǧȗȅȣǡǧ� ƞǧǔ� ǹȅljƺǹ� ǿǔλșȓƺȓǔȗॹ� ƞǔǹǔκǩșǩȅǿॹ� мρǔȗșॹ� ƺǿǐ� ƞǧǔ� ȣǿǩκǔȗșǩƞρেƺгǹǩƺƞǔǐ� λǔljșǩƞǔ� ƺǿǐ� ǔেǿǔλșǹǔƞƞǔȗ� ƺǐvertisements. for the current study, participants were contacted 2-4 years post-intervention on a rolling basis for six months. individuals were eligible for recruitǿǔǿƞ�ǩǟ�઄ࢶ�ઔ�λǔǩǡǧƞ�ǹȅșș�λƺș�ƺljǧǩǔκǔǐ�ǐȣȗǩǿǡ�2ǿvǔ@ঀ� �ǹǩǡǩljǩǹǩƞρ� λƺș� ljȅǿйȗǿǔǐ� ljƺșǔǐ� ȅǿ� șƞȣǐρ� ȗǔljȅȗǐș� ȅǟ� weight loss history. participants were excluded if they had (a) a history of bariatric surgery, (b) unintentional weight loss since participating in the previous weight ǹȅșș�ƞȗǩƺǹॹ�ȅȗ�শljষ�ƺ�ǿǔǐǩljƺǹ�ljȅǿǐǩƞǩȅǿ�ǩǿмȣǔǿljǩǿǡ�ljȅǐρ� weight. the current sample was predominantly female and racially diverse (93% female, 55% african american/other, 45% white, see table 1). the study was approved by the university’s institutional review board. procedure individuals were recruited via mailed letters and telephone calls to assess eligibility. all 44 participants contacted for this study were interested and eligible to enroll in the study. they were scheduled for a two-hour study visit where informed consent procedures were conducted, after which anthropometry measurements were taken, surveys were completed, and ef testing was conducted by a trained graduate student under the supervision of a phd-level clinical psychologist. measures demographic information participants self-reported their age, educational attainment, medical history, race, ethnicity, marital status, and household income. socioeconomic status ses was measured by averaging standardized income and education variables (e.g., pu & rodriguez, 2021; rodriguez et al., 2021; gardner et al., 2017). education was reported on a 5-point scale, ranging from (1) less than a high school diploma to (5) graduate school. annual total gross family income king et al. 51 ef and ses in weight loss maintenance was reported on an 11-point scale, with the following values: 0) under $10,000, 1) $10-20,000, 2) $2030,000, 3) $30-40,000, 4) $40-50,000, 5) $50-60,000, 6) $60-70,000, 7) $70-80,000, 8) $80-90,000, 9) $90100,000, 10) over $100,000. for interaction analyses, simple slopes were calculated at 1 standard deviation above and below the mean according to best practices for moderation analyses when there are no meaningful cut points available (memon et al., 2019). thus, “high ses” refers to an ses level one standard deviation above the mean, or the 84th percentile. “low ses” refers to an ses level at one standard deviation below the mean, or the 16th percentile. for reference, an income one sd above the mean would be an income between $80-90,000 and an income one sd below the mean would be an income of about $30,000. for education, one sd above the mean represents a doctoral or professional degree, while one sd below the mean represents some college, but no degree. anthropometric measurements � eȗƺǩǿǔǐ� șƞƺа� ǿǔƺșȣȗǔǐ� ȓƺȗƞǩljǩȓƺǿƞșঢ়� ǧǔǩǡǧƞ� ƺǿǐ� weight with shoes removed using a wall-mounted stadiometer and digital scale. percent weight loss maintenance (%wlm) to determine %wlm, the following data were self-reported by participants: the most weight they lost in their lifetime (initial weight loss; krueger & reither, 2015; santos et al., 2017) how much they weighed prior to losing that weight (start weight), how much they weighed after losing that weight (post weight), and their current weight which was measured objectively (see anthropometric measurements section). the following formula is based on prior literature (ryder et al., 2005) and was used to calculate %wlm: initial weight loss – (current weight – post weight) initial weight loss performance-based ef the iowa gambling task (igt; bechara, 2007) was utilized to measure performance-based ef. the igt measures decision-making using four virtual decks of cards. the participant is instructed to win as much money as possible and that cards will reward or penalize them. participants are scored based on their use of good decks, which provide smaller rewards more often and have better net outcomes, versus bad decks, which provide larger rewards less often and have poorer net outcomes. a norm-referenced t-score (age-, gender-, race-, ethnicity-matched) is generated based on the total net score, with lower scores indicating more impaired decision making. mixed results have been noted when comparing igt performance to performance on other executive functions, decision making, and memory tasks, with impairments in cognitive skills more associated with “cold” decision making a likely cause for the inconsistencies (buelow & suhr, 2009). however, there is evidence to demonstrate that igt shows good construct validity with some measures of executive function and decision-making, like the wisconsin sorting card task (brand et al., 2007, buelow & suhr, 2009) self-reported ef the behavior rating inventory of executive functioning (brief-a) is a standardized self-report scale of ef that is well-validated and has demonstrated good internal consistency in adults with obesity (roth et al., 2005; rouel et al., 2016). there were ǿȅǐǔȗƺƞǔ�ƞȅ�ǧǩǡǧ�ljȅǔгljǩǔǿƞ�ƺǹȓǧƺș�ǟȅȗ�ƞǧǔ�ǿǩǿǔ�ljǹǩǿǩljƺǹ� șljƺǹǔș� শݽ� ઀� �ষॹࢳࢺঀࢱ৅ࢶࢷঀࢱ ƺǿǐ� ǧǩǡǧ� ƺǹȓǧƺș� ǟȅȗ� ƞǧǔ� ƞǧȗǔǔ� ljȅǿȓȅșǩƞǔ� șljƺǹǔș� শݽ� ઀� �ॹࢴࢺঀࢱ �ॹࢶࢺঀࢱ ƺǿǐ� �ॹࢸࢺঀࢱ ȗǔspectively). three subscales showed internal consisƞǔǿljρ�ljǔǹȅλ�ƞǧǔ�ǔπȓǔljƞǔǐ�κƺǹȣǔ�ȅǟࢱ�ঀࢱࢹ�শݽ�઀ࢱ�ঀࢶࢷॹݽ��઀� �ॹࢹࢸঀࢱ ��઀ݽ �ষঀࢺࢸঀࢱ xƺȗƞǩljǩȓƺǿƞș� ȗƺƞǔ� ƞǧǔ� ǟȗǔȕȣǔǿljρ�λǩƞǧ� which certain behaviors have been a problem in the past month. scoring of the 75-item questionnaire generates t-scores for the global executive composite (gec). higher scores indicate more impaired ef. data analyses descriptive statistics characterized key variables. two candidate covariates (bmi, duration of wlm) were examined via correlations. potential covariates ƞǧƺƞ� șǩǡǿǩйljƺǿƞǹρ� ljȅȗȗǔǹƺƞǔǐ� λǩƞǧ� ઔv@e� λǔȗǔ� ȗǔtained in the model. moderation was tested in a hierarchical linear regression model. step one included bmi as a covariate, step two added mean-centered ses and ef, and step three added the interaction between ses and ef. the hierarchical model was run separately for performance-based and self-reported �'ঀ� ^ǩǡǿǩйljƺǿƞ� ǩǿƞǔȗƺljƞǩȅǿș� λǔȗǔ� ǟȅǹǹȅλǔǐ� ȣȓ� λǩƞǧ�� simple slope testing at low and high ses (one standard deviation below and above the mean). all assumptions and analyses were tested via spss version 25. 52 results preliminary analyses descriptive statistics for key variables are reportǔǐ� ǩǿ� eƺljǹǔ� �ঀࢲ xƺȗƞǩljǩȓƺǿƞș� ƿǔȓƞ� ȅа� ƺȓȓȗȅπǩǿƺƞǔǹρ� 13% of the total weight they lost in their lifetime on average. spearman’s correlations between potential covariates (bmi and duration of wlm) and primary variables of interest only revealed a negative correlation between bmi and %wlm (r = -.41, p < .01) (see table 2). as expected, ses and education were moderately associated (r = .36, p < .05) thus, bmi was included as a covariate in the main analyses. all relevant assumptions for moderation using hierarchical multiple regression were tested and met. moderation analyses performance-based ef (igt) the hierarchical regression model testing ses as a moderator of the relationship between igt and ઔv@e�λƺș�șǩǡǿǩйljƺǿƞॹ�[ࢳ�઀ࢱ�ঀࢵࢳॹ�'শࢵॹࢺࢴ�ষ�઀ࢴ�ঀࢲࢲॹ�ȓ� ઃ�ঀࢶࢱআ�șǔǔ�eƺljǹǔࢴ�ঀ�2ǿ�ƞǧǔ�йȗșƞ�șƞǔȓॹ�ǧǩǡǧǔȗ��e2�ȓȗǔǐǩljƞǔǐ�ǹȅλǔȗ�ઔv@eॹݾ��઀�੽ࢱঀࢸࢴॹ�ȓ�ઃ�ঀࢶࢱআ�[ࢳ�઀ࢱ�ঀࢵࢲॹ�'শࢲॹ� 42) = 6.72, p < .05. in the second step, igt and ses ǐǩǐ�ǿȅƞ�ȣǿǩȕȣǔǹρ�ȓȗǔǐǩljƞ�ઔv@eॹ�۹[ࢳ�઀ࢱ�ঀࢳࢱॹ�۹'শࢳॹ� ��ঀ�2ǿ�șƞǔȓ�ƞǧȗǔǔॹ�ǧȅλǔκǔȗॹࢲࢲॹ�ȓ�઀�ঀࢱࢵঀࢱ�ষ�઀ࢱࢵ'�șǩǡǿǩйljƺǿƞǹρ�ǩǿƞǔȗƺljƞǔǐ�λǩƞǧ�^�^�ǩǿ�ȓȗǔǐǩljƞǩǿǡ�ઔv@eॹݾ��઀� �ॹ�ȓ�ઃࢲࢴঀࢱ ঀࢶࢱআ�۹[ࢳ�઀ࢱ�ঀࢺࢱॹ�۹'শࢲॹ� �ॹ�ȓ�઀�ઃࢸࢵঀࢵ�ষ�઀ࢺࢴ .05, b = 0.31, p < .05. simple slope analyses showed ƺ� ȓȅșǩƞǩκǔ� ǔаǔljƞ� ȅǟ� �'� ȅǿ�v@e� ƺƞ� ǧǩǡǧǔȗ� ǹǔκǔǹș� ȅǟ� ses, a one-point t-score increase in igt correspondǔǐ�λǩƞǧ�ƺࢵ�ঀࢶઔ�ǩǿljȗǔƺșǔ�ǩǿ�ઔv@e�শݾ�઀ࢱ�ঀࢳࢶॹ�ȓ�ઃ�ঀࢶࢱষॹ� while at lower levels of ses, there was no relationșǧǩȓ�ljǔƞλǔǔǿ� 2(e�ƺǿǐ�ઔv@e�শݾ�઀� েࢱঀࢳࢲॹ�ȓ�઀� ঀࢵࢶষআ� șǔǔ�'ǩǡȣȗǔ� �ঀ���ȓȅșƞেǧȅlj�ȓȅλǔȗࢲ ƺǿƺǹρșǩș� ǟȅȗ� ƞǧǔ�йǿƺǹ� ǿȅǐǔǹ�ǐǔǿȅǿșƞȗƺƞǔǐ�ƞǧƺƞ�λǩƞǧ�۹[ࢳ�઀ࢱ�ঀࢺࢱॹ�ǟࢳ�઀ࢱ�ঀࢱࢲॹ� f�઀� �ॹࢵࢵ �ݽ ઀� �ॹࢶࢱঀࢱ ƺǿǐ� ǟȅȣȗ� ȓȗǔǐǩljƞȅȗșॹ� ƞǧǔ� ƺljǧǩǔκǔǐ� ȓȅλǔȗ� ƞȅ� ǐǔƞǔljƞ� ƞǧǔ� ǿȅǐǔȗƺƞǩȅǿ� ǔаǔljƞ� λƺș� ঀࢷࢷঀࢱ self-reported ef (brief) the hierarchical regression model testing ses as a moderator of the relationship between the brief ƺǿǐ�ઔv@e�λƺș�ǿȅƞ�șǩǡǿǩйljƺǿƞॹ�[ࢳ�઀ࢱ�ঀࢶࢲॹ�'শࢵॹࢺࢴ�ষ� ઀� �ॹࢷࢷঀࢲ ȓ�઀� ঀࢹࢲআ� șǔǔ�eƺljǹǔ� �ঀࢴ 2ǿ� ƞǧǔ�йȗșƞ� șƞǔȓॹ� ǧǩǡǧǔȗ� �e2�ȓȗǔǐǩljƞǔǐ�ǹȅλǔȗ�ઔv@eॹݾ��઀�েࢱঀࢹࢴॹ�ȓ�ઃ�ঀࢶࢱআ�[ࢳ� = 0.14, f(1, 42) = 6.72, p < .05. in the second step, ƞǧǔ� �[2�'� ƺǿǐ� ^�^� ǐǩǐ� ǿȅƞ� șǩǡǿǩйljƺǿƞǹρ� ȓȗǔǐǩljƞ� ઔv@eॹ�۹[ࢳ�઀ࢱ�ঀࢲࢱॹ�۹'শࢳॹࢱࢵ�ষ�઀ࢱ�ঀࢷࢲॹ�ȓ�઀� ঀࢶࢹঀ� � 2ǿ� șƞǔȓ� ƞǧȗǔǔॹ� ƞǧǔ� �[2�'� ǐǩǐ� ǿȅƞ� șǩǡǿǩйljƺǿƞǹρ� ǩǿƞǔȗƺljƞ� λǩƞǧ� ^�^� ƞȅ� ȓȗǔǐǩljƞ� ઔv@eॹ� �ݾ ઀� ঀࢴࢱॹ� ȓ� ઀� ঀࢷࢹআ� �ॹࢲॹ�۹'শࢲࢱࢱঀࢱ��઀ࢳ]۹ �ষ�઀ࢺࢴ ঀࢴࢱॹ� ȓ�઀� ঀࢷࢹॹ� lj�઀� ঀࢷࢳࢱॹ� ȓ� ઀� ঀࢷࢹঀ��� ȓȅșƞেǧȅlj� ȓȅλǔȗ� ƺǿƺǹρșǩș� ǟȅȗ� ƞǧǔ� йǿƺǹ�ǿȅǐǔǹ�ǐǔǿȅǿșƞȗƺƞǔǐ� ƞǧƺƞ�λǩƞǧ�۹[ࢳ�઀ࢱ�ঀࢲࢱࢱॹ� ǟࢳ�઀ࢱ�ঀࢲࢱࢱॹ� f�઀� �ॹࢵࢵ �ݽ ઀� �ॹࢶࢱঀࢱ ƺǿǐ� ǟȅȣȗ� ȓȗǔǐǩljƞȅȗșॹ� ƞǧǔ� ƺljǧǩǔκǔǐ� ȓȅλǔȗ� ƞȅ� ǐǔƞǔljƞ� ƞǧǔ� ǿȅǐǔȗƺƞǩȅǿ� ǔаǔljƞ� λƺș� ঀࢹࢱঀࢱ discussion the goal of the present study was to examine the degree to which ses moderates the relationship between ef and wlm to address gaps in the wlm literature that may inform precision medicine approaches. given recent studies demonstrating relationships between ses, ef, and weight loss outcomes, we exƺǿǩǿǔǐ�λǧǔƞǧǔȗ�ǩǿǐǩκǩǐȣƺǹș�ǟȗȅǿ�ǐǩаǔȗǔǿƞ�^�^�ljƺljƿgrounds showed unique relationships between ef and %wlm. ef was measured via a performance-based test and self-reports, as these methods provide unique information about ef and do not correlate highly with each other (garcia et al., 2013; toplak et al., 2013). as ǔπȓǔljƞǔǐॹ�йǿǐǩǿǡș� ǩǿǐǩljƺƞǔǐ� ƞǧƺƞ� ƞǧǔ� ȗǔǹƺƞǩȅǿșǧǩȓ�ljǔtween performance-based ef and %wlm was dependent on ses; contrary to our expectation, however, ƞǧȅșǔ�λǩƞǧ�ǧǩǡǧ�^�^� ǔπȓǔȗǩǔǿljǔǐ� ƺ� ǡȗǔƺƞǔȗ�ljǔǿǔйƞ�ȅǟ� performance-based ef on %wlm than individuals with low ses. regarding self-reported ef, our hypothesis was not supported, as ses and self-reported �'�ǐǩǐ�ǿȅƞ� ǩǿƞǔȗƺljƞ� ƞȅ�ƺаǔljƞ�ƺǿ� ǩǿǐǩκǩǐȣƺǹঢ়ș�ઔv@eঀ� access to high-cost coping strategies in high-ses individuals may best explain the unique relation between ef and ses in high-ses individuals. it is likely that for high ses individuals, having access to an abundance of weight management resources (e.g., grocery stores, gym memberships/classes, meal preparation services, smartphone applications, and gadgets, ǔƞljঀষ�ǿƺρ�ljǔ�ǿȅȗǔ�ǔгljǩǔǿƞǹρ�ƺljljǔșșǔǐ�ƺǿǐ�ȣƞǩǹǩφǔǐ�ǟȅȗ� an individual with stronger ef skills. for example, individuals with higher ses may be more likely to own a wearable device to monitor activity, and those with stronger ef skills may be more likely to utilize the tracking features (e.g., weight, food, and exercise tracking) on the device or its associated phone app. alternativeǹρॹ��'�ǐǔйljǩƞș�ljȅȣǹǐ�ƺǹșȅ�ljǔ�ȣǿǩȕȣǔǹρ�ǧǩǿǐǔȗǩǿǡ�ƞǧȅșǔ� with high ses, perhaps due to increased access to unhealthy foods and mismanagement of extra resources. in contrast, lower ses individuals often lack basic access to these same resources (ailshire & house, �ষআࢲࢲࢱࢳ ƞǧȣșॹ� �'�ǿƺρ�ǿƺǿǩǟǔșƞ� ǐǩаǔȗǔǿƞǹρ� ǩǿ� ǔƺljǧ� ȅǟ� these scenarios. for higher ses individuals with abunking et al. 53 dant opportunities, there is a need to organize options, utilize self-control with grocery shopping, and manage ǿǔǿljǔȗșǧǩȓș�ǔгljǩǔǿƞǹρ�ƺǿǐ�ƺljljȣȗƺƞǔǹρঀ� � ��ǹƞǔȗǿƺƞǩκǔly, for lower ses individuals maintaining weight loss, there are fewer resources through which to apply ef skills of coordinating, organizing, and managing, so ef abilities may have a more limited “range” of impact. in fact, for low ses individuals, the weight-loss intervention program itself may be the primary resource accessible to this group for healthy eating and activity. once the program ends, these individuals may not have the community structures (e.g., gyms, healthy food marƿǔƞșॹ� ǔƞljঀষ� ǩǿ� ȓǹƺljǔ� ƞȅ� șȣȓȓȅȗƞ� ȓȗǔκǩȅȣș� ǔаȅȗƞșঀ� eǧǩș� interpretation is supported by the recent emphasis on the relationship between social determinants of health and adverse health outcomes (medvedyuk et al., 2018). the use of a performance-based ef task is a noƞƺljǹǔ�șƞȗǔǿǡƞǧ�ȅǟ�ƞǧǔ�șƞȣǐρ�ǐǔșǩǡǿঀ�2(e�ǩș�șȓǔljǩйljƺǹǹρ� ǐǔșǩǡǿǔǐ� ƞȅ�ǐǔƞǔljƞ� ǐǔljǩșǩȅǿেǿƺƿǩǿǡ�ǐǔйljǩƞș� ƺǿǐ�ǐȅǔș� șȅ� ǩǿ� ƞǧǔ� ljȅǿƞǔπƞ� ȅǟ� йǿƺǿljǩƺǹ� ǡƺǩǿș� ƺǿǐ� ǹȅșșǔș� শ�ǔchara, 2007). one interpretation of these outcomes could imply unique interactions between ses and a йǿƺǿljǩƺǹǹρেȅȗǩǔǿƞǔǐ��'েǐǔȓǔǿǐǔǿƞ�ƞƺșƿঀ��ǹƞǧȅȣǡǧ�ƞǧǔ� correlation between igt and ses was weak and nonșǩǡǿǩйljƺǿƞ� শșǔǔ� eƺljǹǔ� �ষॹࢳ ƞǧǔȗǔ� ƺȗǔ� йǿƺǿljǩƺǹ� ȓƺƞƞǔȗǿș� ƺljȗȅșș� ǐǩаǔȗǔǿƞ� ^�^� ǡȗȅȣȓș� ƞǧƺƞ� ƺȗǔ�λȅȗƞǧρ� ƞȅ� ǿȅƞǔঀ� for example, individuals with low ses experience ǟȗǔȕȣǔǿƞ� йǿƺǿljǩƺǹ� ȣǿljǔȗƞƺǩǿƞǩǔș� λǧǩljǧ� ȅǟƞǔǿ� ȓȗǔșent as stressors and constraints, rather than solvable complications (chen & miller, 2013). in the context of weight management, which can be characterized as a stressor due to the extensive behavior change, resource allotment, and commitment required to maintain success, if low-ses families are attemptǩǿǡ� ƞȅ� ljƺǹƺǿljǔ�λǔǩǡǧƞেȗǔǹƺƞǔǐ� șƞȗǔșșȅȗș�λǩƞǧ� йǿƺǿljǩƺǹ� stressors, a “spiral of resource loss” (hobfoll, 2001) can occur (e.g., a parent misses work to take care of a șǩljƿ�ljǧǩǹǐॹ�ǹȅșǔș�ƺ�ǵȅljॹ�ljƺǿঢ়ƞ�ƺаȅȗǐ�ǡρǿ�ǿǔǿljǔȗșǧǩȓষঀ� eǧǩș�йǿƺǿljǩƺǹ�ȣǿljǔȗƞƺǩǿƞρ�ǿƺρ�ǹǔƺǐ�ƞȅ�ljȣρǩǿǡ�ljǧǔƺȓer, unhealthy foods or lower quantities of healthy foods. thus, real-world decisions about money, food ljǧȅǩljǔșॹ�ƺǿǐ�ǧǔƺǹƞǧρ�ƺljljǔșș�ƞȅ�ǟȅȅǐ�ljȅȣǹǐ�ljǔ�ǩǿмȣǔǿljing behavior during this performance-based measure ƺǿǐ�ǩǿмȣǔǿljǩǿǡ�ǹǩǟǔșƞρǹǔ�ljǧȅǩljǔș�ǩǿ�ƞǧǔ�ȗǔƺǹেλȅȗǹǐ�șǔƞƞǩǿǡॹ� ƺǿȓǹǩǟρǩǿǡ� ƞǧǔ� șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔ� ǟȅȗ� ǧǩǡǧǔȗ� ses individuals compared to lower ses individuals. self-reported ef was measured using the brief-a questionnaire and is considered more of a global comȓȅșǩƞǔ�ȅǟ�ǐǩаǔȗǔǿƞ�ljǔǧƺκǩȅȗș�ȓǔȗƞƺǩǿǩǿǡ�ƞȅ��'�ƺljǩǹǩƞǩǔșঀ� subjective rating scales tend to have more ecological validity than performance-based testing but can be șƞǩмǔǐ�ǩǟ�șȅǿǔȅǿǔ�ǧƺș�șǔκǔȗǔ�ǔǿȅȣǡǧ�ǩǿȓƺǩȗǿǔǿƞș�ƞǧƺƞ� ƞǧǔρ� ƺȗǔ� ǿȅƞ� ƺλƺȗǔ� ȅǟ� ƞǧǔǩȗ� ǐǔйljǩƞș� ȅȗ� ȅǟ� ƞǧǔ� ǩǿȓƺljƞ� ƞǧǔșǔ�ǐǔйljǩƞș�ǧƺκǔ�ȅǿ�ǔκǔȗρǐƺρ�ljǔǧƺκǩȅȗ�শ�ƺȗƿǹǔρॹࢳࢲࢱࢳ�আ� chan, 2008). a self-rating scale that requires insight into one’s own cognitive abilities may be inherently ǐǩгljȣǹƞ� ǟȅȗ� șȅǿǔȅǿǔ�λǩƞǧ� ǩǿȓƺǩȗǿǔǿƞ� ǩǿ� șǔǹǟেƺλƺȗǔness as compared to performance-based testing which is rated by a trained observer (buchanan, 2016), which could explain some of the discrepancies between the performance-based and self-reported ef results. limitations this study has some limitations that should be mentioned. one of the most important limitations is the sample size, which reduced statistical power and did not now allow more complex modeling techniques, such as additional predictors or covariates. the ȓȅșƞ�ǧȅlj�ƺǿƺǹρșǔș�ȗǔκǔƺǹǔǐ�ǹȅλ�ȓȅλǔȗ�ƞȅ�ǐǔƞǔljƞ�ǔаǔljƞșॹ� supporting the notion that a larger sample size may improve power and allow for more complex modeling. given that this study enrolled only those who lost a ljǹǩǿǩljƺǹǹρ�șǩǡǿǩйljƺǿƞ�ƺǿȅȣǿƞ�ȅǟ�λǔǩǡǧƞॹ�ǟȣƞȣȗǔ�șƞȣǐǩǔș� ȣșǩǿǡ� șǩǿǩǹƺȗ� ǐǔșǩǡǿș� ǿƺρ� ljǔǿǔйƞ� ǟȗȅǿ� ȅκǔȗেȗǔljȗȣǩƞment during a weight loss intervention to allow for a larger recruitment pool of those who lose a clinically șǩǡǿǩйljƺǿƞ�ƺǿȅȣǿƞ�ȅǟ�λǔǩǡǧƞঀ��ǹƞǔȗǿƺƞǩκǔǹρॹ�ǟȣƞȣȗǔ�ȗǔsearch could consider more large-scale designs, such as that of the national weight control registry (hill et al., 2005). however, with this approach, measurements would need to be adapted for remote data collection, which would introduce another limitation in exchange for an increased sample size. a second limitation was the composition of the sample. the majority of the șƺǿȓǹǔ�λƺș�ǟǔǿƺǹǔॹ�ǹǩǿǩƞǩǿǡ�ƞǧǔ�ǡǔǿǔȗƺǹǩφƺljǩǹǩƞρ�ȅǟ�йǿǐings to weight loss experiences for males. despite these limitations, the current study represents an important step toward prioritizing ses and ef in weight management interventions and considering the impacts indiκǩǐȣƺǹ� ǐǩаǔȗǔǿljǔș� ƺǿǐ� ljǧƺȗƺljƞǔȗǩșƞǩljș� ǧƺκǔ�ȅǿ�v@eঀ� for the present study, the best two factors to capture ses included educational history and race, however, it is understood that other variables can be included to strengthen ses as a construct. one recent study acknowledged the complexity of measuring and conceptualizing ses and included a sam ef and ses in weight loss maintenance 54 king et al. ple of additional criteria to be considered in future research (rodríguez-hernández et al., 2020). speljǩйljƺǹǹρॹ� ƞǧǔρ� ǧǩǡǧǹǩǡǧƞ� ȓƺȗǔǿƞƺǹ� ǔǐȣljƺƞǩȅǿॹ� ǟƺǿǩǹρ� income, parental occupation, household resources, and neighborhood resources. alternatively, ses can also be considered subjective, with perceived ses demonstrating its own separate impact on health outcomes (nobles et al., 2013) compared to objective components of ses. therefore, future research should also carefully consider the conceptualization and measurement of ses when studying weight manƺǡǔǿǔǿƞ� ƺǿǐ� ljȅȣǹǐ� ljȅǿșǩǐǔȗ� ƞǧǔ� ǩǿмȣǔǿljǔș� ȅǟ� ljȅƞǧ� perceived ses and more objective ses factors related to actual income, occupation, and education status. � 'ȣƞȣȗǔ�șƞȣǐǩǔș�ǿƺρ�ljǔǿǔйƞ�ǟȗȅǿ�ǔπȓƺǿǐǩǿǡ�ȣȓȅǿ� ƞǧǔ� ȓȗǔșǔǿƞ� йǿǐǩǿǡșঀ� 'ȅȗ� ǔπƺǿȓǹǔॹ� ǔаȅȗƞș� ljȅȣǹǐ� ljǔ� ǿƺǐǔ� ƞȅ� ȗǔljȗȣǩƞ�ǿƺǹǔș� ƺǿǐ�ǔπƺǿǩǿǔ� șǔπ�ǐǩаǔȗǔǿljǔș� ǩǿ� the studied relationships. additionally, it may be advantageous to recruit a mix of individuals with varying degrees of success with wlm, including those experiencing weight regain. this allows for more variance in weight maintenance outcomes and allows for an improved investigation of potential barriers to v@eঀ�kǿǔ�йǿƺǹ�ljȅǿșǩǐǔȗƺƞǩȅǿ�ǩǿljǹȣǐǔș�ǩșȅǹƺƞǩǿǡ�ƞǧǔ� ǐǩаǔȗǔǿƞ� ljǹǩǿǩljƺǹ� ǐȅǿƺǩǿș� ljƺȓƞȣȗǔǐ� ǩǿ� ƞǧǔ� �[2�'� ƞȅ� examine unique associations between individual ef domains, wlm, and ses. continuation of this line of research could ultimately inform the development of precision medicine strategies that take such relationships into account in treatment selection and delivery. conclusion � eǧǔ�ȓȗǔșǔǿƞ�йǿǐǩǿǡș� șȣǡǡǔșƞ� ƞǧƺƞ� ǟȅȗ� ƞǧȅșǔ�λǩƞǧ� ǧǩǡǧ� ^�^ॹ� λǧȅ� ƺǹȗǔƺǐρ� ȓȅșșǔșș� ljƺșǩlj� йǿƺǿljǩƺǹ� ƺǿǐ� community resources, higher ef may facilitate the ƺljǩǹǩƞρ� ƞȅ� ȅȗǡƺǿǩφǔॹ� ȓȗǩȅȗǩƞǩφǔॹ� ƺǿǐ� ǔгljǩǔǿƞǹρ� ƺljljǔșș� available weight management tools and strategies. for ƞǧȅșǔ�λǩƞǧ� ǹλ�^�^�λǧȅ�ǿƺρ� ǹƺljƿ�йǿƺǿljǩƺǹ� ƺǿǐ�ljȅǿmunity resources, research should examine the benǔйƞ� ȅǟ� ȗǔǐȣljǩǿǡ� ljƺȗȗǩǔȗș� ƞȅ� șȣljǧ� ȗǔșȅȣȗljǔș� κǩƺ� ǹȅljƺǹ� programs or providing continuous, free, or low-cost access to wlm treatment programs. overall, if individuals are provided with personalized wlm support aligned with their levels of ses and ef, they may develop the necessary skills to succeed in lifetime wlm. references ailshire, j. a., & house, j. s. 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(2005). long-term weight loss maintenance. the american journal of clinical nutrition, 82(1), 222s–225s. https://doi. org/10.1093/ajcn/82.1.222s king et al. 57 ef and ses in weight loss maintenance 58 king et al. 59 ef and ses in weight loss maintenance 60 king et al. microsoft word vol10_nosen_avk_09-13-08.doc 3 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 online surveys: effect of research design decisions on rates of invalid participation and data credibility elizabeth nosen university of british columbia sheila r. woody university of british columbia designing online research often involves a trade-off between procedures that maximize administration efficiency and those that encourage valid and considerate participation. this article reports on three different online research design conditions (n = 413), differing in participant screening, incentive, and anonymity, that were used in a separate study on cognition in smoking cessation. high rates of invalid participation were observed in a condition in which participants participated anonymously, received a $20 incentive, and were screened for eligibility online. in addition, this condition produced significantly different data (variance, covariance, and central tendency) than the other two conditions, which involved less incentive or personal eligibility screening without participant anonymity. removal of apparent “invalid” participants on the basis of a data screening protocol corrected some, but not all, of these differences. results indicate that online designs offering monetary incentives should implement procedures to enhance data integrity even at the cost of increased participation barriers. online questionnaire-based research has become increasingly popular in recent years. in comparison to traditional paper-based questionnaires, online surveys have been hailed as easier and more efficient to administer, able to reach a broader target audience, more cost effective, and offering greater participant anonymity (krantz & dalal, 2000; kraut et al., 2004; reips, 2000, 2002b; skitka & sargis, 2006). perhaps most importantly, it appears that online surveys can produce valid and trustworthy results. several studies have found that online questionnaires show psychometric properties similar to their paper-and-pencil counterparts (buchanan, johnson, & goldberg, 2005; buchanan & smith, 1999; meyerson & tryon, 2003; pettit, 2002) and that online administration can produce results comparable to paper-based questionnaires (denscombe, 2006; lozar manfreda & vehovar, 2002; mccabe, 2004; mccabe, couper, cranford, & boyd, 2006; mcgraw, tew, & williams, 2000; smith & leigh, 1997). despite these encouraging findings, concern about the validity of web-based research remains. due to the lack of researcher control over testing environments and increased anonymity afforded to online participants, there is a greater risk that some participants will intentionally misrepresent themselves, take part in a study more than once, or provide careless, insincere responses (birnbaum, 2004; johnson, 2005; konstan, rosser, ross, stanton, & edwards, 2005; reips, 2000, 2002a, 2002b; skirtka & sargis, 2006). high rates of invalid participation may jeopardize the correspondence: elizabeth nosen, university of british columbia, department of psychology, 2136 west mal vancouver, b.c. canada v6t 1z4, email: lnosen@psych.ubc.ca reliability and validity of findings from online research. in an online study of risky sexual behaviour, for example, konstan and colleagues (2005) discovered that 11% of their sample was invalid due to study ineligibility or duplicate submission. most importantly, they found that inclusion of these cases actually produced an erroneous rejection of their null hypothesis. fortunately, researchers have suggested several strategies to both prevent and detect invalid participation (johnson, 2005; konstan et al., 2005; reips, 2000, 2002a, 2002b). preventing invalid participation reducing motivation. individuals may be more likely to participate repeatedly, or to respond carelessly or disingenuously, when a strong tangible incentive is offered. konstan et al. (2005), for example, offered $20 for participation in their web-based study and had one individual provide at least 65 unique survey submissions. malicious or mischievous responses may be less likely when individuals are personally invested in providing valid answers, such as when individuals are provided personalized feedback based on their answers to study questions (fraley, 2004; johnson, 2005). not all research, however, readily lends itself to such feedback. in lieu of providing a personal growth experience, more tangible incentives may be required to ensure high survey completion rates. two recent meta-analyses showed that offering survey participants an entry into a lottery for money or prizes significantly increased both survey response and retention rates (göritz, 2006). that said, completion rates can be questionably low even with lottery incentives (bosnjak & tuten, 2003; frick, bächtiger, & reips, 2001; marcus, bosnjak, lindner, pilischenko, & schutz, 2007; o'neil & nosen & woody 4 penrod, 2001; o'neil, penrod, & bornstein, 2003). on balance, does offering a substantial incentive promote good response and retention while providing valid data in online surveys? further research is required to answer this question and determine the extent to which cases like those reported by konstan et al. (2005) reflect isolated occurrences or a more ubiquitous threat to integrity of online research. reducing capacity. researchers have suggested several methods for limiting capacity for invalid participation. among these are informing participants about the detrimental effects of invalid participation, disallowing submissions with duplicate identifying information (e.g., ip addresses and cookies) and collecting personally identifying information (reips, 2000, 2002b; reips, eid, & diener, 2006). because simply asking for personal information does not guarantee online participants will provide it, connecting this request to honorarium payment procedures may be helpful. incentive payment methods that require only an email address (e.g., gift certificate, paypal) allow participants to remain relatively anonymous if they wish, but, given the ease of acquiring multiple email addresses, are unlikely to reduce the risk of repeat respondents. payment by check, on the other hand, essentially guarantees collection of valid names and mailing addresses. personal pre-survey contact with participants, such as personalized participation invitations, can enhance web survey completion rates (heerwegh, vanhove, matthijs, & loosveldt, 2005) and may serve as an additional protection against invalid participation. personal pre-survey screening of participants (e.g., to determine study eligibility) may discourage repeat survey submission or careless, random responding because it reminds participants of the real, nonvirtual aspect of the project, provides participants an opportunity to ask questions, and increases participation burden (which may in turn increase personal investment in the project). while these design strategies sound like common sense, many of them carry a cost, so it is important to investigate empirically whether they make a difference in rates of invalid participation and whether such procedural barriers effectively offset the risks raised by meaningful monetary incentives. detecting invalid participation identifying and removing invalid participants prior to data analysis is another strategy for enhancing integrity of online research. common strategies include searching cases for matching case identifiers (e.g., email or ip addresses), examining data for response patterns indicating duplicate participation or inattentiveness, cross-validating participant eligibility criteria, and looking for suspiciously short completion times (gosling, vazire, srivastava, & john, 2004; johnson, 2005; konstan et al., 2005; reips, 2000). to the extent that these strategies effectively detect cases of repeat participation, deliberate misrepresentation or careless responding, their use may mitigate the risks created by high levels of invalid participation. little is known, however, about the effectiveness of these procedures. one of the most important issues concerns the extent to which researchers can rely on these strategies to preserve the integrity of their data in the face of high rates of invalid participation. in an ideal world, removing cases identified as invalid by these screening measures should leave data that is trustworthy and useable. in other words, these strategies should ensure that the data obtained under highrisk designs (e.g., when providing substantial monetary incentives with few procedural barriers to invalid participation) looks similar to that acquired under lower risk designs (e.g., when motivation or capacity for invalid participation is restricted). to the extent that removing cases identified as invalid by these protocols does not correct between-sample differences in data, it suggests one of two things: either these techniques are not catching all cases of invalid participation or differences in study designs are attracting fundamentally different samples. either way, such a result would suggest that such strategies cannot be relied upon to preserve a valid sample. present study the opportunity to gain insight into several of these issues arose while collecting data for an online survey of individuals who were attempting to quit smoking (nosen & woody, submitted). over the course of data collection, we encountered several problems (i.e., poor participant retention and high rates of invalid participation) that necessitated alteration of the study design. in the end, data were obtained in three phases differing in motivation and capacity for invalid participation; one at high risk (strong incentive and weak barriers to fraudulent participation) and two at lower risk (weak incentive and weak barriers; strong incentive and strong barriers). the present study examines how these design conditions differ in rates of participant recruitment, retention, and invalid participation. we also examined how the data produced by high-risk designs compared with those produced by low-risk designs on the same measures and whether removing the cases identified as invalid by available post-hoc data screening techniques effectively corrected these differences. because participants were not randomly assigned to conditions, this was not a true experiment. that said, it is unlikely that individuals truly interested in participating fraudulently will volunteer to take part under any condition other than the one from which they feel they can benefit. this means that investigating how these types of design decisions affect rates of invalid participation is not amenable to random assignment. the present study therefore represents a naturalistic study of the predictors and consequences of fraudulent participation in online survey research. online survey design 5 method participants participants were english-speaking adults currently engaged in a serious effort to quit smoking. participants were eligible if they reported having been a regular smoker for more than a year prior to recently beginning an attempt to quit. a total of 413 individuals completed the survey and asked us to use their data. average reported age was 34.3 years (sd = 10.1). across conditions, most participants indicated they were female (64.2%), caucasian (83.5%), and living in canada, the united states or the united kingdom (96.6%). most participants reported being employed full-time (53.0%) and having completed a post-secondary degree (47.5%). table 1 provides details of participants’ reported demographic and smoking history backgrounds broken down by design condition. procedure design. data were obtained in three phases varying in the degree to which they provided a monetary incentive and protected against invalid participation. in the first phase of data collection (condition a; n = 100), participants were entered into a draw for a $200 gift certificate (i.e., low incentive). because of the low incentive to participate, minimal barriers to prevent invalid participation were implemented; participation was impersonal (no researcher contact) and could be anonymous (only valid email required). after three months of collecting data in condition a, we decided to introduce an incentive to speed data collection and ensure adequate survey completion rates (see results for further details); this created a second design condition. participants in the second phase of data collection (condition b; n = 203) chose between a $20 check or a $20 online gift certificate as incentive (i.e., high incentive). in the interests of maintaining congruence with data collected in condition a, procedures were kept as similar as possible. as such, minimal barriers to prevent invalid participation were implemented in condition b—participation was again impersonal (no researcher contact) and could be anonymous (only valid email requested). after a few days of collecting data in condition b, suspicions of invalid participation (see results for further details) prompted us to implement greater procedural barriers; this created the third design condition. in the final phase of data collection (condition c; n = 110), participants received a $20 check and were personally screened by researchers via email or telephone. condition c thus involved high incentive to participate in combination with strong procedural barriers to invalid participation, as participants were not anonymous and engaged in personal contact with researchers before gaining access to the online survey. to summarize, conditions a and b used the same impersonal and anonymous procedure but differed in incentive. conditions b and c had the same $20 incentive, but the screening procedure differed in the degree of personal communication (and anonymity). conditions a and c were different in both incentive and screening procedures. all procedures were approved by the behavioral research ethics board at our university. recruitment. participants were sequentially recruited under condition a, then b, then c. recruitment was similar for all conditions; researchers placed links on smoking cessation websites and online discussion forums and posted advertisements in transit stations, universities, hospitals and health centers in the vancouver area. eligibility screening. all participants were screened for study eligibility prior to participation using identical questions about age, language, and smoking history. screening questions were asked online, immediately before completion of the survey (conditions a and b), or personally via email or phone (condition c). participants who were screened online (conditions a and b) took part by clicking on a direct link to the study; qualified participants based on responses to multiple-choice questions were automatically directed to the informed consent page of the survey. participants who were personally screened (condition c) were instructed to call or email the investigators for more information and to participate. via telephone or email, research assistants screened potential participants who contacted the lab using the same questions as in the online screening procedure. eligible condition c participants provided their first and last names, email address, telephone number, and mailing address (all information required to receive payment in check form) and were subsequently emailed a link to the study. survey design. participants completed all questionnaires over the internet, facilitated by surveymonkey.com, a webbased survey development and hosting service. informal pilot testing was conducted with volunteers from the university and community to ensure survey functionality across browsers and operating platforms. pilot testing also addressed issues of english language proficiency and item clarity and applicability. informed consent. the informed consent page described the purpose of the study, participation requirements, and confidentiality. participants were informed that questionnaire responses would be stored in a secure, encrypted database, that all answers would remain confidential, and that data would be presented in aggregate format only. participants were instructed that they could complete the survey as many times as they liked, but that they would receive remuneration one time only. before completing the questionnaires, participants were required to indicate that they had one hour available to complete the survey. participants who were screened online (conditions a and b) were asked to provide an email address for study purposes and a home mailing address as a back-up method of contacting participants for remuneration. names were optional. questionnaire presentation. each questionnaire occupied its own page, with questionnaire-specific instructions provided at the top of each page. most questions were multiple choice, involving clicking on a box displayed below the nosen & woody 6 response choices; a few questions required a typed response. participants continued through the survey by clicking a “next” button at the bottom of each page. missing responses were not permitted, and respondents were not allowed to return to a previous page after leaving it. a heading at the top of each page informed participants how far they had progressed through the survey (e.g., page 6/11). the survey consisted of 17 pages, plus two additional pages for individuals who were screened for eligibility online. participant opt-out. upon completion of all the questionnaires, a question asked participants if they would like their data to be used in study analyses. this question informed participants of the importance of using valid data for the research and asked participants to indicate not to use their data if they thought, for any reason, that their answers did not accurately reflect their true opinions (e.g., did not actually read the questions, answered randomly, filled it out pretending to be someone else). this page informed participants that they would receive remuneration for completion of the study thus far, regardless of whether they indicated that their data should be used. following this question, a debriefing page appeared that described the study and listed some common smoking cessation resources. measures full information about the measures and the purposes of the smoking cessation cognition study is available in nosen and woody (submitted). four questionnaires assessed obsessional thinking (oc cognitions): the obsessional beliefs questionnaire (obsessive compulsive cognitions working group (occwg), 1997, 2001, 2003), the thought–action fusion scale – revised (shafran, thordarson, & rachman, 1996), the white bear suppression inventory (wegner & zanakos, 1994), and the punishment scale from the thought control questionnaire (wells & davies, 1994). seven measures assessed variables relevant to nicotine addiction and smoking cessation difficulty, including the obsessive compulsive drinking scale-revised, smoking version (morgan, morgenstern, blanchard, labouvie, & bux, 2004), the smoking self-efficacy questionnaire (etter, bergman, humair, & perneger, 2000), the positive scale from the smoking effects questionnaire (rohsenow et al., 2003), the center for epidemiological studies depression scale–short form (kohout, berkman, evans, & cornoni-huntley, 1993), the fagerström test for nicotine dependence (heatherton, kozlowski, frecker, & fagerström, 1991), the appraisals of cravings questionnaire (acq; nosen & woody, submitted), and the catastrophic appraisals index (nosen & woody, submitted). post-hoc validity screening procedures we applied several validity-screening methods suggested by other authors (gosling et al., 2004; johnson, 2005; konstan et al., 2005; reips, 2000, 2002b). specifically, we screened cases for repeat participation, study ineligibility, and suspicious participation behavior. we did not examine for long strings of identical responses (johnston, 2005) because individual questionnaires were relatively short (ranging from 10 to 44 items). nor did we examine for nearly identical survey submissions (as would occur when someone pressed the “back” button and changed only a few answers to make their submission appear new; johnston, 2005) because survey software did not permit participants to return to a previous page. repeat participation. participants were identified as repeat respondents if they provided information matching that of a previous participant for either 1) the preliminary portion of an email address, 2) a name and home address, or 3) an ip address. duplicate cases were identified using the lag function in spss. cross-check of eligibility criteria. eligibility for the study was cross-checked with information participants provided in the screen with information provided later in the survey. variables checked were participants’ age, duration of regular smoking before quitting, time elapsed since quitting smoking, and number of cigarettes smoked before quitting. suspicious participation behavior. two methods were used to detect individuals responding in a deceitful, careless, or inattentive fashion. first, we searched for cases that appeared to gain access to the survey by responding to the online screening questions in a trial-and-error fashion. these cases were identified as participants who completed the questionnaires within one hour of a case with the same ip address that had previously answered the screening questions in an ineligible fashion. we also identified cases with suspiciously short survey completion times. long completion times were not used as an exclusionary criterion because the survey program did not record completion time for individual pages. as such, long completion times are ambiguous because they could reflect something relatively innocuous, such as a person opening the first information page of the survey then deciding they would rather complete it later, or something more questionable, such as someone filling out half of the survey at one time and the other half at a later date. to identify a cut-point for unacceptably short completion times, we examined how long trustworthy respondents took to finish the survey. during pilot testing, individuals who were known to the experimenter, highly educated, and very familiar with the questionnaires took approximately 3540 minutes to complete the full survey while skimming questions and selecting random answers (to test the pro gramming). participants in the conditions hypothesized to be at lower risk for invalid participation (conditions a and c) completed the survey in an average of 44.9 minutes (sd = 15.8)1; fewer than 5% of these participants completed the 1 not including participants with abnormally long completion times (i.e., over two hours, n = 24), which could represent, for example, taking a break from the survey before completing it. online survey design 7 table 1 demographic and smoking history variables before and after validity screening full sample after removing “invalid” cases condition a condition b condition c condition a condition b condition c variable n = 100 n = 198 n = 110 n = 89 n = 83 n = 92 gender (% female) 64.0% ab 57.6% a 76.4% b 61.8% a 67.5% a 78.3% a ethnicity (% caucasian/european) 95.0% a 73.9% b 90.9% a 96.6% a 85.5% b 92.4% ab employment (% working) 87.0% a 86.2% a 70.9% b 86.5% a 79.5% a 69.6% b age 37.86 (9.78) a 28.00 (7.41) b 36.50 (11.30) a 38.60 (9.74) a 31.79 (8.12) b 39.67 (10.87) a years of education 14.71 (2.61) a 14.79 (2.29) a 14.49 (2.43) a 14.67 (2.68) a 14.27 (2.07) a 14.63 (2.47) a cigarettes per day, before quit 22.88 (9.80) a 18.64 (9.86) b 20.24 (7.92) ab 23.35 (10.06) a 20.52 (7.66) a 20.79 (7.76) a years smoking, before quit 18.25 (10.59) a 9.01 (6.89) b 20.03 (11.91) a 19.44 (10.35) a 12.00 (7.46) b 21.21 (11.53) a previous quit attempts 6.34 (7.19) a 5.48 (7.16) a 6.48 (10.77) a 6.35 (7.56) a 5.88 (9.20) a 6.92 (11.66) a longest previous attempt (months) 8.55 (12.85) a 6.61 (12.06) a 7.99 (14.98) a 8.84 (13.88) a 5.40 (7.94) a 10.03 (26.68) a months into current quit attempt 1.74 (6.49) a 5.75 (10.74) b 2.26 (5.84) c 0.82 (1.02) a 2.03 (1.74) b 1.43 (1.45) b reduction in cigarettes per day 21.78 (10.49) a 16.73 (10.11) b 18.54 (8.39) ab 22.52 (10.65) a 18.10 (8.45) b 19.77 (7.80) ab cigarettes per day, at time of assessment 1.10 (3.46) a 1.69 (5.18) a 1.90 (3.82) a 0.81 (2.36) a 2.42 (4.02) a 1.01 (2.91) a note: disimilar superscripts (a, b, c) indicate that the percentages or means (shown with standard deviations) associated with the design condition are significantly different, based on either chi-square or anovas with post-hoc fisher’s lsd tests, p >.05. survey in less than 25 minutes. thus, completion times of less than 25 minutes were taken as an indicator of participants who were unlikely to have fully read or adequately considered all of the questions. results participant recruitment and retention in condition a, 156 participants completed the first page of the survey over a 10-week period, for an average of one interested and willing participant about every 11 hours. of these, 102 completed the survey, and 100 asked that we use their data (a 64.1% retention rate). under condition b, 238 people completed the first page of the survey over a 54-hour period (one willing participant about every 14 minutes). of these, 211 participants finished the survey and 203 asked that we use their data (85.3% retention rate). finally, 115 participants in condition c completed the first page of the survey over a 10-week period (one willing participant about every 14 hours), of which 111 completed the survey, and 110 asked us to use their data (a 95.6% retention rate). table 1 provides details on how the three samples differed in terms of reported demographic and smoking variables of interest to the original study. rates of invalid participation across groups table 2 presents the number of participants flagged by validity screening protocols in each condition. after using all screening protocols to flag cases with indicators of invalid participation, chi-square analyses revealed that significantly more participants in condition b were flagged as invalid (58.6% of survey completers) than in either condition a (11.0% of survey completers), 2 (n = 303) = 62.02, p < .01, = -.45, or condition c (16.4% of survey completers), 2 (n = 313) = 51.76, p < .01, = -.41. conditions a and c did not differ in the proportion of cases identified as invalid, 2 (n = 210) = 1.26, p > .05, = -.08. effects of design condition on data to better understand the effects of research design decisions (and essentially, invalid participation) on results obtained, we examined the questionnaire data for group differences in variance, covariance, and central tendency. we anticipated that the group participating under strong participation incentive with few procedural barriers to invalid participation (condition b) would differ from the other two conditions, despite the fact that our advertisement was the same and the study questionnaires were conceptually unrelated to the recruitment conditions. we did not expect the groups at lower risk for invalid participation (conditions a and c) to differ, despite being maximally different in incentive and barriers to invalid participation. variables were first examined for missing values, outliers, and fit with multivariate assumptions. next, two om-nibus multivariate analyses of variance (manovas) were conducted on conceptually related questionnaires; one analyzed the four-smoking-related variables, one analyzed the seven cognition variables. between-group differences in covariance, variance, and central tendency were tested using box’s test of equality of covariance matrices, levene’s test for equality of error variances, and manovas, nosen & woody 8 table 2 frequency of indicators of invalid participation across conditions design condition type of invalid participation a (n = 100) b (n = 203) c (n = 110) repeat participation duplicate ip address 3 (3.0%) 26 (12.8%) 2 (1.8%)* duplicate identity (name and address) 0 0 0 duplicate email address† 0 1 (0.5%) 0 ineligible participants accessed survey through trial and error 1 (1.0%) 34 (16.7%) n/a failed eligibility cross check 6 (6.0%) 56 (27.6%) 11 (10.0%) short completion time (< 25 minuntes) 4 (4.0%) 82 (40.4%) 5 (4.5%) total invalid cases among survey completers 11 (11.0%) 119 (58.6%) 18 (16.4%) note: percentages reflect proportion of invalid cases among individuals who completed the survey and asked that we use their data. † matching portion of email address before the “@” symbol * because participants in condition c had provided reliable names and mailing addresses, further examination of the database permitted confidence that these two duplicate ip addresses represented unique individuals sharing a household with another participant. respectively. omnibus gateway analyses were used where available and alpha was set at .05 for all tests.2 through a technical error in the computer administration of the survey, three cases from condition b were missing all responses on one questionnaire each (affecting the wbsi, ocds, and sseq). these cases were removed from analyses. no other cases had missing data. univariate outliers were replaced with scores adjacent to the next highest or lowest. this procedure affected five scores on the obq (three from condition b, two from condition c), one score on the tcq punishment subscale (from condition c), and two scores on the wbsi (from condition b). scores on the catastrophic appraisals index (cai) were moderately positively skewed for conditions a and c, but were severely negatively skewed for condition b. as such, the cai was excluded from analyses of variance and covariance but was included in analyses of central tendency. after removing two multivariate outliers from condition b, 408 cases were available for analyses (100 in condition a, 198 in condition b, and 110 in condition c). covariance. table 3 provides details of box’s tests of equality of covariance matrices. when using the four cognition questionnaires as dependent variables, box’s test was significant for two of the three between-group comparative 2 we opted for less stringent control of type 1 error rates because we were more interested in examining the broad pattern of results than the significance of any one particular test. analyses, indicating that the covariance matrix of condition b was significantly different from the covariance matrices produced by both condition a and condition c. box’s test was not significant when conditions a and c were compared, indicating similar patterns of variable interrelationships in these groups. for the smoking-relevant questionnaires, box’s test was significant for one comparison, indicating that the covariance matrix of condition a was significantly different from the covariance matrix of condition b. box’s test suggested that the pattern of variable inter-relationships in condition c was not significantly different from that of condition a or b. variance. standard deviations can be found in table 4. levene’s test for equality of error variances was conducted to investigate between-group differences in data variability. as an omnibus test, levene’s test was significant for five of the 10 scales, indicating that the variability differed in some way between the three groups for the tcqpunishment, wbsi, tafs, sseq, and acq, f’s (2, 416) 3.79, .06 |r’s| .07, p < .05. levene’s test showed homogeneity of variance across conditions for the remaining measures, f’s (2, 416) 2.89, |r’s| .06, p > .05. subsequent levene’s tests comparing each of three design groups to each other indicated that, in all cases, the heterogeneity was due to anomalies in condition b data. comparisons of conditions a and c indicated homogeneity of variance for all of the questionnaires, f’s (1, 211) 3.42, |r’s| .06, p .07. compared to condition a, however, condition b produced significantly different variability in scores on the five measures mentioned above, f’s (1, 306) 8.69, r’s = .06, p < .01. compared to condition c, condition b again produced significantly different variance for four of the five measures, f’s (1, 315) 8.61, .05 |r’s| .06, p < .01. variability did not differ on wbsi across conditions b and c, f (1, 315) = 1.57, r = .05, p > .05. central tendency. questionnaire means are presented in table 4. an omnibus manova with the four cognition variables was statistically significant, pillai’s trace = 0.22, f (8, 806) = 12.22, p 2 = .11, p < .001, indicating the presence of significant group differences in questionnaire central tendency. the omnibus manova using the smoking relevant variables was also significant, pillai’s trace = 0.13, f (12, 802) = 4.72, p 2 = .07, p < .001. follow-up analyses of variance (or welch tests, as appropriate) revealed significant between-group differences on three of the four cognition variables and five of the six smoking-relevant measures. significant differences were observed on all measures (fs > 5.39, p < .01), except the wbsi, welch’s f (2, 204.11) = 2.74, r = .09, p > .05, and ftnd, f (2, 405) = 0.25, p = .78, p 2 = .001. post-hoc fisher’s lsd and games-howell tests (as appropriate) suggested that the condition b data again drove these differences. indeed, means in conditions a and c were not significantly different for any questionnaire, d’s 0.21, p > .05. participants in condition b, however, displayed means online survey design 9 table 3 box’s tests of equality of covariance before and after validity screening condition comparisons omnibus a vs. b vs. c a vs. b b vs. c a vs. c full sample f p f p f p f p four cognition variables 5.49 <.001 7.00 <.001 5.91 <.001 0.88 >.05 six smoking variables 1.43 <.05 2.15 <.01 1.39 >.05 0.65 >.05 “invalid” participants deleted four cognition variables 3.50 <.01 3.50 <.01 3.50 <.01 0.48 >.05 six smoking variables 0.74 >.05 n/a n/a n/a n/a n/a n/a notes: full sample n’s for conditions a, b and c were 100, 198 and 110, respectively. after removing invalid participants, sample sizes were reduced to 89, 83 and 92, respectively. that were significantly different from those in both conditions a and c on all three cognition measures that showed differences in the omnibus test and on four of the six smoking-related questionnaires showing omnibus test differences (the acq, seq-positive, ces-d, and sseq). on all of these measures, condition b means were in the direction of more pathological than those in the other conditions; 0.33 d 0.87. similarly, median tests revealed that cai central tendency was equivalent for conditions a and c (medians = 3.00, 2 (n = 210) = 0.15, p > .05), but that the condition b group (median = 9.00) scored significantly higher than both of the other conditions, 2‘s (n = 298) 47.92, p < .001, .16). does removing invalid participants correct the problem? because condition b contained a significantly greater proportion of participants identified as invalid than did the other two groups, we were interested in examining the extent to which removal of these cases would remedy the group b anomalies in data variance, covariance and central tendency. as such, the above analyses were repeated without participants identified as “invalid” by the previously described data screening protocols. for these analyses, 264 cases were available (89 in condition a, 83 in condition b, and 92 in condition c). covariance. table 3 shows details of box’s test of equality of covariance matrices after removing “invalid” participants. as with the full samples, the covariance matrix of cognition questionnaires in condition b differed significantly from the covariance matrices of both conditions a and c , which did not differ from each other. thus, removing participants identified as invalid by our screening procedures did not eliminate group differences in covariance among the cognition variables. the smoking-relevant questionnaires showed a different result. removing participants who were identified as invalid using the data screening procedures resulted in equivalent covariance matrices across groups. variance. standard deviations for questionnaires after removing “invalid” participants can be found in table 4. removing participants identified as invalid reduced the number of variables for which there was cross-condition heterogeneity in variance from five to three questionnaires: tcq-punishment, tafs, and ces-d, f’s (2, 416) 3.29, r’s = .08 .09, p < .05. follow-up tests showed that condition a was discrepant from the other two conditions for ces-d variance, f’s (1, 416) 4.49, r’s = .07, p’s < .05. as with the full sample, condition b was discrepant from the other two conditions on the tcq-punishment and tafs, f’s (2, 416) 5.06, r’s = .07, p < .05. thus, removing “invalid” participants corrected some, but not all, of the between-group differences in questionnaire variability. central tendency. repeating the manovas showed that group differences in central tendency still remained in both the cognition variables and the smoking variables after removing invalid participants, pillai’s trace’s 0.11, f’s 2.58, p < .01, p 2 0.06. follow-up tests showed that all differences on cognition measures that had been apparent in the full sample were still present following removal of invalid participants. in all cases (with the obq, tcqpunishment, and tafs) condition b means were significantly different, d 0.36, p < .05, from those of conditions a and c, which did not differ, d < 0.18, p > .05. some of the differences observed on smoking relevant variables in the full sample were ameliorated by removing invalid participants, but three of the six variables still showed differences; the sseq and acq, f’s (2, 261) 7.50, p < .01, as well as the ces-d, welch’s f 172.35) = 5.17, p < .01. as before, condition b was discrepant from the other two conditions, d 0.45, p < .05, which did not differ, d < 0.18, p >.05. median tests on the cai were also unchanged from the full sample results, with participants in condition b (median = 7.00) scoring significantly higher than participants in conditions a and c (medians = 3.00), 2 ’s (n’s 172) 6.08, p <.05, _ .03. in sum, many between-group differences in central tendency remained after removing “invalid” participants. nosen & woody 10 table 4 means and standard deviations of study questionnaires before and after validity screening condition a condition b condition c m sd m sd m sd full sample n = 100 n = 198 n = 110 craving severity (ocds) 25.40 6.30 26.89 6.22 24.52 6.52 cessation self-efficacy (sseq) 38.40 12.81 34.82 9.71 40.16 12.12 positive smoking expectations 1.28 0.56 1.44 0.58 1.25 .52 depression (ces-d) 8.33 4.63 9.83 4.19 7.63 4.24 nicotine dependence (ftnd) 5.46 2.15 5.30 2.16 5.45 2.50 appraisals of cravings (acq) 72.60 37.99 91.34 30.53 68.01 36.53 thought suppression (wbsi) 50.30 11.89 53.42 9.43 52.02 11.44 obsessional beliefs (obq) 146.00 37.18 173.61 41.74 138.40 38.45 tcq-punishment 9.26 2.20 12.11 4.11 9.01 2.40 thought action fusion (tafs) 18.84 13.03 29.78 18.22 17.74 12.77 “invalid” participants deleted n = 89 n = 83 n = 92 craving severity (ocds) 25.49 6.52 27.27 7.08 25.08 6.68 cessation self-efficacy (sseq) 39.26 12.76 33.82 11.22 40.58 12.24 positive smoking expectations 1.29 0.58 1.35 0.60 1.30 0.52 depression (ces-d) 8.19 4.77 9.67 4.02 7.79 3.95 nicotine dependence (ftnd) 5.51 2.13 5.49 2.29 5.85 2.35 appraisals of cravings (acq) 74.48 37.54 90.63 33.09 67.84 36.39 thought suppression (wbsi) 50.55 12.00 54.35 10.30 52.75 10.97 obsessional beliefs (obq) 145.48 37.12 165.07 40.42 138.47 39.35 tcq-punishment 9.29 2.11 10.90 3.56 9.04 2.30 thought action fusion (tafs) 18.51 12.72 23.63 15.69 17.41 12.58 note: bold figures (means or standard deviations) are significantly different from comparable figures in the other two conditions. underlined figures indicate significant difference from one other condition. tcq-punishment refers to the punishment subscale from the thought control questionnaire. discussion results of the current study suggest that online survey design decisions have important implications for the reliability and validity of research results. when few procedural barriers to invalid participation were present, provision of a strong monetary incentive (condition b) was associated with extremely high rates of questionable survey submissions, including cases of repeat participation, study ineligibility, and improbably fast completion times. rates of invalid participation were significantly lower when either the incentive was reduced (while limited procedural barriers were maintained, as in condition a) or when procedural barriers in the form of personal participant contact and limited anonymity were implemented (while the incentive was maintained, as in condition c). unsurprisingly, condition b produced data that were significantly different, in terms of questionnaire covariance, variance, and central tendencies, from the data obtained in the other two conditions. deletion of participants identified through data screening procedures as “invalid” corrected some, but not all, of these differences in the data. how design affects ease of data collection the design features of condition b (high monetary incentive and anonymous, automated participation) had one big advantage, which was ease of participant recruitment. with a seemingly eligible and willing participant completing the study every 14 minutes, we reached our targeted sample size in only three days of data collection. recruitment was much slower in the conditions lacking the high monetary incentive (condition a) or implementing greater participation barriers (condition c); both of these conditions averaged about two new willing and eligible participants per day. interestingly, recruitment rates were similar for conditions a and c, despite the fact that condition c involved a guaranteed financial payoff, whereas the incentive in condition a was an entry in a drawing. the personal screening and decreased anonymity in condition c likely contributed to this effect. contacting the researcher, waiting for a response, providing answers to the screening questions, and waiting for a decision about eligibility are much more burdensome for the participant than simply clicking on a link and beginning to complete the survey. also, in the era of identity theft and online fraud, providing one’s real name, date of birth, email address, home address, and phone numonline survey design 11 ber to someone who claims to be a researcher in canada may be a risk many people would rather not take. despite the increased burden, however, offering a monetary incentive under more stringent participant screening conditions did seem to bolster participant retention, which was almost 96% in condition c, markedly higher than in condition a (65%). how design affects risk of invalid participation invalid participation, which we judged on the basis of data screening procedures indicating repeat participation, accessing the survey through trial and error, failure to meet study eligibility criteria, and improbably fast survey completion times, was detected in condition b at rates nearly five times those seen in the other two conditions. variations in condition incentive, anonymity, and personal contact likely contributed to this difference by influencing both motivation and capacity for fraudulent participation. in particular, participants in conditions b and c (but not in a) had financial motivation for fraudulent participation. at the same time, participants in conditions b and a (but not in c) had few procedural barriers to invalid participation. in other words, participants in condition b had both motivation and capacity for fraudulent participation, while participants in the other two conditions were missing one of these critical elements. the fact that no participant in condition b provided an email address matching that of another participant, despite many obvious instances of repeat survey submission, seems to support the idea that many of these participants deliberately took part under false pretenses. research suggests that offering tangible rewards for behavior may undermine intrinsic motivations (deci, koestner, & ryan, 1999). thus, participants in conditions b and c may have been particularly likely to have been motivated by the monetary reward rather than, for example, the pleasure of helping science or learning more about themselves or the research. in and of itself, this may not be disastrous. the problem, rather, may lie in the fact that participation in condition b was anonymous and automated, such that it required little effort or personal investment from participants. termed the “overjustification effect” (lepper, greene, & nisbett, 1973), individuals offered a larger payment than necessary may perceive the task more negatively (e.g., less enjoyable) than tasks associated with lower incentives (freedman, cunningham, & krismer, 1992). anonymity and lack of personal contact with the researchers may have compounded the effects of poor motivation and negative expectations by removing social pressures for conscientious behaviour. how design affects integrity of collected data practically speaking, the more important questions here concern data integrity in the context of high rates of invalid participation. with respect to similarity of the data obtained under different incentive and anonymity conditions, the data produced by condition b was anomalous from the other two conditions in questionnaire variance, covariance, and central tendency. highlighting the irregular data obtained in condition b, data did not differ in the conditions at low risk for invalid participation (conditions a and c). the types of data abnormalities seen in condition b would critically threaten the validity of any findings based on the sample. not only would they complicate analyses by violating statistical assumptions and distorting type i error rates, but also they would raise serious questions about the representativeness of the sample. the most parsimonious explanation for the anomalous data in condition b is that invalid participation wreaked havoc on the data. indeed, it is easy to imagine how high rates of repeat participation, misrepresenting study eligibility, or failing to devote adequate care and attention to the task could affect results. the possibility exists, then, that simply removing the questionable individuals from the sample could salvage the data. if these procedures can effectively remedy the data abnormalities produced by using a high-risk design, then reducing the incentive or implementing burdensome barriers to participation may not be necessary to ensure trustworthy data. in the present study, removing participants who were flagged by validity screening protocols corrected many, but not all, between-group differences in questionnaire variability, central tendency, and covariance. this suggests that either the screening techniques used were not 100% effective at identifying invalid participants, or that there were fundamental differences in the samples attracted by the various design conditions. in support of the former explanation, most post-hoc validity screening strategies are subject to particular weaknesses. participants could avoid submitting surveys with duplicate ip addresses, for example, by taking part on different computers at a library or another public internet access site. detecting individuals who do not genuinely meet study eligibility criteria is also fallible. in particular, many individuals could have guessed the “correct” responses to screening questions based on recruitment advertisements or information passed on from previous participants. asking about eligibility criteria later in the survey, using different wording and response formats (e.g., open-ended vs. multiple-choice), may identify some (but probably not all) of these participants. finally, screening for implausibly fast completion times based on total (not page-by-page) survey completion times would miss invalid participants who took their time, who actually read the questions, or who took a break mid-survey. data differences that remained after removing invalid participants could also be due to fundamental, legitimate differences in the samples attracted to participate under the various design conditions. indeed, individuals displaying more psychological difficulties (e.g., more pathological obsessive compulsive or smoking-related thoughts and behaviors) may be less likely to take part in online studies nosen & woody 12 that are not both highly rewarding and relatively painless. this possibility is consistent with evidence indicating that survey design features like method of informed consent and amount of personal information requested can influence sample characteristics (o'neil et al., 2003). design choices related to incentive and barriers to invalid participation may similarly affect sample representativeness. limitations several factors are important to bear in mind when considering the results of the current study. first, participants were recruited sequentially (into condition a, then b, then c), without random assignment. thus, we cannot be certain that the anomalies seen in condition b are due solely to differences in design. nevertheless, this remains the most parsimonious explanation. additionally, the nature of this topic does not readily lend itself to more conclusive experimental designs. in particular, individuals intending to profit by fraudulent participation are unlikely to take part if randomly assigned to incentive. another caveat to note concerns the post-hoc validity screening strategies. those employed were tailored to the current study, as they would be in other forms of online research. however, this means that some potentially useful strategies were not applied. for example, we did not exclude on the basis of long strings of identical responses because individual questionnaires were relatively short. thus, use of different strategies could potentially yield different rates of invalid case detection. recommendations results suggest that providing a sizeable monetary incentive to online participants is an acceptable strategy to boost recruitment and retention, as long as strong procedural barriers to invalid participation are implemented. apart from an improved retention rate, this design did not convey apparent advantages over offering a minimal incentive with fewer procedural barriers. if retention rate is not a concern, then a design offering minimal incentive and anonymous, automated participation may be the cheapest and easiest solution. either way, researchers should take measures to ensure that participants do not have both motivation and capacity to profit from participation. use of data validity screening techniques is also strongly recommended, particularly since we found rates of invalid participation as high as 16.4% among designs at low risk for fraudulent participation. that being said, current results suggest that use of these validity screening strategies does not fully ameliorate the problem of invalid participation. references birnbaum, m. h. 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(1994). the thought control questionnaire: a measure of individual differences in the control of unwanted thoughts. behaviour research and therapy, 32(8), 871-878. graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 sudden unexpected death of the therapist: reconciling ethical and clinical concerns for providing continuing care melanie merola o’donnell antioch new england graduate school the sudden unexpected death of a therapist is examined with consideration given to ethical, clinical, and legal implications for therapists in planning for the possibility of their deaths. a vignette is provided for illustration. the code of ethics (apa, 2002) is reviewed for relevant guidance, and the professional literature is summarized. it is concluded that while the code of ethics only dictates minimal activity in preparation for death, the professional literature makes a strong case for more elaborate planning in order to reduce harm to clients. a summary of recommendations for therapists in planning for their sudden unexpected deaths is provided. as usual, dr. molinari arises at 5:30 a.m. to start her day. it is another full day. she will attend her morning exercise class, return home to eat breakfast and shower, and head to the office for her prompt 8:00 a.m. arrival. on her professional agenda for the day are three individual psychotherapy sessions, one couples session, one hour of supervision with a student at the local graduate school, and a meeting with colleagues about a program that is being developed for at-risk youth. she is prepared for each session but her mind is focused on a former client who terminated several years ago. this client is on her mind because it is the tenth anniversary of the day that the client quit drinking. she has been sober since. dr. molinari saw this client in treatment intermittently for approximately six years, and she knows that this is a day of celebration for that person. as dr. molinari leaves her neighborhood in the pre-dawn darkness, her car is struck by an eighteen-wheeler and she is killed instantly. within a few hours dr. molinari’s body has been identified and her family and one colleague have been notified. if you were the colleague of dr. molinari that was notified of her death, how would you proceed with the dispensing of her professional responsibilities? what issues might arise as dr. molinari’s practice is terminated? the case described above forces consideration of the ethical, clinical, and legal obligations that therapists have in making plans for their own unexpected deaths. recent data suggest that such planning is not common. a survey conducted with therapists involved in the resolution of professional responsibilities for deceased therapists indicated that 90% of the deceased therapists had no preplanned less than two weeks after submitting this article for publication, the author died in an automobile accident. she was 33 years old. her husband, george o’donnell, completed the edits for this article prior to publication. correspondence concerning this article should be addressed to george o'donnell, 55 birch street, saratoga springs, ny, 12866; email: geodonnell@yahoo.com. procedure to assist their clients with the transition following their deaths, and that 94% of clients were not provided with referrals (garcia-lawson, lane, & koetting, 2000). such statistics reinforce the need for clarity on the ethical responsibilities of therapists in planning for their clients should the therapists die unexpectedly. culling the ethics code there are few ethics codes proposed by the american psychological association (apa) that speak directly to the question at hand. standard 3.12, interruption of psychological services states: unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s/patient’s relocation or financial limitations. (apa, 2002, p. 1066) fisher (2003) interprets this standard to mean that a trusted colleague should be prepared to contact clients in the event of unplanned interruptions and that a therapist’s “reasonable efforts” reflect the reality of the unpredictable nature of life. standard 6.02c, maintenance, dissemination, and disposal of confidential records of professional and scientific work states: “psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice” (apa, 2002, p. 1067). in fisher’s (2003) clarifying comments, the psychologist’s death is specifically mentioned as one such reason for withdrawal, and the methods of record transfer are identified as in person, by mail, by fax, through the internet, or through private company networks, as long as confidentiality is maintained. 45 o’donnell 46 aside from these two specific references to death, therapists can only speculate as to whether or not other standards apply in the case of the sudden unexpected death of the therapist. for example, does standard 3.04, avoiding harm (apa, 2002, p. 1065) apply? it indicates that psychologists take reasonable steps to avoid harm to clients. is harm caused to a client when his or her therapist dies unexpectedly, and no plan is in place to continue care? does standard 10.09, interruption of therapy (apa, 2002, p. 1073) apply? it indicates that psychologists at the outset of employment establish a plan for continuity of care in the event of employment termination. does standard 10.10c, terminating therapy (apa, 2002, p. 1073) apply? it indicates that psychologists provide pretermination counseling and suggest alternative service providers to clients prior to termination. should therapists at the outset of therapy discuss the possibility of their untimely death and provide emergency referrals at that time? as if these questions were not enough to consider, some standards complicate the handling of notification and transitional services for clients. most notably, psychologists are bound by standard 4.01, maintaining confidentiality (apa, 2002, p. 1066). yet the allowances for breaking confidentiality do include circumstances in which the therapist has died unexpectedly and another person contacts the client for notification of the death or to offer transitional services. in summary, the ethics code indicates that psychologists have a responsibility to plan for their unexpected deaths to the extent of facilitating transitional services. these services can include identifying a colleague to notify clients of the therapist’s death and to have a plan in place for the confidential transfer of client files. the answers to other questions, such as whether or not harm is done or a breach of confidentiality has occurred if plans for continued care are not implemented, are unclear. further, the interaction of these responsibilities with others, such as maintaining confidentiality, is left to interpretation. a look to the literature may be useful for further clarification. culling the literature in turning to the literature on the handling of professional responsibilities following the sudden unexpected death of a therapist, an interesting point emerges. several authors have noted that there is very little in the literature about this topic (beder, 2003; cohen, 1983; garcia-lawson et al., 2000). garcia-lawson et al. suggest that this silence may be tied to a broader discomfort with the topic of death and dying, and specifically resistance to considering one’s own death. cohen echoes that speculation, and adds that other factors specific to the psychotherapeutic setting may influence such silence. for example, cohen argues that the practice of psychotherapy can be isolating and can lead therapists to experience a sense of separateness from others. contemplation of issues around death may exacerbate this experience and raise anxiety. further, cohen argues that psychotherapy often carries with it a sense of timelessness that may blur the realities of life, such as the inescapability of death. whatever the reason, the dearth of writing on the topic is notable. this is especially true when considering the implications drawn from reviewing the existing literature. on interruption of services most of the literature on handling the interruption of services following a therapist’s death implies that he or she has a clinical obligation—above and beyond the ethical obligation—to identify a colleague who will notify clients of the death. the literature that refers specifically to the handling of notification raises several points. first is the issue of how a client is informed of the death. the foundation demonstrating the relevance of this issue comes from studies that suggest that the psychological impact on the client of the unexpected death of his or her therapist is influenced by the death notification received (beder, 2003; tallmer, 1989). garcia-lawson et al. (2000) found that notification has been received by clients via widely different sources, including from colleagues of the deceased therapist, from the therapist’s spouse, from their own friends, from a member of their therapy group, by being present at the time of death, and by reading an obituary. they further note that many clients reported being confused about who, if anyone, was responsible for handling the information. several authors have suggested methods for a more appropriate handling of the death notification. garcia-lawson et al. (2000) suggest (a) changing the therapist’s answering machine message immediately to note the cancellation of all future appointments; (b) posting a note on the therapist’s door noting the cancellation of all future appointments and providing a number to call to get further information; and, (c) providing the doorman and elevator operator (if they exist) with similar information. cohen (1983) suggests that a colleague of the deceased therapist maintain phone numbers for the therapist’s clients along with instructions on what to tell them about the death. others suggest that the list need not be kept by a colleague but in an accessible place of which colleagues are aware (bram, 1995). if therapists rely on an appointment book for listing clients, and that book holds initials only (in an attempt to maintain confidentiality), a separate list would need to be located in an accessible location so that colleagues have the full names of the individuals that they will need to contact (freedman, 1990). a second related issue that is addressed in the literature has to do with what, if any, services should be provided to clients upon learning that their therapist has died unexpectedly. bram (1995) argues that all therapists should ensure that clients will be taken care of in the event of their therapist’s unexpected death. garcia-lawson et al. (2000) suggest that the care come in the form of providing options to the client, such as entering treatment immediately with anunexpected death of therapist 47 other therapist to process grief; waiting a time period and returning to therapy with a new therapist; or, not attending therapy again in the foreseeable future. garcia-lawson et al. argue that there is often a need to share and process reactions to loss, and clients should be offered the option to do so with another therapist. cohen (1983) takes this argument further, stating that therapists should maintain clinical directions for each client so that the therapists’ colleagues have some information on how to proceed. it is further noted that these directions should be provided directly to the colleagues, rather than be recorded in a will that may not be read for some time following the death. others have echoed this suggestion (freedman, 1990). in the study conducted by garcia-lawson et al. (2000), 56% of clients of deceased therapists were offered a consultation session within one month of the deaths and most accepted the invitation. in addition, some authors have cited the offer of a referral, or lack thereof, as an influencing factor in the psychological impact of the therapist’s death on the client (tallmer, 1989). these findings suggest that the offering of some form of intervention is useful. should such an intervention be offered, several authors have suggested that therapists to whom clients are referred be educated on special issues that may be present for these clients. this may include education on clients initially being difficult to treat and having mixed transferences (garcia-lawson et al., 2000); the loss associated with losing the unique role of a therapist in a client’s life (beder, 2003); and, a client’s feelings of disloyalty to the deceased therapist (garcia-lawson & lane, 1997). though not mentioned in the literature, it also seems relevant to consider any impediments to providing unbiased care that may arise should the client be referred to a therapist who is a close friend of the deceased therapist, and therefore grieving as well. on disposing of confidential records the study by garcia-lawson et al. (2000) indicated that 90% of the clients from the sample were not provided their records following the deaths of their therapists. despite this, the literature seems to indicate that it is good practice to offer clients their records at the time of the death notification (mcgee, 2003). others indicated that files be protected by a colleague of the deceased therapist until a future date when they could be transferred to a referring therapist or destroyed (cohen, 1983; garcia-lawson et al., 2000). on avoiding harm as stated previously, the ethics code is unclear as to whether or not a psychologist is considered to be causing harm if he or she does not make plans for clients in the event of the psychologist’s sudden unexpected death. the professional literature, however, makes a strong statement about the clinical obligation to do so. for example, beder (2003) notes that positive treatment outcomes may be eliminated as a result of a poor termination. cohen (1983) agrees, suggesting that such an occurrence can be psychologically devastating to the client. these premises suggest a clear tie to causing harm. several authors have reviewed the common client reactions to the unexpected termination of therapy. these include intense grief reactions with feelings of anger, despair, depersonalization, and somatization (garcia-lawson et al., 2000); rage, feelings of abandonment, and betrayal of trust (beder, 2003); guilt, disappointment, and bitterness (garcia-lawson & lane, 1997); loneliness (levin, 1998); and, the retriggering of previous experiences of separation (freedman, 1990; levin, 1998). in addition, some positive reactions were found, such as learning to cope better with tragedy, separation, and loss (garcialawson et al., 2000), and making a break from therapy that was otherwise difficult for the client to do on his or her volition (garcia-lawson & lane, 1997). speculation on the reasons for such impact has focused predominately on the unique nature of the therapeutic relationship (cohen, 1983; garcia-lawson & lane, 1997; garcia-lawson et al., 2000). in addition it has been noted that the sudden unexpected termination of therapy robs the client of a termination phase wherein the object loss may be confronted directly (garcia-lawson et al., 2000). as such, several authors imply that there is a clinical and ethical obligation to plan for sudden unexpected death as one way of avoiding harm (cohen, 1983; freedman, 1990; garcialawson, et al., 2000; koocher, 2003; mcgee, 2003). it is worth noting that most of the literature on this issue comes from practitioners of psychoanalysis or psychoanalytic therapy. as bram (1995) notes, this may relate to several factors specific to psychoanalytic therapy, including (a) the focus on the relationship between client and therapist; (b) the tendency towards longer treatment periods; and, (c) the emphasis on issues of separation and loss. on talking about death in advance one of the areas of most disagreement surrounds the topic of whether or not clients should be confronted with the possibility of the sudden unexpected death of the therapist during therapy. some authors suggest that preplanned instructions to assist the client in the event of an unexpected death be included in the framework at the start of therapy (garcia-lawson, et al., 2000; mcgee, 2003), such that termination begins with the first session (garcia-lawson & lane, 1997). other authors suggest that nothing be said at the start of therapy, though plans should be in place in case death occurs (cohen, 1983; freedman, 1990). cohen suggests that information about the therapist’s possible death at the start of therapy could hinder the client in his or her treatment. the lack of clarity on the topic has led to the suggestion that further data be collected to determine the most appropriate way of handling such conversations, and the level of detail to discuss (abend, 1982). o’donnell 48 on confidentiality the issue of handling confidentiality while simultaneously trying to avoid harm is murky at best. cohen (1983) is the most extensive in attention to this issue. he acknowledges that preparing a client list with treatment recommendations is a breach of confidentiality. the alternatives to handling the situation which do not involve such a breach are listed as (a) choosing to do nothing, (b) leaving a note on the door, and (c) asking advance permission to break confidentiality in the event that death occurs. cohen argues that each of these situations would be highly anxietyprovoking for the client, possibly harmful, and therefore inappropriate. in addition, cohen argues that the ethical responsibility of therapists to clients in the unusual event of death overrides the issue of breaking confidentiality. in interviewing several clients who had experienced the death of their therapists, freedman (1990) reports that all were accepting of the breach in confidentiality given the circumstances. this provides support for cohen’s conclusion. still, the issue remains that what seems to be ethically and clinically appropriate regarding preparing for a therapist’s death is ethically at odds with maintaining confidentiality. as cohen states, all options should be considered by the therapist, even those that he or she has deemed inappropriate. other issues the ethical issues reviewed above relate to the standards in the ethics code that appear relevant to the scenario of a therapist’s unexpected death. the literature raises several additional points. these points will be considered briefly below. first is the important issue of ensuring that therapists consult state law when considering how to handle the possibility of unexpected death. as mcgee (2003) notes, state jurisdictions typically have laws regarding informed consent, confidentiality, the transfer of records, and the amount of time that records are retained. therapists should be considering all aspects of the issue of possible sudden unexpected death. this includes ethical, clinical, and legal considerations. a related point, made by cohen (1983), is that therapists should include legal counsel in the planning and preparation for their deaths and the execution of wishes after their death. this helps ensure that both the therapists’ and their clients’ interests are protected. second, it has been suggested that, rather than simply providing referrals to clients or a list of names and treatment recommendations to colleagues, therapists actually appoint a colleague as a professional executor to handle all aspects of their professional responsibilities (cohen, 1983; mcgee, 2003). this would enable better coordination and ensure that nothing is overlooked (e.g., logistics like billing). third, freedman (1990) points out that a therapist should maintain notes with the possibility of his or her death in mind. in other words, ensure that what is written is clearly understandable to others—including the client— without the therapist’s verbal input as the therapist may not be around to provide it. fourth is the issue of whether or not former clients should be notified when a therapist dies. cohen (1983) suggests that this determination be part of the advanced planning done by therapists in preparation for death. mcgee (2003) provides suggested guidelines for when to contact former clients of a therapist’s death. these include contacting (a) individuals who were clients within the past five years, (b) individuals who had especially strong transference feelings, (c) individuals who participated in several periods of therapy, and (d) individuals who participated in long-term therapy. finally, several authors suggest advance consideration of whether or not clients will be invited to participate in funeral services or other rituals for the deceased therapist (beder, 2003; garcia-lawson et al., 2000). in the study conducted by garcia-lawson et al., 81% of clients participated in either a funeral or memorial service for their deceased therapists. tallmer (1989) reviewed anecdotal evidence that found that such participation was helpful for some clients and not for others. if the therapist is comfortable with the idea of their clients participating in death rituals, it may be that providing the option to each is most beneficial. regardless, this decision is best made in advance by the therapist and not left to be sorted by their colleagues. conclusion the code of ethics (apa, 2002) provides limited guidance to psychologists looking to address the possibility of their sudden unexpected death. at a minimum it seems to suggest that psychologists select a colleague to notify their clients and plan for the confidential handling of records should such a tragedy occur. it is less clear what provisions are needed to ensure that client harm is avoided and on how to handle client notification without breaching confidentiality. in addition, it is less clear whether or not some form of service should be offered in order to promote continuity of client care. suggestions on these topics and others can be found in the professional literature, which touches on the ethical, clinical, and legal considerations in preparing for an unexpected death. the most extensive suggestion entails the designation of a professional executor to handle all aspects of the dismantling of the therapist’s practice. this would include the notification of clients, the offering of continuing care, the handling of office logistics such as billing and changing answering machine messages, the handling of records, the oversight of confidentiality, and contact with legal counsel. in order to do so, therapists must do extensive planning. they must create client lists that are accessible, understandable, and continually updated to include contact information and treatment recommendations. therapists must keep their death in mind while recording notes such that the notes will be understandable to others in their abunexpected death of therapist 49 sence. they must give instructions on what to tell clients; how to handle former clients; whether or not to include clients in death rituals; whether or not the possibility of death has been addressed in advance; and to whom clients should be referred, keeping in mind how referring therapists will be coping with the therapist’s death. they must indicate their desire for the types of services offered to clients (e.g., grief counseling, therapy referral, consultation). they must indicate how they have accounted for confidentiality issues and provide instructions on the handling of records including related limitations of state laws. they must identify legal counsel. finally, they should educate the executor as to the process and special issues that might arise, such as the difficulty that referring therapists may experience in taking on clients of a deceased therapist. ragusea (2002) has proposed a sample of a professional living will, which contains much of this information. if therapists have not considered their feelings about death, and specifically their own deaths, it is suggested that they force themselves to ponder the topic (garcia-lawson et al., 2000). the dearth of literature on the topic suggests that many therapists have not done so. yet if a therapist has not thought through the impact of his or her death on clients, it is unlikely that his or her clients’ best interests are being served. references abend, s. m. (1982). serious illness in the analyst: countertransference considerations. journal of american psychoanalysis association, 30, 365-379. american psychological association (2002). ethical principles of psychologists and code of conduct. american psychologist, 57, 1060-1073. beder, j. (2003). picking up the pieces after the sudden death of a therapist: issues for the client and the inheriting therapist. clinical social work journal, 31, 2536. bram, a. d. (1995). the physically ill or dying psychotherapist: a review of ethical and clinical considerations. psychotherapy: theory, research, practice, & training, 32, 568-580. cohen, j. (1983). psychotherapists preparing for death: denial and action. american journal of psychotherapy, 37, 222-226. fisher, c. b. (2003). decoding the ethics code: a practical guide for psychologists. thousand oaks, ca: sage press. freedman, a. (1990). death of the psychoanalyst as a form of termination of psychoanalysis. in a. l. s. silver & h. j. schwartz (eds.). illness in the analyst: implications for the treatment relationship (pp. 299-232). madison, ct: international universities press. garcia-lawson, k. a., & lane, r. c. (1997). thoughts on termination: practical considerations. psychoanalytic psychology, 14, 239-257. garcia-lawson, k. a., lane, r. c., & koetting, m. g. (2000). sudden death of the therapist: the effects on the patient. journal of contemporary psychotherapy, 30, 85-103. koocher, g. (2003). ethical and legal issues in professional practice transitions. professional psychology: research and practice, 34, 383-387. levin, d. (1998). unplanned termination: pain and consequences. journal of analytic social work, 5, 35-46. mcgee, t. f. (2003). observations on the retirement of professional psychologists. professional psychology: research and practice, 34, 388-395. ragusea, s. a. (2002). a professional living will for psychologists and other mental health practitioners. in l. vandecreek & t. l. jackson (eds.), innovations in clinical practice: a source book (vol. 20, pp. 301305). sarasota, fl: professional resource press. tallmer, m. (1989). the death of an analyst. psychoanalytic review, 76, 529-542. culling the literature graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 mothers with borderline personality disorder andrea e. lamont teachers college, columbia university children of mothers with borderline personality disorder (bpd) are a particularly vulnerable population who have thus far been relatively neglected in the empirical research within the field of clinical psychology. this paper aims at identifying the need for increased research on the psychosocial outcomes of these children. diagnostic characteristics of the disorder, such as problems with interpersonal relationships and instability of sense of self, impede a mother with bpd’s ability to face the challenges associated with parenting and negatively affect her explicit parenting behaviors. these maladaptive parenting behaviors of the mother with bpd are anticipated to negatively affect child development. this paper explores the cognitive and social/emotional development of children of mothers with bpd. increased research on this population is called for and future directions are suggested. borderline personality disorder (bpd) is a pervasive disturbance of personality that is marked by a pattern of unstable relationships, a history of impaired self image, identity problems, and recurrent, severe impulsivity that is present in a variety of psychosocial domains (american psychological association, 2000). it affects approximately 2% of the general population, about 10% of patients seen at outpatient health care clinics, and about 20% of psychiatric inpatients (apa, 2000; paris, 1999). researchers have long been interested in examining the familial patterns of bpd. masterson (1976) once commented that “the mother of any borderline is herself a borderline,” and since then, research in this area has focused on the increased prevalence of psychopathology in biological families (e.g., links, steiner, & huxley, 1988). family members of those with bpd are at an increased risk for a myriad of psychopathological diagnoses. the prevalence rate of borderline personality disorder is five times greater in first degree relatives of people with bpd than in the general population (apa, 2000; links et al., 1988; paris, 1999) with an even higher prevalence of subsyndromal phenomenology of the disorder in first degree relatives (zanarini et al., 2004). additionally, substance dependence, antisocial personality disorder and recurrent mood disorders (primarily, unipolar depression) are commonly diagnosed within the family of origin (apa, 2000; links et al., 1988). nonetheless, despite the fact that approximately 75% of bpd sufferers are women, many of whom are in their child bearing years (apa, 2000), little attention has been paid to the psychosocial development of children whose mothers have bpd. it is hypothesized that children of mothers with bpd will suffer a myriad of psychosocial problems resulting from the mother’s borderline symptoma correspondence concerning this article should be addressed to andrea e. lamont, 78 maple drive, brewster, ny 10509; e-mail: ael2112@columbia.edu. tology; however, there is very little empirical evidence to date that addresses the unique effects of a maternal diagnosis of bpd on a child’s development. it is the aim of this paper to highlight the importance of and need for increased research focus on children of mothers with bpd. scant research exists to validate the notion that essential features of borderline personality disorder directly interfere with a parenting efficacy, despite the predictions of the attachment literature suggesting that maternal bpd should have negative ramifications for the developing child. for example, mothers with bpd, by the very nature of the disorder, display low levels of warmth, and high levels of intrusiveness and hostility. the mother’s inability to display “good enough” parenting interferes with healthy child development. likewise, borderline personality disorder by its very nature interrupts the mother’s ability to be emotionally available for her children. a mother with bpd’s unresolved mental representations (from her own early childhood experiences) may act as “ghosts in the nursery” that impede the her ability to be fully present and emotionally available to her child (hobson, patrick, & valentine, 1998; hobson et al., 2005). it should be noted that psychosocial development of children with fathers with borderline personality disorder is an equally important area of study. however, the focus shall be given to mothers with bpd due to the gender differences of the diagnosis and the uniqueness of the symbiotic relationship in infancy, as well as to be consistent with prior literature on bpd. this paper begins with a brief review of the literature on the diagnosis of borderline personality disorder and the early experiences of adults with bpd. this review is followed by an exploration of the ways in which the characteristic features of the diagnosis may come into play within the mother-child relationship. an overview of the limited research on the development of children of mothers with bpd is then presented, and future directions are suggested. 39 lamont 40 attachment status and early experiences of mothers with bpd according to the diagnostic and statistical manual of mental disorders, fourth edition – text revision (apa, 2000), individuals are considered to have borderline personality disorder if they meet at least five of the following nine diagnostic criteria: frantic efforts to avoid real or imagined abandonment; a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; identity disturbance; impulsivity in at least two areas that are potentially self-damaging; recurrent suicidal behavior, gestures, threats or self-mutilating behavior; affective instability due to a marked reactivity of mood; chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling anger; and transient, stress-related paranoid thoughts or severe dissociative symptoms (apa, 2000). in the psychoanalytic literature, borderline personality disorder is a disorder rooted in pre-oedipal disturbances in the mother-child relationship. many adults with bpd were raised in disorganized families marked by dissolution, emergencies, and feats for survival (golomb et al., 1994). many recall their own parents as insensitive, neglectful, unempathic, overprotective, and intrusive (newman & stevenson, 2005; paris, 1999). family environments were often chaotic, and the varying emotions of the child were not validated (newman & stevenson, 2005; paris, 1999). it is noteworthy that many adults with bpd had a history of childhood abuse, loss, and trauma (apa, 2000; feldman et al., 1995; millon, blaney, & davis, 1999; trull, stepp, & durrett, 2003) and continue to struggle from unresolved issues resulting from this trauma into their adult years. thus, almost all adults with bpd maintained a “disorganized” pattern of attachment during childhood (holmes, 2005). children with a disorganized pattern display an inconsistent and unorganized response to the attachment relationship (davies, 2004). their lack of consistency in attachment behaviors may develop out of a dynamic in which the disorganized child feels frightened and perceives the mother as frightening (davies, 2004; stevenson-hinde & verschueren, 2002). in fact, the child’s inability to sustain a secure attachment in childhood plays a tremendous role in the etiology of the disorder above and beyond the effects of the childhood trauma (see trull et al., 2003). as adults, individuals with bpd continue to display maladaptive attachment behaviors, typically revealing maladaptive “enmeshed” or “unresolved” pattern of adult attachment (crandell, patrick, & hobson, 2003; hobson et al., 2005). mothers with bpd in the parental role mothers with bpd are characterized by a history of broken relationships and marked instability in multiple domains of their lives. it is anticipated that the characteristic behaviors of bpd will infiltrate the mother-child relationship as much as it interferes with other relationships. as such, the characteristic features of borderline symptomatology create an environment that is non-conducive to the optimal social and emotional development of children. this section will illuminate how borderline features and unresolved early experiences interfere with a mother with bpd’s ability to parent effectively. borderline symptoms in context of parenting characteristic symptoms of borderline personality disorder are likely to hinder the ability of a mother with bpd to parent effectively, thereby negatively affecting the social and emotional development of the child. for instance, adults with bpd typically display a pattern of unstable relationships and a host of interpersonal problems (apa, 2000). they generally show a disorganized way of dealing with interpersonal stress and frequently fluctuate between extreme idealization and devaluation of others (holmes, 2005; apa, 2000). it is suggested that the mother-child relationship is not protected from these interpersonal problems. likewise, people with bpd often cross interpersonal boundaries and role expectations. many people with bpd, for instance, will be empathic towards, and care for, other people only under the expectation that the other person will “be there” for them on demand (apa, 2000). many habitually make impractical claims that others are not “there” enough and make unrealistic demands for amount of time spent together. they often inappropriately respond with intense anger to even brief separations or slight changes in plans (apa, 2000). concomitantly, a mother with bpd tends to treat the child as a “need gratifying object” as opposed to an individual, an autonomous person. such behaviors, mixed with the powerful, alternating idealization and devaluation characteristic of bpd, are likely to obviate a positive mother-child relationship and negatively affect the child’s developing interpersonal skills and sense of self. moreover, effective parenting by the mother with bpd is compromised by instability in her sense of her own self. overall, those with bpd maintain a negative self-image and feelings of worthlessness. it is also typical for adults with bpd to make abrupt changes in aspirations, vocation, sexual identity and values (apa, 2000). since it is through the unique relationship with the mother that the infant develops a sense of self, this distorted, unpredictable, and fluctuating self image of the mother is likely to have negative effects on the child’s own self image. furthermore, a mother with bpd’s inability to adequately regulate her own emotions may obstruct her ability to cope with the varying affective states of her child (newman & stevenson, 2005; paris, 1999). it is common for mothers with bpd to feel anxious, estranged, confused, or overwhelmed by their infants (hobson et al., 2005; holman, 1985; newman & stevenson, 2005). when these parents get stuck in their own “defensive and entangled organization of thought” (crandell, fitzgerald, & whipple, mothers with borderline personality disorder 41 1997, p. 250), they prevent their children from integrating certain affective experiences and behaviors. mothers with bpd, for instance, are characteristically volatile and have difficulty controlling intense, inappropriate anger that is often precipitated by environmental changes and/or intense abandonment fears (apa, 2000; paris, 1999). their strong outbursts of anger can be detrimental to the developing child, and many children of mothers with bpd are victims of verbal and/or physical abuse (newman & stevenson, 2005). glickhauf-hughes & mehlman (1998) suggest that “a mother’s hostility, rage, and destructive behavior may be disguised as love, making it difficult for a child to trust his or her own perceptions of reality” (p. 296). additionally, a mother with bpd’s inability to adequately regulate her emotions causes her to inappropriately react to environmental stimuli. her inability to regulate her emotions often yields impulsive and self-mutilating behaviors. people with bpd, for example, frequently engage in gambling, substance abuse, reckless driving, binge eating and other self-destructive behaviors. roughly 8-10% of patients with bpd commit suicide, and an even higher percentage (roughly 70%) attempt suicide or engage in behaviors that are physically harmful (apa, 2000; paris, 1999; trull et al, 2003). the psychological effects of this selfmutilating behavior on the children can be enormous. specifically, children bereaving a parent after suicide feel immense guilt, question ‘why,’ and suffer from complicated and internal grieving (emerson, 2003). these children feel isolated and angry, and face an increased risk of experiencing post traumatic stress disorder symptoms and other psychopathology (cerel, fristad, weller, & weller, 2000; emerson, 2003). early experiences and child attachment research consistently demonstrates that a parent’s adult attachment status is associated with infant attachment status (crandell et al., 1997). many bpd mothers’ own childhood attachments to their primary caregivers were “disorganized,” and they continue to suffer from “enmeshed” or “unresolved” attachments in adult relationships (crandell et al., 2003; hobson et al., 2005; holmes, 2005). thus, it is logical that the children of mothers with bpd display a high level of disorganization (holmes, 2005; lyons-ruth & jacobvitz, 1999). it has been found that a mother with bpd’s maladaptive childhood attachment status is passed down to the next generation through the replication of the unresolved trauma in the mother’s life (for a discussion of the extent of transmission, see crandell et al., 1997; crandell et al., 2003; van ijzendoorn, 1995). in fact, the manner in which a mother reflects on past trauma in her own life is related to the quality of the relationship between the mother and her own child (crandell et al., 1997; van ijzendoorn, 1995). the mother with bpd’s history of childhood trauma becomes replicated in her own family through the reproduction of a maladaptive family environment and explicit parenting behaviors. feldman, zelkowitz, weiss, vogel, heyman, & paris (1995) discovered that families of mothers with bpd, similar to the families of origin of mothers with bpd, were significantly less cohesive, less organized and marked overall by more instability than families without borderline pathology. unresolved trauma and explicit parenting behaviors unresolved trauma, which is associated with bpd, often obstructs a mother’s ability to parent effectively. parents who are unable to reflect back on their childhood history and integrate their experiences have a limited capacity for emotional availability to their children (crandell & hobson, 1999). specifically, a mother with bpd may lack the capacity to respond appropriately to her children by projecting past material into the mother-child interaction (crandell et al., 1997). for example, defensive splitting may interfere with the parent-child relationship via the mother with bpd’s perception of the child as either “all good,” who needs to be saved, or “all bad,” who needs to be reprimanded (newman & stevenson, 2005, glickhaufhughes & mehlman, 1998). even the act of care giving itself may trigger painful memories from the mother’s history of trauma, making it very difficult for the mother with bpd to cope with the daily challenges of parenting (main, 1995). these triggers often causes her to engage in maladaptive, “frightened/frightening” behaviors, whereby the she is both frightening to the child and frightened herself at the same time (holmes, 2005; hobson, et al, 2005). in this way, mothers with bpd are often classified as “high risk” parents (newman & stevenson, 2005), at risk of child abuse and/or drastically overprotective behaviors. crandell et al. (1997) empirically verified that the manner in which mothers mentally organized and accurately perceived their childhoods predicted the manner in which the mothers interacted with their children. thus, mothers identified as having a ‘secure’ attachment in childhood interacted more fluidly and synchronistically with their children than mothers identified as ‘insecure.’ congruently, a mother with bpd’s history of traumatic early experiences and a maladaptive attachment status results in behavioral patterns that are less supportive of child autonomy. mothers with bpd tend to interact with their children in an “intrusively insensitive” manner (hobson et al., 2005). these interactions may interfere with the child’s developing ability to relate to other people within the environment and yield myriad interpersonal problems for the child. development in children of mothers with bpd despite the difficulties mothers with bpd have with emotional regulation and the importance of the motherchild relationship in a child’s social and emotional development, there is little known at present about the psychosolamont 42 cial development in children of mothers with bpd. to date, the strongest research examining the psychosocial outcomes of these children is a small pilot study conducted by weiss, zelkowitz, feldman, vogel, heyman, and paris (1996). weiss et al. (1996) confirmed that children of mothers with bpd, compared to children with mothers without bpd, had a significantly higher number of psychiatric diagnoses and scored higher on a global rating of impairment. the authors demonstrated that children of mothers with bpd are at an increased risk for developing impulse control disorders and borderline tendencies of their own. even when childhood trauma was controlled for, significant group differences in functioning between children of mothers with and without bpd were found; approximately 20% of the variation in child functioning and 8% of the variation in borderline pathology was accounted for by maternal diagnosis alone. weiss et al.’s findings provide insight into the development of children of mothers with bpd. however, the study was limited by a small sample size and lack of attention to comorbid diagnoses, and it has not been replicated to date. these preliminary results point to the need for further research with larger sample sizes inclusive of mothers with comorbid diagnoses. the following section examines the attachment status of children raised by mothers with bpd and reviews the attachment literature in order to illuminate potential cognitive, interpersonal and affective problems in these children. attachment status of children children of mothers with bpd show a significantly higher prevalence of ‘disorganized’ attachment than children of mothers without bpd (hobson et al., 2005). mothers with bpd’s intrusive insensitivity, affective deregulation, confusion over role expectations, and unresolved traumatic experiences have been identified as possible precursors for this disorganization (see van ijzendoorn et al., 1999; hobson et al., 2005). disorganization in children typically arises in response to recurrent stress. in the case of children of mothers with bpd, children’s disorganized responses develop out of what main (1995) refers to as an approach-avoidant dilemma. the stress associated with borderline symptomatology (e.g., erratic or volatile behavior) causes children to simultaneously cling to and push away from their caregiver. in other words, in times of danger or stress, the child searches for the mother as a “secure base” to cling to, but in the case of a mother with bpd, it is often the mother herself who is posing the threat. behavioral disorganization in children is inherently maladaptive and therefore of concern to mental health professionals working with children of mothers with bpd. research shows that disorganization in childhood attains modest levels of long term stability and is linked to a host of pathological sequelae (holmes, 2005; van ijzendoorn et al., 1999). disorganized children face stress management problems, frequently engage in externalizing behaviors, and may even face dissociative behaviors later in life (lyonsruth & jacobvitz, 1999; van ijzendoorn et al., 1999). cognitive development there is little known about cognitive development in children of mothers with bpd specifically, but high levels of ‘disorganized’ attachment status suggest that these children will face significant cognitive impairments. attachment security with the primary caregiver is correlated with intellectual development and functioning of children in that responsiveness and attunement, maternal involvement, and emotional sensitivity support healthy cognitive development (see crandell & hobson, 1999 for a brief overview of the literature). hence, a mother with bpd’s intrusive insensitivity and unpredictability is bound to negatively affect a child’s cognitive development. crandell & hobson (1999) conducted a study of intellectual functioning in children of mothers with a ‘secure’ vs. ‘insecure’ adult attachment status. they found that children of ‘insecure’ mothers scored an average of 19 points lower on the stanford-binet test than children of ‘secure’ mothers. likewise, neurobiological studies reveal that disorganized children have increased levels of cortisol and decreased mental development (hertsgaard, gunnar, erickson, & nuchmias, 1995). since most children of mothers with bpd display high levels of disorganization, it is reasonable to presume that children of mothers with bpd are significantly stressed children who are placed at a cognitive disadvantage (holmes, 2005). it is likely that the attachment status of children of mothers with bpd mediates the relationship between the mother’s psychopathology and the child’s level of cognitive functioning. interrelatedness and affective regulation in children of mothers with bpd since children of mothers with bpd typically display a disorganized behavioral pattern and are forced to consistently cope with their mother’s borderline symptomatology (including their maladaptive interpersonal relations, repeated broken relationships, and affective deregulation), it would be expected that children of mothers with bpd would show deficits in interpersonal relatedness. while there is very minimal research in this area at present, there is evidence to suggest that infants of mothers with bpd have an alternative way of dealing with interpersonal stress than children with mothers without bpd (crandell et al., 2003). during the ‘strange situation’ experimental paradigm designed to elicit secure base attachment behaviors, infants of mothers with bpd are less available for positive engagement with a stranger (hobson et al., 2005). these infants become less satisfied from the mother-child interaction after the interpersonally stressful separation than children of parents without bpd. crandell et al. (2003) discusses how this alternate mode of coping reflects the child’s mothers with borderline personality disorder 43 expectation that the parent will not return to soothe the child in times of high stress. it is noteworthy that exploratory evidence finds that children of mothers with bpd also show signs of affective dysregulation during the experimental ‘still face procedure.’ in the still face procedure, children of mothers with bpd show a pattern of dazed glare and glance away from the parent more frequently than children of mothers without bpd (crandell et al., 2003). crandell et al. found that, whereas children of mothers with and without bpd presented with similar affect before the procedure, children of mothers with bpd showed a rapid decline during and after the procedure. they maintained an overall depressed affect and exhibited more dazed looks than the control group. additionally, children of mothers with bpd scored lower on measures of behavioral organization under stress (hobson, 2005) and required more time to recover from the stressful situation. these preliminary findings regarding emotional conflict in children of mothers with bpd is bolstered by psychoanalytic observations. anecdotal reports describe children of mothers with bpd as having tendencies toward defensive splitting, and displaying “emotional needs through denial, acting-out, self destructive behavior and role reversals…[and] frequently express fears of abandonment and engulfment” (glickauf-hughes & mehlman, 1998, p. 300). there is also evidence to suggest that, even in middle childhood, children of mothers with bpd may display problems with interpersonal relatedness and affective regulation. follow-up studies show that disorganized children have more difficulty engaging in ‘democratic’ play with peers at ages six and seven. these children often make executive decisions and are overall more controlling in interactions with both peers and parents. additionally, disorganized children maintain an inability to appropriately resolve frightening situations in middle childhood years (see holmes, 2005 for a brief overview of the research). future directions children of mothers with bpd are a potentially disadvantaged group of children that are at risk for future psychopathology. however, as crandell et al. (1997) demonstrated, attachment status is not completely stable, and children who are able to resolve early traumatic experiences are able to obtain an ‘earned secure’ attachment status in adulthood. adults with an earned secure status function comparably to adults who had secure attachment status as children (crandell et al, 1997). these findings hold great promises for the prognosis of children of mothers with bpd. with adequate attention and intervention, there is hope that children of mothers with bpd will overcome the risks associated with this maternal psychopathology. nonetheless, the long term psychosocial outcomes of children of mothers with bpd have thus far been neglected in empirical research. a few exploratory studies have looked at infants of mothers with bpd, but these studies have been limited by small sample sizes, and have only targeted children in infancy. there is a need for more longitudinal studies that examine the long term outcomes of children who cope daily with a mother with bpd. similarly, it is important for researchers to examine the effects of protective environmental factors that may buffer the effects of a mother with bpd, such as non-pathological fathers and/or extended family that may protect the child from the borderline patterns of instability. an increased knowledge regarding moderators of risk and the qualities of borderline symptomatology that affect children above and beyond the effects of disorganized attachment and/or childhood abuse is needed in order to adequately intervene in the lives of these vulnerable children. references american psychiatric association. 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(1999). disorganized attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae. development and psychopathology,11, 225-249. weiss, m., zelkowitz, p., feldman, r. b., vogel, j., heyman, m., paris, j. (1996). psychopathology in offspring of mothers with borderline personality disorder: a pilot study. canadian journal of psychiatry, 41, 285-290. zanarini, m. c., frankenburg, f. r., yong, l., raviola, g., reich, d. b., hennen, j., et al. (2004). borderline psychopathology in the first-degree relatives of borderline and axis ii comparison probands. journal of personality disorders, 18, 449-447. attachment status and early experiences of mothers with bpd mothers with bpd in the parental role borderline symptoms in context of parenting early experiences and child attachment unresolved trauma and explicit parenting behaviors attachment status of children 10 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 the development of cognitive vulnerability to hopelessness depression sabina sarin john r. z. abela yale university mcgill university while several studies have supported the hopelessness theory’s claim that depressogenic inferential styles serve as vulnerability factors to depression, little research has examined how these styles develop. the current study examined three theories of their development in children between the ages of 7 and 13. results supported two of these theories, indicating that children with pessimistic inferential styles report experiencing higher levels of specific negative life events than children without these styles. furthermore, parents of children with a depressogenic inferential style about consequences provided more pessimistic feedback about the consequences of negative events in their child’s life than parents of children without this style. results suggest that different pathways lead to the development of the three pessimistic inferential styles. while it was once believed that childhood depression was a rare or transitory developmental phenomenon, evidence has since accumulated depicting the high prevalence rate, chronic course and debilitating consequences of depression in children (schwartz, gladstone, & kaslow, 1998). as prevalence rates of depression have soared to epidemic proportions (lewinsohn, rohde, seeley, & fisher, 1993), the average age of onset has decreased (reich et al., 1987). epidemiological studies have recently reported that by 14 years of age, as many as 9% of children have already experienced at least one episode of severe depression (lewinsohn et al., 1993). research further indicates that childhood depression is a chronic disorder with up to 84% of depressed children experiencing depressive episodes in adulthood (harrington, rutter, & frombonne, 1996). childhood depression has been shown to be associated with a wide range of psychiatric and physical health problems in adulthood, as well as impairment in multiple domains of functioning (e.g., fleming, boyle, & offord, 1993; kandel & davis, 1986; rao et al., 1995). the research reported in this article was supported by a new scholar award from the social sciences and humanities research council of canada awarded to john r. z. abela. we would like to thank nadia castiel, david d’alessandro, melanie ewing, hugo gagnon, nima ghomeshi, emily haigh, alexandra mcintyresmith, zohreen murad, anna radzioch, caroline sullivan, and krystyna zaluski for administering questionnaires to children and their parents, as well as for scoring questionnaires. portions of this article were presented at the meeting of the association for the advancement of behavior therapy, philadelphia, pa, november, 2001. correspondence concerning this article should be addressed to sabina sarin, department of psychology, yale university, p.o. box 208205, new haven, ct 06520-8205; e-mail: sabina.sarin@yale.edu. the hopelessness theory of depression in response to such alarming statistics, a vast amount of research has been conducted examining the etiology of depression. one cognitive theory that has obtained promising results in both adult and child samples is the hopelessness theory of depression (abramson, metalsky, & alloy, 1989). according to the hopelessness theory, certain individuals possess depressogenic inferential styles that make them vulnerable to experiencing depressive episodes. the theory delineates three such styles. the first is the tendency to attribute negative events to global and stable causes. the second is the tendency to perceive negative events as having many disastrous consequences. the third is the tendency to view the self as flawed or deficient after negative events occur. each of these styles predisposes individuals to hopelessness depression by making it more likely that they will make depressogenic inferences following the occurrence of negative events. making such inferences increases the likelihood that hopelessness will develop. hopelessness is defined as the expectation that negative events will occur or that positive events will not occur, coupled with the expectation that one can do nothing to change this forecast. once hopelessness develops, hopelessness depression is inevitable, since hopelessness is viewed as a necessary and sufficient cause of this subtype of depression. several studies have provided strong support for the hopelessness theory’s claim that depressogenic inferential styles serve as vulnerability factors to depression, in both adult (abela, 2002b; abela & seligman, 2000; alloy & clements, 1998; alloy et al., 2000; metalsky & joiner, 1992; metalsky, halberstadt, & abramson, 1987; metalsky, joiner, hardin, & abramson, 1993) and child (abela & sarin, 2002; cole & turner, 1993; dixon & ahrens, 1992; hilsman & garber, 1995; nolen-hoeksema, girgus, & seligman, 1992; panak & garber, 1992; robinson, garber, & hilsman, 1995; turner & cole, 1994) samples. however, hopelessness theory, origins of cognitive vulnerability 11 relatively little research has examined the factors that lead to the development of such negative cognitive styles. if depressogenic inferential styles serve as vulnerability factors to depression, then it becomes important to understand the developmental origins of these cognitive styles. such an understanding may lead to the development of early interventions to prevent the initial onset or future recurrences of depression. theoretical origins of the depressogenic inferential styles: the modeling hypothesis to date, several theories have been proposed to explain the origins of negative cognitive styles. one theory is that children acquire depressogenic inferential styles in part by observing and modeling the inferential styles of significant others, such as their parents (abramson et al., 1999; alloy et al., 1999; garber & flynn, 1998; haines, metalsky, cardamone, & joiner, 1999). most studies have attempted to test this hypothesis by examining the covariation between parents’ and children’s cognitive styles. the results of such studies have, however, been mixed. on the one hand, several studies have found support for the modeling hypothesis. for example, in a sample of college students and their parents, alloy et al. (2001) found that the mothers of students with pessimistic inferential styles had more negative inferential styles themselves than did the mothers of optimistic students, even after controlling for mothers’ levels of depression. no differences were obtained, however, for fathers’ cognitive styles. at the same time, however, other studies have failed to provide support for the modeling hypothesis. for example, in a sample of 240 sixth-grade children and their mothers, garber and flynn (2001) found no association between mothers’ and children’s general attributional styles. thus, results from studies examining the modeling hypothesis (with respect to the similarity of parents’ and children’s inferential styles) have been mixed. theoretical origins of the depressogenic inferential styles: the feedback hypothesis a second theory that has been proposed to explain the origins of pessimistic inferential styles is that children model the feedback that parents communicate to them about the meaning of negative events in their children’s lives. in other words, rather than modeling parents’ own inferential styles, children model the inferential feedback communicated to them about events in their own lives. most studies have tested this feedback hypothesis by examining whether parents’ typical inferential communications to their children are associated with their offspring’s cognitive styles. the few studies that have examined the feedback hypothesis have found consistent support (e.g., alloy et al., 2001; dweck, davidson, nelson, & enna, 1978; fincham & cain, 1986; garber & flynn, 2001; turk & bry, 1992). for example, in a recent study, alloy et al. (2001) found that the parents of students with pessimistic inferential styles communicated more negative feedback about the causes and consequences of stressful events in their child’s life than did the parents of optimistic students. moreover, they found that parents’ pessimistic inferential feedback predicted the onset of depressive episodes in their child’s life during a 2.5-year prospective follow-up, and this relationship was partially mediated by the students’ pessimistic inferential styles. in addition, although they did not find an association between mothers’ and children’s general attributional styles, garber and flynn (2001) did report a significant association between mothers’ and children’s attributions for the same child-focused events. garber and flynn argued that although children may not copy what their parents say in general, they might incorporate their parents’ cognitions regarding things that are personally salient to the children, such as their own behavior. the strong initial support generated for the feedback hypothesis suggests that this mechanism may be a more powerful determinant of children’s inferential styles than is observing and modeling parents’ own inferential styles. theoretical origins of the depressogenic inferential styles: the role of negative life events another theory that has been proposed to explain the origins of cognitive vulnerability to depression is that experiencing certain types of negative events leads to the development of depressogenic inferential styles (beck, 1967, 1987; janoff-bulman, 1992; rose & abramson, 1992). while it is normative to be exposed to disappointments, losses, failures, and other negative events over the course of development, they nonetheless can affect an individual’s outlook on life, particularly if they are pervasive and severe (janoff-bulman, 1992). theorists have speculated that either (1) experiencing a large number of negative events that occur in the context of multiple and likely interacting domains (e.g., a highly dysfunctional family, divorce, high levels of poverty, loss of a parent, problematic peer relationships), or (2) experiencing negative events that are chronic (e.g., parental/marital discord) and/or extremely traumatic (e.g., parental death, rape) are likely to generate personal themes of helplessness, derogation and unworthiness that become deeply encoded in self-structures (abramson, seligman, & teasdale, 1978; janoff-bulman, 1992; rose & abramson, 1992). such self-structures consequently lead to the development of depressogenic inferential styles. thus, stressful life experiences can provide the foundation for the development of negative beliefs. several studies have provided support for the hypothesized relationship between the occurrence of negative life events and the development of depressogenic inferential sarin and abela 12 styles. for example, garber and flynn (1998) found that mothers’ reports of negative life events that had occurred in their child’s life during the prior year predicted significant increases in their child’s depressive attributional style one year later, after controlling for baseline measures of attributional style. these results were found when the children were in seventh grade and were replicated one year later. these findings suggest that exposure to stressors predicts unfavorable changes in explanatory style towards more internal, global, and stable attributions for negative events. interestingly, rose and abramson (1992) have recently hypothesized that childhood maltreatment is likely to play a particularly important role in the development of cognitive vulnerability to depression. according to their model, when a negative life event occurs, individuals are motivated to understand its causes, meaning, and consequences, and to take action to deal with it. rose and abramson speculate, however, that a child’s single experience of maltreatment is unlikely to contribute to the formation of a negative cognitive style because inferences about first experiences of maltreatment are more likely to be “hopefulness-inducing.” in other words, the young child is more likely to attribute first instances of maltreatment to external, unstable, and specific causes, which, according to the hopelessness theory, is an inferential pattern hypothesized to maintain hope in the face of negative events. however, if the maltreatment is more chronic and pervasive, recurring over time and situations, it is much more likely to contribute to the formation of a negative cognitive style. that is, children will be more likely to make internal, stable, and global attributions for the maltreatment. therefore, through the repetition of the negative event-specific cognitive process, a more general negative cognitive style will be formed. consistent with rose and abramson’s (1992) hypothesis, several studies have provided support for the relationship between a history of childhood maltreatment and the presence of negative cognitive styles (gibb et al., 2001; feiring, taska, & lewis, 1998; rose, abramson, hodulik, halberstadt, & leff, 1994; for an exception see gross & keller, 1992). for example, in a sample of children and adolescents with a documented history of sexual maltreatment, feiring et al. (1998) found that the number of maltreatment events experienced was positively related to the negativity of the victims’ cognitive styles. moreover, cognitive style mediated the relation between number of maltreatment events and levels of depression. at the same time, however, given that the majority of past studies testing the relationship between maltreatment and the development of negative inferential styles have examined sexual, rather than emotional or physical maltreatment, it is unclear whether the relation found between childhood sexual maltreatment and adult cognitive styles is due to the unique influence of sexual maltreatment or to its overlap with either or both of the other forms of abuse (gibb et al., 2001). indeed, in the first study to examine the unique association of all three forms of maltreatment with negative cognitive styles, gibb et al. (2001) found that reported levels of childhood emotional, but not physical or sexual maltreatment were related to levels of hopelessness, as well as to episodes of nonendogenous major depression and hopelessness depression. moreover, these relationships were partially or fully mediated by cognitive risk. these results suggest that prior findings of significant relations for physical and sexual maltreatment may have been due to the overlap or third-variable effects of childhood emotional maltreatment with the other two forms of maltreatment, given that the occurrence of emotional maltreatment was not controlled for in previous studies. if confirmed, these findings would support rose and abramson’s (1992) hypothesis that childhood emotional maltreatment is particularly likely to lead to the development of negative cognitive styles. in emotional maltreatment, the depressive cognitions are directly supplied to the child by the abuser, therefore teaching the child to have a negative inferential style and eliminating the chance for the child to make more benign inferences. goals of the current study the goal of the current study was to further explore the origins of cognitive vulnerability to hopelessness depression in children between the ages of 7 and 13, who were selected to be at highand low-risk for hopelessness depression based on the presence or absence of depressogenic inferential styles. in line with preliminary research, the current study assessed whether the modeling of parents’ depressogenic inferential styles, parental inferential feedback regarding events in a child’s life, as well as the experience of negative events, distinguished children with depressogenic inferential styles from children without such styles. improving upon past research, the current study examined the factors that are associated with each of the three depressogenic inferential styles proposed by the hopelessness theory, rather than just those associated with a pessimistic attributional style, in order to ascertain whether similar pathways lead to the development of the three cognitive styles. in order to test hypotheses, children and their parents completed a series of questionnaires assessing depressogenic inferential styles about causes, consequences and the self, as well as the occurrence of major negative life events, daily hassles, and physical, sexual, and emotional abuse. in line with past research, we hypothesized that the parents of children with depressogenic inferential styles would exhibit more depressogenic inferential styles themselves than would the parents of children without these styles. second, we hypothesized that the parents of children with depressogenic inferential styles would provide more negative inferential feedback for stressful events in their child’s life than would the parents of children without such styles. last, we hypothesized that children with depressogenic inferential styles would report experiencing higher levels of negative events in the past than would children without these cognitive styles. hopelessness theory, origins of cognitive vulnerability 13 method participants sixty-six children (30 girls and 36 boys) and one of their parents (59 mothers and 7 fathers) participated in the current study. families were recruited by means of newspaper advertisements placed in several english-language newspapers in the montreal area. families were compensated $90 for their participation. the children in the current study were between the ages of 7 and 13. the mean age of the children was 10 years and 2 months. parents’ ages ranged from 28 to 51 with a mean age of 42 years and 5 months. the sample was 70.8% caucasian, 9.2% hispanic, 4.6% asian, 1.5% african american, and 13.9% self-identified as another ethnicity. of the parents, 72.7% were married or living common law, 15.2% were divorced, 10.6% were separated, and 1.5% were single. the median annual family income was in the range of $45,000 to $60,000. the highest levels of education completed by the parents were a high school diploma (16.9%), a community college diploma (20%), a bachelor degree (36.9%), and a graduate degree (7.8%). procedure families who responded to the advertisements were scheduled to come into the lab for an assessment. upon arrival, parents completed a consent form and a demographics form. children were told that their participation was voluntary and that they could choose not to participate. research assistants then verbally administered the following questionnaires to the child alone: (1) children’s attributional style questionnaire (casq; seligman et al., 1984); (2) children’s cognitive style questionnaire, (ccsq; abela, 2001); (3) social support scale for children (sssc: harter, 1986); (4) the children’s life events scale (cles; coddington, 1972); (5) children’s hassles scale (chas; kanner, feldman, weinberger, & ford, 1987); and (6) childhood trauma questionnaire (ctq; bernstein & fink, 1998). at the same time, the parents separately completed the following questionnaires: (1) expanded attributional style questionnaire (asq; peterson & villanova, 1988); (2) expanded cognitive style questionnaire (csq; abramson & metalsky, 1986); and (3) parental feedback style questionnaire (pfsq; abela, 2002a). upon completion of the assessment, the children and their parents were debriefed. measures children’s attributional style questionnaire (casq). the casq contains 48 items. each item is a hypothetical event (24 negative and 24 positive) that respondents are asked to imagine happened to them. since the hypotheses of the current study only involved participants’ attributional styles for negative events, only the 24 negative event items were used. respondents are presented with two possible causes of each event and are asked to choose which cause best describes the way they would think about the event if it happened to them. the two causes hold constant two attributional dimensions (internal-external, global-specific, and stable-unstable) while varying the third. the casq is scored by assigning a value of 1 to each internal, global, or stable response and a 0 to each external, unstable, specific response. there are eight items assessing each dimension, thus scores for each dimension range from 0-8. in line with the hopelessness theory, we used the generality composite score to measure attributional style. this score is equivalent to the sum of all global and stable responses and can range from 0-16, with higher scores indicating a more depressogenic attributional style. in a study examining the reliability and validity of the casq in children (aged 8-13), seligman et al. (1984) found that casq scores were fairly consistent over a 6-month interval, showing attributional style to be a stable individual difference among children (r = .66, p < .001). cronbach’s alpha for the negative events composite score ranged from .50 to .54 across administrations, indicating moderate internal consistency. regarding validity, children exhibiting depressive symptoms were more likely than nondepressed children to endorse internal, global, and stable explanations for negative events. furthermore, a pessimistic attributional style predicted depressive symptoms at the 6-month followup above and beyond initial levels of depression in children. since this study, several other studies using the casq have obtained similar findings (i.e., abela, 2001; hilsman & garber, 1995; nolen-hoeksema et al., 1992). in the current study, we obtained an alpha of .47 for the generality subscale, indicating moderate internal consistency. children’s cognitive style questionnaire (ccsq). the ccsq is a two-part questionnaire. part one assesses the tendency to catastrophize the consequences of negative events. part two assesses the tendency to view oneself as flawed or deficient following negative events. each part contains 12 items, each of which is a hypothetical negative event involving the child. as with the casq, respondents are instructed to imagine that the event happened to them and then to choose the response that would best describe the way they would think. in part one, the child is given the following four choices: (a) this won’t cause other bad things to happen to me; (b) this might cause other bad things to happen to me; (c) this will cause other bad things to happen to me; and (d) this will cause many terrible things to happen to me. each response is assigned a value from 0-3, with higher scores indicating a greater tendency to catastrophize the consequences of negative events. scores for the 12 items are added yielding a composite score ranging from 0-36. in part two, the child is given the following three choices: (a) this does not make me feel bad about myself; (b) this makes me feel a little bad about myself; and (c) this makes me feel very bad about myself. sarin and abela 14 each response is assigned a value of 0-2, with higher scores indicating a greater tendency to view oneself as flawed or deficient following negative events. scores for the 12 items are added yielding a composite score ranging from 0-24. in a study examining the reliability and validity of the ccsq in third and seventh grade children, abela (2001) administered the ccsq twice with a 7-week interval between administrations. for the inferential style about consequences subscale, time 1 and time 2 scores significantly correlated with each other in both third (r = .41, p<.001) and seventh grade students (r = .46, p<.001). similarly, for the inferential style about the self subscale, time 1 and time 2 scores significantly correlated with each other in both third (r=.31, p<.001) and seventh grade students (r=.63, p<.001). these correlations indicate that the infe rential styles about consequences and the self are relatively stable individual differences in this age group. cronbach’s alphas for the ccsq subscales ranged from .64 to .81 across administrations, indicating moderate internal consistency. in the current study, we obtained an alpha of .80 for the inferential style about consequences subscale and .72 for the inferential style about the self subscale, indicating moderate internal consistency. social support scale for children (sssc). the sssc is a 24-item questionnaire that was used to assess the child’s perceived level of social support. the sssc contains four subscales, each with six items pertaining to the assessment of perceived levels of social support from parents (e.g., my parents really understand me), teachers (e.g., i have a teacher who cares if i feel bad), classmates (e.g., my classmates pay attention to what i say), and friends (e.g., i have a close friend i can tell my problems to). the child is asked to indicate how true each of the statements is for him or her by choosing from among three possible answers (i.e., not true for me, sort of true for me, really true for me). each response is scored on a scale from 0 to 2. scores on each subscale range from 0 to 12. a summary score is created by summing scores across all four subscales of the sssc. total social support scores range from 0 to 48, with higher scores indicating higher levels of perceived social support. previous research has indicated that the sssc exhibits adequate levels of reliability and validity for use in clinical research (harter, 1986). in the current study, we obtained an alpha of .77 for the total social support score and alphas of .69, .46, .72, and .85 for the parents, teachers, classmates, and friends subscales respectively. these alphas indicate moderate internal consistency. the children’s life events scale – lifetime version (cles). the cles consists of a list of 30 negative events that children may experience (e.g., your mother or father died; you failed a grade in school; a family member or close friend went to jail). for each item, respondents are asked whether or not they have ever experienced that event in the past. if they have, they receive a score of 1. if they have not, they receive a score of 0. scores on the cles range from 0-30 with higher scores indicating a greater number of lifetime stressful events. children’s hassles scale (chas). the chas is a questionnaire that lists 39 hassles that children may experience (e.g., you had trouble learning something new; kids at school teased you; your schoolwork was too hard). children are asked to rate how often each event happened to them in the past year on a scale of 1 (i.e., it has never happened) to 5 (i.e., it has happened all the time). for each item, respondents receive a score of 0 if they have never experienced the event, a score of 1 if it has happened a few times, a score of 2 if it has happened sometimes, a score of 3 if it has happened many times, or a score of 4 if it has happened all the time. summary scores are created by summing the scores across the 39 items. scores range from 0 to 156, with higher scores indicating a greater number and frequency of hassles experienced in the past year. the children’s trauma questionnaire (ctq). the ctq is a 27-item questionnaire that examines children’s past histories of emotional, physical and sexual abuse, as well emotional and physical neglect. each of the 27 statements refers to a possible occurrence in the child’s life, using vocabulary that is geared towards school-age children and adolescents. the child is asked to rate how often each event has happened to them throughout their lifetime on a scale of 1 (i.e., it has never happened) to 5 (i.e., it has happened all the time). for each item, respondents receive a score of 0 if they have never experienced the event, a score of 1 if it has happened a few times, a score of 2 if it has happened sometimes, a score of 3 if it has happened many times, or a score of 4 if it has happened all the time. in the current study we utilized the following subscales, each of which contains five items: emotional abuse (e.g., people in your family called you things like “stupid,” “lazy,” or “ugly”), physical abuse (e.g., people in your family hit you so hard that you had bruises or marks), and sexual abuse (e.g., someone tried to touch you in a way that made you feel bad). scores on each subscale range from 0 to 20, with higher scores indicating greater levels of abuse experienced by the child. expanded attributional style questionnaire (easq). the easq consists of a total of 24 hypothetical negative events. twelve of the events are of an interpersonal nature (e.g., you and your family have a serious argument). the other 12 events are of an achievement nature (e.g., you have been looking for a job unsuccessfully for some time). subjects are asked to write down one major cause of each event. they are then asked to rate the cause on a 1-7 scale for internality, globality, and stability. the higher the scores are on these dimensions, the more internal, global, and stable the attributional style. consistent with the hopelessness theory (i.e., abramson et al., 1989), we used the generality subscale (average of globality and stability; easqgenerality) to test our predictions. scores were averaged across the 24 negative life events, yielding one score ranging from 1 to 7, with higher scores corresponding to more depressogenic attributional styles. in the current study, we obtained an alpha of .85, indicating high internal consistency. hopelessness theory, origins of cognitive vulnerability 15 expanded cognitive style questionnaire (csq). the csq assesses cognitive styles about consequences and the self. to assess the cognitive style about consequences, subjects are asked the following question for each of the 12 negative life events in the easq (peterson & villanova, 1988): “how likely is it that the [negative event] will lead to other negative things happening to you?” they are asked to respond on a 1-7 scale, with 1 meaning “it is not at all likely that the [negative event] will lead to other negative things happening to me” and 7 meaning “it is extremely likely that the [negative event] will lead to other negative things happening to me.” to assess the cognitive style about the self, participants are asked the following question for each of the 12 negative life events in the easq (peterson & villanova, 1988): “to what degree does the [negative event] mean that you are flawed in some way?” participants are asked to respond on a 1-7 scale, with 1 meaning “the [negative event] definitely does not mean i am flawed in some way” and 7 meaning “the [negative event] definitely does mean i am flawed in some way.” scores were averaged across the 12 negative life events, yielding subscale scores for consequences and the self. scores on each subscale can range from 1 to 7, with higher scores indicating more depressogenic cognitive styles. in the current study, we obtained alphas of .87 and .90 for the inferential styles about consequences and the self subscales, indicating high internal consistency. the parental feedback style questionnaire (pfsq). the pfsq is a self-report questionnaire that assesses parental inferential styles about the self, consequences, and causes for events in their child’s life. it consists of a total of 12 hypothetical negative life events. the parents are asked to imagine that each event happened to their child and then to choose the response that would best describe the way they would think in that particular situation (e.g., your child gets into a fight with another kid). to assess parental inferential feedback styles about the causes of negative events in their child’s life, parents are asked to write to write down one major cause of each event. they are then asked to rate the cause on a 1-7 scale for internality, globality, and stability. the higher the scores are on these dimensions, the more internal, global and stable the attributional feedback style. consistent with the hopelessness theory (i.e., abramson et al., 1989), we used the generality subscale (average of globality and stability; pfsq-generality) to test our predictions. scores were averaged across the 12 negative life events, yielding one score ranging from 1 to 7, with higher scores corresponding to more depressogenic attributional feedback styles. in the current study, we obtained an alpha of .79, indicating moderate internal consistency. in order to assess the cognitive feedback style about consequences, parents are asked the following question for each of the 12 negative life events: “how likely is it that the [negative event] will lead to other negative things happening to your child?” they are asked to respond on a 1-7 scale, with 1 meaning “it is not at all likely that the [negative event] will lead to other negative things happening to them” and 7 meaning “it is extremely likely that the [negative event] will lead to other negative things happening to them.” scores were averaged across the 12 negative life events, yielding one score ranging from 1 to 7, with higher scores corresponding to more depressogenic feedback about the consequences of negative events in their child’s life. in the current study, we obtained an alpha of .89, indicating high internal consistency. to assess parents’ cognitive feedback style about the self for negative life events in the child’s life, parents are asked the following question for each of the 12 negative life events: “to what degree does the [negative event] mean that your child is flawed in some way?” participants are asked to respond on a 1-7 scale, with 1 meaning “the [negative event] definitely does not mean that they are flawed in some way” and 7 meaning “the [negative event] definitely does mean they are flawed in some way.” scores were averaged across the 12 negative life events, yielding one score ranging from 1 to 7, with higher scores corresponding with more parental pessimistic feedback about the “self” implications of negative events in the child’s life. in the current study, we obtained an alpha of .92, indicating high internal consistency. results overview of statistical analyses t-tests were conducted in order to determine whether children with depressogenic inferential styles differed significantly from children with optimistic styles on the basis of parental inferential styles, parental inferential feedback for children’s stressful events, and past experiences with negative life events. in order to test hypotheses, we identified children who exhibited optimistic and pessimistic levels of each of the three inferential styles. for each of the inferential styles, children who scored greater than one standard deviation above the mean on the measure of interest were considered to have a pessimistic inferential style, whereas those who scored less than one standard deviation below the mean were classified as having an optimistic inferential style. thus, the same child could be classified as having one or more pessimistic and/or optimistic inferential styles. results indicated that 9 out of 66 children had a pessimistic inferential style about causes (i.e., scored more than one standard deviation above the mean on the generality composite index of the casq), and 9 out of the remaining 57 children had an optimistic inferential style about causes (i.e., scored less than one standard deviation below the mean on the generality composite index of the casq). ten out of 66 children were identified as having a pessimistic inferential style about consequences (i.e., scored more than one standard deviation above the mean on the consequences subscale of the ccsq), whereas 6 of the remaining 56 children were identified as having an optimistic inferential style about consequences (i.e., scored less than one standard desarin and abela 16 viation below the mean on the consequences subscale of the ccsq). finally, 12 out of 66 children were identified as having a pessimistic inferential style about the self (i.e., scored more than one standard deviation above the mean on the self subscale of the ccsq), and 12 of the remaining 54 children had an optimistic inferential style about the self (i.e., scored less than one standard deviation below the mean on the self subscale of the ccsq). attributional style results pertaining to the inferential style about causes are presented in table 1. in support of our hypotheses, results indicated that children with a pessimistic inferential style about causes reported lower levels of social support (t(16) = 2.21, p < .05) than children with an optimistic inferential style about causes. exploratory analyses of the subscales of the sssc revealed that pessimistic children reported lower levels of support from friends (t(16) = 2.07, p < .06) and classmates (t(16) = 2.56, p < .06) but not from parents (t(16) = 1.10, ns) and teachers (t(16) = 1.73, ns). analyses also revealed a nonsignificant trend in which children with a pessimistic attributional style reported experiencing a greater number of hassles in the past year than children with an optimistic inferential style about causes (t(16) = 2.02, p < .07). at the same time, contrary to hypotheses, the parents of children with a pessimistic attributional style did not possess more depressogenic inferential styles about causes than did the parents of children with an optimistic attributional style (t(16) = .667, ns). in addition, children with a pessimistic inferential style about causes did not receive more negative parental inferential feedback about the causes of negative events in the their child’s life than did children with an optimistic attributional style (t(16) = 1.16, ns). last, contrary to our hypothesis, children with a pessimistic attributional style did not report experiencing more negative life events (t(16) = .798, ns), emotional abuse (t(16) = .537, ns), physical abuse (t(16) = .161, ns), or sexual abuse (t(16) = .290, ns) than did children with an optimistic attributional style. table 1 means and standard deviations for all measures for children with optimistic and pessimistic inferential styles about causes optimistic inferential style pessimistic inferential style about causes about causes 1. asq-gen 3.23 (0.93) 3.52 (0.92) 2. pfsq-gen 3.09 (0.96) 3.60 (0.93) 3. sssc 43.78 (2.17) 34.44 (12.50) 4. chas 86.89 (13.60) 101.78 (17.49) 5. cles 9.22 (3.27) 10.33 (2.60) 6. ctq-ea 8.44 (2.19) 9.11 (3.02) 7. ctq-pa 6.56 (1.13) 6.44 (1.74) 8. ctq-sa 4.44 (2.00) 4.67 (1.12) note. asq-gen = expanded attributional style questionnaire, generality subscale. pfsq-gen = parental feedback style questionnaire, feedback about causes subscale. sssc = social support scale for children. hasc= hassles scale for children. cles = children’s life events scale. ctq-ea = childhood trauma questionnaire, emotional abuse subscale. ctq-pa = childhood trauma questionnaire, physical abuse subscale. ctq-sa = childhood trauma questionnaire, sexual abuse subscale. inferential style about consequences results pertaining to the inferential style about consequences are presented in table 2. in support of our hypotheses, results revealed that children with a pessimistic inferential style about consequences reported experiencing a greater number of major negative life events than children with an optimistic inferential style about consequences (t(14) = 2.27, p < .05). analyses also revealed a nonsignificant trend in which the parents of children with a pessimistic inferential style about consequences exhibited a greater tendency to give their child pessimistic feedback about the consequences of negative events occurring in their child’s life (t(14) = 2.05, p < .07) than parents of children with an optimistic inferential style about consequences. however, parents’ own inferential styles about consequences (t(14) = hopelessness theory, origins of cognitive vulnerability 17 .563, ns) were not related to their child’s inferential style about consequences. at the same time, contrary to hypotheses, children with a pessimistic inferential style about consequences did not report experiencing lower levels of social support (t(14) = .345, ns) than children with optimistic inferential styles about consequences. furthermore, children with a pessimistic inferential style about consequences did not differ from optimistic children in terms of the number of hassles reported in the last year (t(14) = .927, ns), nor in terms of levels of emotional abuse (t(14) = .516, ns), physical abuse (t(14) = .446, ns), or sexual abuse (t(14) = .677, ns. table 2 means and standard deviations for all measures for children with optimistic and pessimistic inferential styles about consequences optimistic inferential style pessimistic inferential style about consequences about consequences 1. csq-cons 2.67 (0.90) 2.98 (1.15) 2. pfsq-cons 1.93 (0.86) 3.06 (1.22) 3. sssc 40.00 (9.45) 38.40 (8.71) 4. chas 89.00 (15.61) 95.70 (13.01) 5. cles 7.00 (2.45) 9.70 (2.21) 6. ctq-ea 9.17 (3.55) 10.30 (4.60) 7. ctq-pa 6.33 (1.37) 6.70 (1.70) 8. ctq-sa 5.00 (3.10) 5.90 (2.23) note. csq-cons = cognitive style questionnaire, inferential style about consequences subscale. pfsqcons = parental feedback style questionnaire, feedback about consequences subscale. sssc = social support scale for children. hasc = hassles scale for children. cles = children’s life events scale. ctqea = childhood trauma questionnaire, emotional abuse subscale. ctq-pa = childhood trauma questionnaire, physical abuse subscale. ctq-sa = childhood trauma questionnaire, sexual abuse subscale. inferential style about the self results pertaining to the inferential style about the self are presented in table 3. in support of our hypotheses, children with a depressogenic inferential style about the self reported higher levels of emotional abuse (t(23) = 2.11, p <.05) and sexual abuse (t(23) = 2.91, p < .01) than children with an optimistic inferential style about the self. however, children with a pessimistic inferential style about the self did not report higher levels of physical abuse (t(23) = .894, ns) than children with an optimistic inferential style about the self. at the same time, contrary to hypotheses, the parents of children with a pessimistic inferential style about the self did not themselves exhibit more pessimistic inferential styles about the self than the parents of optimistic children (t(23) = .099, ns). in addition, the parents of children with a pessimistic inferential style about the self did not provide their children with more pessimistic feedback about the self-implications of negative events occurring in their child’s life than did the parents of optimistic children (t(23) = .951, ns). furthermore, contrary to our hypothesis, children with pessimistic inferential styles about the self did not report experiencing lower levels of social support (t(23) = .222, ns) than children with optimistic inferential styles about the self. children with pessimistic inferential styles about the self also did not report a greater number of hassles in the past year (t(23) = 1.70, ns), or a greater number of major negative life events (t(23) = .742, ns), than children with optimistic inferential styles about the self. sarin and abela 18 table 3 means and standard deviations for all measures for children with optimistic and pessimistic inferential styles about the self optimistic inferential style pessimistic inferential style about the self about the self 1. csq-self 2.51 (0.93) 2.47 (1.17) 2. pfsq-self 2.04 (1.24) 1.66 (0.61) 3. sssc 39.92 (7.82) 39.25 (7.34) 4. chas 86.10 (16.84) 97.66 (17.21) 5. cles 9.04 (3.73) 10.00 (2.59) 6. ctq-ea 7.15 (2.61) 9.50 (2.94) 7. ctq-pa 5.80 (1.96) 6.42 (1.62) 8. ctq-sa 3.62 (1.71) 5.50 (1.51) note. csq-self = cognitive style questionnaire, inferential style about the self subscale. pfsq-self = parental feedback style questionnaire, feedback about self implications subscale. sssc = social support scale for children. hasc= hassles scale for children. cles = children’s life events scale. ctq-ea = childhood trauma questionnaire, emotional abuse subscale. ctq-pa = childhood trauma questionnaire, physical abuse subscale. ctq-sa = childhood trauma questionnaire, sexual abuse subscale. discussion the results of the current study indicate that different pathways lead to the development of the three pessimistic inferential styles. specifically, the inferential style about causes was associated with non-family related chronic hassles in the past year, as well as with low levels of social support from classmates and peers. interestingly, these are all current stressors in the child’s life and all pertain to the child’s peer environment. on the other hand, the inferential style about consequences was associated with the occurrence of major negative life events, as well as with the inferential feedback the children received from their parents about the consequences of such negative life events. finally, inferential style about the self was associated with past histories of emotional and sexual abuse. congruence between current findings and past research although the results of the current study replicate several findings in the literature examining the development of cognitive vulnerability to depression, they also contradict other findings. for example, in line with past research, the results of the current study provide support for the feedback hypothesis in that children’s inferential styles about consequences were associated with the inferential feedback they received from their parents about the consequences of negative events in the child’s life. moreover, in support of recent speculations, findings from the current study suggest that parental inferential feedback was a more powerful determinant of children’s inferential style about consequences than was the parents’ own inferential style about consequences. in addition, also in line with past research, the results of the current study suggest that certain types of negative life events are associated with each of the three inferential styles. that is, a pessimistic attributional style was associated with chronic hassles and low levels of perceived social support. an inferential style about consequences was related to the experience of major negative life events during childhood. finally, the inferential style about the self was associated with the occurrence of sexual and emotional abuse. thus, the results of the current study are congruent with past research in that they suggest that both the modeling of inferential feedback and the experience of negative events play a role in the development of cognitive vulnerability to hopelessness depression. at the same time, however, the results of the current study are inconsistent with other findings of past research in that the pathways hypothesized to lead to the development of cognitive vulnerability to hopelessness depression were each associated with only one of the three inferential styles, rather than predicting negative cognitive styles in general. thus, whereas past research has suggested that similar pathways lead to the development of all three inferential styles, the results of the current study suggest that distinct pathways lead to the development of the pessimistic inferential styles about causes, consequences, and the self. limitations of past research: the use of adult hopelessness theory, origins of cognitive vulnerability 19 samples in order to integrate the results of the current study with those of past research, it is important to acknowledge limitations of past research that could account for the apparent inconsistencies between the current and past findings. in particular, a substantial number of studies testing theories of the origins of cognitive vulnerability to hopelessness depression have utilized adult samples (e.g., alloy et al., 2001; gibb et al., 2001; rose et al., 1994). these studies have asked adults to retrospectively recall the occurrence of abuse or negative life events, or have examined the association between the inferential styles of these adults and their parents. the use of adult samples in this context is problematic given that the relationships among the three inferential styles proposed by the hopelessness theory appear to differ in child and adult populations. that is, although research examining the depressogenic inferential styles in adult populations has found these styles to be empirically indistinguishable (e.g., abela, 2002b; abela & seligman, 2000; abela, brozina, & seligman, 2002; metalsky & joiner, 1992), research with child populations has not. for example, studies using adult populations consistently report high degrees of interrelatedness among these three styles, whereas studies using child populations often find them to be virtually independent of one another (abela, 2001; abela & sarin, 2002). in addition, although research using adult populations has failed to find age or gender differences with respect to the three inferential styles, child research has suggested that the three styles may emerge as vulnerability factors to depression at various stages of development in different children (abela, 2001). furthermore, in a study by abela and sarin (2002), children’s propensities towards depressogenic thinking were found to vary tremendously depending on which inferential style was examined. specifically, 20.7% of children were classified as extremely pessimistic on one inferential style but extremely optimistic on at least one other. thus, it appears that in contrast to adults, a significant portion of children exhibit a dramatic range in their styles of thinking such that their inferential styles about causes, consequences, and the self are almost completely independent of each other. consequently, when researchers attempt to examine theories of cognitive vulnerability to depression using adult populations, they run the risk of two potential pitfalls. first, they are likely to limit their ability to identify the specificity of the etiological pathways leading to the development of the three distinct inferential styles. given that the inferential styles are highly intercorrelated with one another in adults, any developmental pathway elucidated by studies employing adult populations will appear to be an important determinant of the development of all three styles, when in reality, this factor may have only been crucial to the development of one of the styles. second, in light of the highly indistinguishable nature of the pessimistic inferential styles in adults, the construct of interest in adult populations becomes broad pessimism rather than pessimism of specific types. when examining broad pessimism, vulnerability factors that are strongly associated with only one type of pessimism become much less strongly associated with pessimism in general. consequently, important effects may become muted or washed out, and hence remain undetected. methodological inconsistencies between past research and the current study at the same time, the use of adult samples cannot entirely account for discrepancies between the current findings and those of past studies, as the findings of the current study are also incongruent with past studies that have utilized child samples. specifically, in contrast to the current findings, past studies using child samples have found support for the role of parental inferential feedback (e.g., fincham & cain, 1986; garber & flynn, 2001), the occurrence of negative events (e.g., garber & flynn, 1998) and sexual abuse (e.g., feiring et al., 1998) in the development of a pessimistic attributional style. several factors may account for these discrepancies. first, measurement differences between studies are likely to account for inconsistencies in findings. for example, although the majority of studies have utilized the casq to assess attributional style, other studies have used alternative measures such as the perceived control scale (rudolph, kurlakowsky, & conley, 2001). in addition, in line with the hopelessness theory, the current study used the generality composite score (i.e., global-specific and stable-unstable) of the casq to assess attributional style for negative events. in contrast, the majority of past research has utilized the casq composite scores that involve all three subscales of the casq (i.e., internal-external, global-specific, and stable-unstable), as well as items from the casq for both positive and negative events. last, in order to assess parental inferential feedback, the current study used the pfsq. however, past research examining this hypothesis has used various other measures such as the casq-p (garber & flynn, 2001). a second factor that may account for inconsistencies in results across child studies is the use of different age groups. that is, while the current study employed a sample of children between the ages of seven and thirteen, other studies have utilized samples of pre-adolescents (e.g., garber & flynn, 2001; rudolph et al., 2001). in addition, the few studies that have utilized samples of younger children focused on a very narrow age range (fincham & cain, 1986; seligman & peterson, 1986; for an exception see kaslow, rehm, pollack, & siegel, 1988). finally, a third factor that may account for inconsistencies in findings is variation in study designs. that is, both cross-sectional (e.g., fincham & cain, 1986) and longitudinal designs (e.g., nolen-hoeksema et al., 1992) have been employed to test theories of the origins of cognitive vulnerability to depression. however, these designs may detect different developmental pathways. longitudinal designs, in which the dependent variable is change in depressogenic sarin and abela 20 inferential styles during the course of the study, will detect factors that are responsible for change in these styles during the participant’s current developmental period. in contrast, cross-sectional studies, such as the present one, will detect the factors that played the greatest role in the past in distinguishing optimists and pessimists, regardless of when these factors occurred in the child’s developmental trajectory. thus, future research with children should continue to examine the development all three inferential styles using similar measures of constructs, samples that encompass a wide age range, as well as both longitudinal and crosssectional designs. limitations of the current study several limitations of the current study should be noted. first, the current study utilized a cross-sectional design. as such, we were only able to demonstrate correlations between hypothesized vulnerability factors to hopelessness depression and the three pessimistic inferential styles, but could not establish causation. future research should continue to examine these hypotheses using both longitudinal and cross-sectional designs. second, the current study used a small sample size, which may have limited our statistical power to detect significant relationships. third, self-report measures were used to assess all constructs. such a format is inherently prone to informant bias. thus, future researchers examining these hypotheses should utilize more sophisticated methods of analysis such as interviewing procedures, observational techniques and peer ratings. in addition, although the casq exhibits adequate levels of internal consistency for use in empirical research, a measure of attributional style with a higher level of internal consistency is needed in order to rule out the possibility that inconsistent findings across studies are the result of the poor psychometric properties of this measure. fifth, the current study assessed a few main theories of the development of cognitive vulnerability to hopelessness depression. specifically, the current study examined whether parental inferential styles, parental inferential feedback and the occurrence of negative events were associated with the pessimistic inferential styles about causes, consequences, and the self. future research should continue to examine these theories, as well as additional theories of vulnerability to depression, such as the role of past episodes of childhood depression, attachment styles between children and caregivers, and communication patterns (i.e., expressed emotion), in the development of pessimistic inferential styles. future research should also examine the interaction among the etiological pathways addressed by such developmental theories. conclusion in conclusion, the results of the current study suggest that both the modeling of inferential feedback and the experience of negative events play a role in the development of cognitive vulnerability to hopelessness depression. in addition, results reveal that different pathways are likely to lead to the development of depressogenic inferential styles about the self, consequences, and causes. future research using longitudinal designs, larger sample sizes, and multiple methods of assessment is likely to help us gain an even deeper understanding of the factors that play a role in the development of cognitive vulnerability to hopelessness depression. such research is also likely to benefit from examining a broader range of theories of the origins of depressogenic inferential styles than those examined in the current study. discovering the factors that lead to the development of depressogenic inferential styles provides clinicians with a tool for identifying children at risk for developing cognitive vulnerability to depression. identification of such children is essential so that the development of such vulnerability factors can be 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(1994). developmental differences in cognitive diatheses in child depression. journal of abnormal child psychology, 103, 15-32. 75 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university mask-wearing and facial emotion recognition: a preliminary analysis of the relevance of depressive symptoms mateus morante mazzaferro, teachers college, columbia university depression is a psychiatric condition that impairs the life of millions of people around the globe. previous reșǔƺȗljǧ� ǧƺș� șǧȅλǿ� ƞǧƺƞ� ǐǔȓȗǔșșǔǐ� ǩǿǐǩκǩǐȣƺǹș� ƞǔǿǐ� ƞȅ� ȓȗǔșǔǿƞ� ǐǔйljǩƞș� ǩǿ� ǟƺljǩƺǹ� ǔǿȅƞǩȅǿ� ȓǔȗljǔȓƞǩȅǿঀ� 'ȅȗ� ǩǿșƞƺǿljǔॹ� perception accuracy may be reduced and biases in perceived intensity may be enhanced. mask-wearing practices initiated in response to the covid-19 pandemic have become a new social norm often enforced by local mandates. preliminary studies have shown that mask-wearing may impair facial emotion recognition. in this study, we aimed at understanding how facial emotion recognition impairment interacts with depressive symptoms in a samȓǹǔ� ȅǟ�(ǔȗǿƺǿ� ƺǐȅǹǔșljǔǿƞș� ƺǿǐ� ƺǐȣǹƞș� শf�઀� �ॹࢲࢺ �ઔࢷࢶ ǟǔǿƺǹǔॹ�ǿǔƺǿ� ƺǡǔ� ȅǟ� �ࢸঀࢳࢴ ρǔƺȗșষ� ljρ� ȣƞǩǹǩφǩǿǡ� ƺ�ǿǩπǔǐেǔаǔljƞș� linear regression analysis. we found evidence that mask-wearing may be a limiting factor for facial emotion recȅǡǿǩƞǩȅǿॹ� ƺș�λǔǹǹ� ƺș� ǟȅȗ� ǔǿȅƞǩȅǿ� ǩǿƞǔǿșǩƞρ� ȗƺƞǩǿǡșঀ�/ȅλǔκǔȗॹ� ƺ� șǩǡǿǩйljƺǿƞ� ƺșșȅljǩƺƞǩȅǿ�ȅǟ�ǐǔȓȗǔșșǩκǔ� șρǿȓƞȅǿș�λǩƞǧ� these outcome variables was not detected. still, larger sample sizes may have the potential to substantiate a trend toward an interaction of depressive symptoms and mask-wearing for the rating of happy faces. future research should be committed to psychophysiological processes and to improving the quality of the stimulus material. theoretical background depression and facial emotion recognition in 2017, the who issued a report estimating ƞǧƺƞॹ� ǡǹȅljƺǹǹρॹ� ȅκǔȗ� �ࢱࢱࢴ ǿǩǹǹǩȅǿ� ȓǔȅȓǹǔ� șȣаǔȗ� ǟȗȅǿ� depression, equivalent to 4.4% of the world’s population (who, 2017). a review from 2014 shows that the average 12-month prevalence estimate of dsm-iv major depressive episodes varies from 5.5% to 5.9% in most countries (kessler et al., 2014). in the u.s. alone, around 30 million adults have met the criteria for major depressive disorder at least once in their lifetime (haro et al., 2006). the core symptoms of clinǩljƺǹǹρ� ȗǔǹǔκƺǿƞ� ǐǔȓȗǔșșǩȅǿ� ǩǿljǹȣǐǔ� йȗșƞ� ƺǿǐ� ǟȅȗǔǿȅșƞ� a persistently depressed mood and loss of interest or pleasure in almost all activities (apa, 2013). in adǐǩƞǩȅǿॹ� ƞǧǔȗǔ� ƺȗǔ� șǔκǔȗƺǹ�ȅƞǧǔȗ� ƺаǔljƞǩκǔॹ� ljȅǡǿǩƞǩκǔॹ� șȅmatic, and motivational-behavioral features that play a role in depression, such as sleep disturbances, a sense of guilt, and impaired executive function (berking & rief, 2011). the presentation of each symptom can vary greatly in nature and intensity so the overƺǹǹ� ȓǩljƞȣȗǔ� ljƺǿ� ǐǩаǔȗ� ljȅǿșǩǐǔȗƺljǹρ� ǟȗȅǿ� ljƺșǔ� ƞȅ� ljƺșǔঀ early theories of depression, such as beck’s (1976) schema and bower’s (1981) network theory, proposed that, in depressive patients, cognitive biases operate throughout information processing, including perception, attention, and memory. beck (1976) proposes that those with depression develop cognitive distortions and tend to overlook positive attributes of reality and selectively attend to the negative. the associative network theory of emotion and memory, outlined by bower (1981), suggests that depressed mood leads to biases favoring the perception of mood-congruent inǟȅȗǿƺƞǩȅǿঀ��ȅƞǧ�ǿȅǐǔǹș�ƺșșȣǿǔ�ƞǧƺƞ�ƺаǔljƞǔǐ�ǩǿǐǩκǩǐuals selectively process information related to sadness, loss, and failure. furthermore, poor interpersonal relationships have been proposed as a critical aspect in both the etiology and maintenance of depression (finch & zautra, 1992; platt et al. 2013). impaired emotion recognition may contribute to the interperșȅǿƺǹ� ǐǩгljȣǹƞǩǔș� ƺǿǐ� ƺκȅǩǐƺǿljǔ� ljǔǧƺκǩȅȗ� șǔǔǿ� ǩǿ� ǐǔȓȗǔșșǔǐ� ȓƺƞǩǔǿƞș� শxǔȗșƺǐ�૭� xȅǹǩκρॹ� �ষঀࢴࢺࢺࢲ ^ǩǿljǔ� ǐǔйcits in emotion recognition could contribute to the maintenance of depressive symptoms, investigating the relationship between these two variables has important implications for both existing and the development of novel cognitive-behavioral interventions. for a long time now, research has shown that peoȓǹǔ� șȣаǔȗǩǿǡ� ǟȗȅǿ�ƺаǔljƞǩκǔ�ǐǩșȅȗǐǔȗș�ǧƺκǔ�ǐǩгljȣǹƞǩǔș� correctly interpreting human emotions from the perception of facial expressions. in adults, the facial emotion recognition (fer) impairments have been associated, for example, with bipolar disorder (derntl et al. 2009) and also very commonly with depression (e.g., demenescu et al., 2010; bistricky et al 2011, rubinow ૭�xȅșƞॹࢳࢺࢺࢲ�ষঀ��/ȅλǔκǔȗॹ�йǿǐǩǿǡș�ǩǿ�ƞǧǩș�ƺȗǔƺ�șǔǔǿ�ƞȅ� vary strongly based on symptom severity, psychiatric comorbidity, and the nature of stimuli (bistricky et al., 2011). a meta-analysis conducted by dalili et al. (2015) using 22 independent samples found signifǩljƺǿƞ� ȗǔljȅǡǿǩƞǩȅǿ� ǐǔйljǩƞș� ǩǿ� ǐǔȓȗǔșșǔǐ� ȓƺȗƞǩljǩȓƺǿƞș� in all basic emotions except sadness. but the main 76 feature of facial emotion recognition in depression is ǿȅƞ�ƺ�ǐǔйljǩƞ�ǩǿ�ƞǧǔ�ƺljǩǹǩƞρ�ƞȅ�ǩǐǔǿƞǩǟρ�ǔǿȅƞǩȅǿș�ȓǔȗ�șǔॹ� it is rather a bias in emotional valence rating. many studies have reported a negative bias in depressed patients (e.g., schmid & schmid mast, 2010; milders et ƺǹঀॹࢱࢲࢱࢳ�ॹ�?ƺǿ�ǔƞ�ƺǹঀॹࢵࢱࢱࢳ�ষॹ�λǧǩljǧ�ǿǔƺǿș�ƞǧǔ�ƺаǔljƞǔǐ� populations sometimes perform better in recognizing sad faces, tend to interpret neutral or ambiguous faces as sad more often and label happy faces as less happy. the literature presents similar evidence for adolescents and younger children. nyquist & luebbe, শࢱࢳࢱࢳষ�ȗǔκǩǔλǔǐࢷࢳ��șƞȣǐǩǔș�ƺǿǐ�ǩǐǔǿƞǩйǔǐ�ƞǧȗǔǔ�ƞȗǔǿǐș� for fer in youth that were either depressed or qualiйǔǐ�ƺș�ǧǩǡǧেȗǩșƿ�ȓȅȓȣǹƺƞǩȅǿș�ǟȅȗ�ǐǔȓȗǔșșǩȅǿॸ�șǔǿșǩƞǩκǩƞρ� to sadness (higher accuracy in recognizing sadness and biased rating towards sad faces), over-perception of anger (falsely recognizing ambiguous or neutral faces as angry), and under-perception of happiness (lower accuracy in recognizing happiness and biased rating towards happiness). investigating features of depression in families, lopez-duran et al. (2013) observed sensitivity to sadness as a potential mechanism of risk among boys at familial risk for depression. in a similar vein, kluczniok et al. (2015) found that children from mothers with remitted depression displayed depressive-like emotion recognition bias that correlated with their mothers’ performance. as suggested by the literature, emotion recognition bias is a common correlate of depressive symptomatology in all age groups. it is, ƞǧǔȗǔǟȅȗǔॹ�ǔșșǔǿƞǩƺǹ�ƞȅ�ǩǿκǔșƞǩǡƺƞǔ�ǧȅλ�ƞǧǔșǔ�ǐǔйljǩƞș�ljƺǿ� impair social functioning and contribute to the pathological behavior of clinically relevant populations. masks and emotion recognition since march of 2020, the covid-19 pandemic ǧƺș�ljȗȅȣǡǧƞ�șǩǡǿǩйljƺǿƞ�ljǧƺǿǡǔș�ƞȅ�ƞǧǔ�ǐƺǩǹρ�ǹǩκǔș�ȅǟ�ǔκeryday citizens. to help stop the spread of the virus, the wearing of a protective face mask, which has been shown to drastically reduce viral transmission (cheng et al., 2020), has become a largely accepted norm (e.g., cheng et al., 2020; hong et al., 2020; howard et al., 2020). albeit necessary for keeping the virus under control, masks may have important psychological imȓƺljƞș�ȅǿ�șȅljǩƺǹ� ǩǿƞǔȗƺljƞǩȅǿșॹ�ǟȅȗ�ǔπƺǿȓǹǔॹ�ljρ�ǿȣжǩǿǡ� speech and other forms of communicative vocalization (mheidly et al., 2020). social distancing and mask-wearing can also impair interpersonal communication by limiting physical touch and body language, as well as by hindering visibility of the lower half of the face. regarding facial emotional recognition, recent studies have found that mask-wearing can make emotions less well recognized or interpreted (e.g., carbon, 2020a; carbon, 2020b), faces less well-remembered, or critically impair holistic processing (freud et al., 2020). new data, nonetheless, shows that emotions can still be recognized both in adults (e.g., calbi et al., 2021; kastendieck, et al., 2021) and in children (e.g., ruba & pollak, 2020), even if the intensity of the emotion decreases (kastendieck et al., 2021). studies also show that sad and angry faces cause ǿȅȗǔ� йπƺƞǩȅǿ� ȅǿ� ƞǧǔ� ǔρǔșॹ� λǧǩǹǔ� ǧƺȓȓρ� ǟƺljǔș� ƺƞƞȗƺljƞ� ǿȅȗǔ� йπƺƞǩȅǿ� ȅǿ� ƞǧǔ�ǿȅȣƞǧॹ� ǐȣǔ� ƞȅ� ƞǧǔ� λƺρ� ǐǩаǔȗǔǿƞ� ǔǿȅƞǩȅǿș� ǿȅljǩǹǩφǔ� ǐǩаǔȗǔǿƞ� ǟƺljǩƺǹ� ǿȣșljȣǹƺƞȣȗǔ� (eisenbarth, 2011; schurgin, 2014) curiously, psyljǧǩƺƞȗǩlj� ȓƺƞǩǔǿƞș� șǔǔǿ� ƞȅ� ǧƺκǔ� ǹǔșș� йπƺƞǩȅǿ� ȅκǔȗƺǹǹ� (eisenbarth, 2011). these facts may account for йǿǐǩǿǡș� ȗǔȓȅȗƞǩǿǡ� ƞǧƺƞ�λǧǔǿ�ȅǿǹρ� ƞǧǔ�ȣȓȓǔȗ�ȓƺȗƞ� ȅǟ� the face is visible, participants perceive and recognize negative emotions, like anger and fear, better than positive ones (marta et al., 2021; fischer et al., 2012). in sum, it is possible that mask-wearing does not impair or even relatively increase the perception of negative facial expressions and, at the same time, diminishes the perception of positive ones (spitzer, �ষঀࢱࢳࢱࢳ eǧǔȗǔǟȅȗǔॹ� ǩƞ� ǿƺρ� ǧƺκǔ� șǩǡǿǩйljƺǿƞ� ǔаǔljƞș� ȅǿ� day-to-day activities that rely on interpersonal communication and social interaction (freud et al., 2020). � eǧǔ� ǟƺljƞȅȗș� ƞǧƺƞ� ǩǿмȣǔǿljǔ� ǟƺljǩƺǹ� ǔǿȅƞǩȅǿ� ȗǔljȅǡnition in laboratory settings remain unclear when individuals wear masks. the type of stimuli, for instance, is discussed as a possible moderator: so far, mainly adult faces have been used (e.g., ruba & pollak, 2020), whereas in real-life interactions children as well as adolescents and adults represent their counterpart. for this reason, emotional child and adult faces will be used in the current study. moreover, static photos are mostly used (e.g., carbon, 2020a, carbon, 2020b; ruba & pollak, 2020), whereas closer proximity to reality can be assumed when videos are used (rymarczyk et al., 2016). for that reason, this study is going to use video stimulus material. research gap and current research purpose as to this point, we are unaware of any research ȓȗȅǵǔljƞș� ƞȗρǩǿǡ� ƞȅ� йǹǹ� ƞǧǔ� ǿǔλǹρ� ljȗǔƺƞǔǐ� ȗǔșǔƺȗljǧ� ǡƺȓ� of how mask-wearing interacts with psychopatholo mazzaferro 77 mask-wearing and facial emotion recognition gy in impairing social function. considering that the covid-19 pandemic has introduced a new norm in face-to-face interactions (which now almost always include the wearing of face masks), research on fer must rise to the challenge of understanding how this phenomenon can impact the nature of social exljǧƺǿǡǔॹ� ǔșȓǔljǩƺǹǹρ� ǟȅȗ�ȓȅȓȣǹƺƞǩȅǿș� ƞǧƺƞ� ƺǹȗǔƺǐρ� șȣаǔȗ� ǟȗȅǿ� șȅljǩƺǹ� ǐǩгljȣǹƞǩǔșॹ� ǹǩƿǔ� ƺ� șǩǡǿǩйljƺǿƞ� ƺǿȅȣǿƞ� ȅǟ� patients diagnosed with mental disorders (lehmann et al., 2019) – since these people may be particularly challenged by the pandemic (druss, 2020). this preliminary study was conducted as a part of the gesichter lesen1 project, an initiative seeking to investiǡƺƞǔ� ǧȅλ� ǿƺșƿেλǔƺȗǩǿǡ� ǐǩаǔȗǔǿƞǩƺǹǹρ� ǩǿȓƺljƞș� șȅljǩƺǹ� exchange in children, adolescents, and adults. here, we aim to understand how depressive symptoms inƞǔȗƺljƞ�λǩƞǧ�ƞǧǔ�ǔаǔljƞș�ȅǟ�ǿƺșƿেλǔƺȗǩǿǡ�ǩǿ�ǟƺljǩƺǹ�ǔǿȅtion recognition processes in adolescents and adults. in the future, the gesichter lesen project intends to analyze data from multiple psychopathological variables and attitudes in emotion recognition and facial mimicry in children and adolescents. considering that children’s and early adolescents’ development are ǹƺȗǡǔǹρ� ǩǿмȣǔǿljǔǐ�ljρ�ƞǧǔ�șȅljǩƺǹ�ljȅǿƞǔπƞ�λǩƞǧǩǿ�λǧǩljǧ� they interact (richards & light, 1986), the impact ȅǟ�ǿƺșƿেλǔƺȗǩǿǡ�ǿǩǡǧƞ�ljǔ�ȓƺȗƞǩljȣǹƺȗǹρ� șǩǡǿǩйljƺǿƞ� ǟȅȗ� them, notably if they struggle with any form of psychoȓƺƞǧȅǹȅǡρঀ�'ȅȗ�ƞǧǩș�йȗșƞ�ǔπȓǔȗǩǿǔǿƞॹ�λǔ�șǔǹǔljƞǔǐ�ƺ�ǿȅȗǔ� accessible sample of adults recruited online and decided to focus on a single psychopathology-related construct (depressive symptoms, continuous) and mask-wearing (binary) as independent variables. we aim to examine how the wearing of face masks interacts with the biases in facial emotion reading found to be associated with depressive symptoms in adolescents and adults (see above). the dependent variables of interest are, therefore, emotion recognition and emotion intensity rating. hypotheses � eǧǔ�йȗșƞ�ȅȣƞljȅǿǔ�ljǔǩǿǡ�ǔπƺǿǩǿǔǐ�ǩș�ǔǿȅƞǩȅǿ�ȗǔljognition. we hypothesize that participants’ emotion recognition of anger, sadness, and happiness is negaƞǩκǔǹρ�ƺаǔljƞǔǐ�ljρ�ƞǧǔ�ȓȗǔșǔǿljǔ�ȅǟ�ƺ�ǟƺljǔ�ǿƺșƿ�শ/ࢲঀࢲষঀ�2ǿ� addition, recognition of anger, sadness, and happiness are associated with the participant’s depressive symptoms (h1.2). in line with the presented literature, we expect sadness and anger to be overperceived and happiness to be underperceived by participants with elevated depressive symptoms. finally, there is an inƞǔȗƺljƞǩȅǿ� ǔаǔljƞ� ljǔƞλǔǔǿ� ƞǧǔ� ȓȗǔșǔǿljǔ� ȅǟ� ƺ� ǟƺljǔ�ǿƺșƿ� and the participant’s depressive symptoms in emotion recognition for anger, sadness, and happiness (h1.3). for the second outcome, emotion intensity rating, we hypothesize that all emotions (anger, sadness, and happiness) are rated as less intense in masked faces than emotions in unmasked faces (h2.1). additionally, the intensity rating of all perceived emotions (anger, sadness, and happiness) is associated with the participant’s depressive symptoms (h2.2). in line with the presented literature, we expect sadness and anger to be rated more intensively and happiness to be rated less intensively by participants with elevated depressive sympƞȅǿșঀ�@ƺșƞǹρॹ�ƞǧǔȗǔ�ǩș�ƺǿ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞ�ljǔƞλǔǔǿ�ƞǧǔ� presence of a face mask and the participant’s depressive symptoms in the rating of emotion intensity for all emotions (anger, sadness, and happiness) (h2.3). methods sample. inclusion criteria for the online experiment ljȅǿșǩșƞǔǐ�ȅǟ�ljȣȗȗǔǿƞǹρ�ǹǩκǩǿǡ�ǩǿ�(ǔȗǿƺǿρॹ�șȓǔƺƿǩǿǡ�мȣent german, and being at least 14 years old. recruiting was conducted between january and june 2021 through ǿȣǹƞǩȓǹǔ�ljǧƺǿǿǔǹșॹ�ǩǿljǹȣǐǩǿǡ�xȗȅǹǩйlj2ॹ�ǐǩаǔȗǔǿƞ�șȅljǩƺǹ� media platforms (facebook and twitter), and student recruiting resources from the institute of psychology at the humboldt university berlin, which consist of ǿƺǩǹǩǿǡ� ǹǩșƞș� ƺǿǐ� мρǔȗ� ǐǩșƞȗǩljȣƞǩȅǿঀ� xƺȗƞǩljǩȓƺǿƞș� ȗǔceived 5 eur on average for their participation, which ǩș� ljǹƺșșǩйǔǐ� ƺș� ǡȅȅǐ� ȓƺρǿǔǿƞ� ǩǿ� xȗȅǹǩйljঀ��ȅǿȓǔǿșƺƞǩȅǿ�λƺș�ljƺȗȗǩǔǐ�ȅȣƞ�ǔǩƞǧǔȗ�κǩƺ�xȗȅǹǩйljॹ�ljƺǿƿ�ǐǔȓȅșǩƞॹ�ȅȗ� as test person points for undergraduate credit. a total of 108 participants (adults and adolescents 14 years and over) completed the online experiment and gave their consent via sosci survey. after the exclusion of subjects that did not complete psychopathology measures or dropped out before the end of the experiment, ƞǧǔ�йǿƺǹ�șƺǿȓǹǔ�ljȅǿșǩșƞǔǐ�ȅǟ�ǐƺƞƺ�ǟȗȅǿࢲࢺ��ȓƺȗƞǩljǩȓƺǿƞș� (51 women, 56%) with a mean age of 32.7 years (sd = 15.6, range 14-71), who reported having seen the video stimuli and for whom at least one video upload 1 1 for more information on the gesichter lesen project, see https://www.kinderprojekte-psychologie.de/projekte/gesichter-lesen/ for more information on the gesichter lesen project, see https://www.kinderprojekte-psychologie.de/projekte/gesichter-lesen/ 2 2 'ȅȗ�ǿȅȗǔ�ǩǿǟȅȗǿƺƞǩȅǿ�ȅǿ�ƞǧǔ�ȗǔljȗȣǩƞǩǿǡ�ǔǿǡǩǿǔ�xȗȅǹǩйljॹ�șǔǔ�ǧƞƞȓșॸইইλλλঀȓȗȅǹǩйljঀljȅইॾǧȅλেǩƞেλȅȗƿș'ȅȗ�ǿȅȗǔ�ǩǿǟȅȗǿƺƞǩȅǿ�ȅǿ�ƞǧǔ�ȗǔljȗȣǩƞǩǿǡ�ǔǿǡǩǿǔ�xȗȅǹǩйljॹ�șǔǔ�ǧƞƞȓșॸইইλλλঀȓȗȅǹǩйljঀljȅইॾǧȅλেǩƞেλȅȗƿș 78 mazzaferro was successful. we did not collect information on race, ethnicity, income level, or educational attainment. material. for the diagnostic material, we selected the phq-9 for the recording of depressive symptoms (patient health questionnaire 9; richardson et al., 2010). the phq-9 is a versatile instrument for screening and measuring the severity of depression using only 9 items. it incorporates diagnostic criteria from the dsm-iv and other important major depressive symptoms into a short self-report tool (kroenke et al., 2001). this instrument has been shown to have adequate internal consistency (>0.8; kim & lee, 2019; titov et al., 2010), a one-factor replicable structure (kim & lee, 2019; titov et al., 2010), and satisfactory convergent validity (kim & lee, 2019; beard et al., 2016). in this study, the phq-9 had a cronbach’s alpha of 0.86. 'ȅȗ� ƺ� ǐǩаǔȗǔǿƞ� șǔƞ� ȅǟ� ƺǿƺǹρșǔș� ǿȅƞ� ȗǔǹǔκƺǿƞ� ƞȅ� ƞǧǔ� present study, the experiment materials also included the inclusion of other in the self scale (ios, aron et al., 1992), the gad-7 (spitzer et al., 2006), and a short questionnaire on the participant’s attitudes towards mask-wearing (an et al, 2021). as video stimuli, we selected validated child and adult faces from the online radbound faces database (bijsterbosch et al., 2020), which were presented as videos through a morphing process created using fantamorph5. facial expressions ranged from neutral to emotional. selected examples of the stimuli are presented in figure 1. a surgical mask was added to half of the stimuli with the help of the video editing softλƺȗǔ�@ǔǿș�^ƞȣǐǩȅ�ljρ�^ǿƺȓ�2ǿljঀ�eǧǔ�йǿƺǹ�κǩǐǔȅș�λǔȗǔ� ƞǧǔǿ� ljȅǿȓȅșǔǐ� λǩƞǧ� �ǐȅljǔ� �ǟƞǔȗ�аǔljƞș� ƺș� ǟȅǹǹȅλșॸ� -�șǔljȅǿǐș�ǟȅȗ�ƞǧǔ�ǿȅȗȓǧ�șǔࢶ��șǔljȅǿǐș�йπƺƞǩȅǿ�ljȗȅșșॹࢶঀࢲ quence, 1.5 seconds post-stimuli neutral background. for the sad videos, the morph sequence is 6 seconds long instead of 5 because research has shown that the onset and development of a sad facial expression take somewhat longer than happiness or anger (fayolle & droit-volet, 2014). the pool of stimuli consists of 48 videos of 16 agents (8 adults, 8 children; 50% of all agents being female) showing three selected emotions (happiness, anger, and sadness). half of all κǩǐǔȅș� șǧȅλ�ƺǡǔǿƞș�λǔƺȗǩǿǡ� ǟƺljǔ�ǿƺșƿșঀ��� șȣȓǔȗйljǩƺǹ� qualitative evaluation of how well a face mask would йƞ�ƞǧǔ�ǿȅȗȓǧ�λƺș�ljȅǿǐȣljƞǔǐ�ƞȅ�ǐǔƞǔȗǿǩǿǔ�λǧǩljǧ�κǩǐeos would feature face masks. each agent appears on 3 videos (one for each emotion), with either 1 out of 3 or 2 out of 3 videos being masked. the stimuli were randomized using a block design to prevent the same gender from being presented more than twice in a row. procedure. the study was conducted entirely online. for adolescents 14 years and over and adults, particǩȓƺƞǩȅǿ�λƺș�ljȅǿȓǹǔƞǔǹρ�șǔǹǟেșȣгljǩǔǿƞॹ�ƺș�ƺȓȓȗȅκǔǐ�ljρ� the ethics committee of the humboldt university berlin. participants were informed that they would be required to watch 48 short videos, that the task would take about 40 minutes, and that participation in the experiment would only be possible if they had a webcam-enabled computer/laptop and agree to a webcam recording of their face during the experiment. informed consent included standard details ȅǿ� ljȅǿȓǔǿșƺƞǩȅǿॹ� ljȅǿйǐǔǿƞǩƺǹǩƞρॹ� ƺǿǐ� ljȅǿƞƺljƞ� ǩǿǟȅȗmation. participants who agreed to participate were instructed to set up their webcam to allow recordǩǿǡॹ�ƞȅ�ƺȗȗƺǿǡǔ�șȣгljǩǔǿƞ�ǹǩǡǧƞǩǿǡॹ�ƺǿǐ�ƞȅ�ȗǔǟȗƺǩǿ�ǟȗȅǿ� eating or covering their face during the experiment. � eǧǔ� йȗșƞ� șǔƞ� ȅǟ� ȕȣǔșƞǩȅǿș� ƺșƿǔǐ� ǟȅȗ� ǐǔǿȅǡȗƺȓǧic information. participants then watched the video stimuli while their facial activity was recorded. following each video, using 7-point likert-scales, participants rated the targets’ emotion expressions using ƺǿ� ǔǿȅƞǩȅǿ� ȓȗȅйǹǔ� শǧƺȓȓǩǿǔșșॹ� șƺǐǿǔșșॹ� ǟǔƺȗॹ� ƺǿǡǔȗॹ� disgust, and surprise) and were asked to indicate how close they felt to the person shown using the ios scale and how much they would like to meet the displayed ƺǡǔǿƞঀ�'ȅǹǹȅλǩǿǡ�ƞǧǔ�κǩǐǔȅ�ƞƺșƿॹ�ȓƺȗƞǩljǩȓƺǿƞș�йǹǹǔǐ�ȅȣƞ� figure 1: on the left, a woman with a mask expressing happiness. on the right a child without a mask expressing anger. 79 mask-wearing and facial emotion recognition psychopathology measures (phq-9 and gad-7) and were asked about their attitudes toward mask-wearing ƺǿǐ�ȕȣǔșƞǩȅǿǔǐ�ƺljȅȣƞ�ǧȅλ�ƞǧǔ�ȓƺǿǐǔǿǩlj�ǧƺǐ�ƺаǔljƞǔǐ� their lives with the scale adapted from an et al. (2021). finally, participants were given the opportunity to opt-out by requiring their videos to be erased (no participant used this option), informed about the purpose of the experiment, thanked for their participation, and received the necessary instructions for payment. statistical analysis. hypothesis for both outcome variables (emotion recognition and emotion intensity rating) were analyzed with linear mixed models (lmms) using the statistical programming language [�ƺǿǐ�ǩƞș�ȓƺljƿƺǡǔș�ǹǿǔࢵ�ƺǿǐ�ǹǿǔȗeǔșƞঀ�eǧǔ�ǿƺǩǿ�ǔаǔljƞ� of mask, depression score and the interaction between the two were estimated by random intercept/ random șǹȅȓǔ�ǿȅǐǔǹșঀ� �ȅǧǔǿঢ়ș� ǐ� ǔаǔljƞ� șǩφǔș� λǔȗǔ� ljȅǿȓȣƞǔǐ� ǟȅȗ� ǔκǔȗρ� șǩǡǿǩйljƺǿƞ� ljȅǔгljǩǔǿƞঀ� eǧǔ� ǐƺƞƺ� șƞȗȣljƞȣȗǔ� characterized a repeated measures design since we collected many observations on the same variables ǟȗȅǿ� ǔκǔȗρ� ȓƺȗƞǩljǩȓƺǿƞঀ� eǧȣșॹ� ȓƺȗƞǩljǩȓƺǿƞ� ǩǐǔǿƞǩйljƺtion (id) was included in the model as a cluster variable. hence, the full model was computed as follows: outcome ~ mask * depression + (1+mask+depression | id). results � �ǿȅƞǩȅǿ� ǩǿƞǔǿșǩƞρ� ȗƺƞǩǿǡঀ� eǧǔ� ǿƺǩǿ� ǔаǔljƞ� ȅǟ� the mask factor on emotion intensity rating can be observed in the descriptive bar plot in figure 2. the mask factor (after controlling for depression score) ρǩǔǹǐǔǐ�șǩǡǿǩйljƺǿƞ�ljǔƞƺ�ljȅǔгljǩǔǿƞș�ǟȅȗ�ǧƺȓȓǩǿǔșș�শݾ�઀� -1.57, p < 0.001, cohen’s d = -0.41, ci95% = [-0.47; েࢱঀࢶࢴযষॹ�ƺǿǐ�ǟȅȗ�șƺǐǿǔșș�শݾ�઀�েࢱঀࢺࢺॹ�ȓ�ઃࢱ�ঀࢲࢱࢱॹ��ȅǧǔǿঢ়ș� d = -0.24, ci95% = [-0.28; -0.19]), but not for anger. eǧǔ�ǿƺǩǿ�ǔаǔljƞ�ǟȅȗ�ǧƺȓȓǩǿǔșșॹ�ǧȅλǔκǔȗॹ�λƺș�ȕȣƺǹǩйǔǐ� by the interaction mask*depression score and thus λƺș� ǩǿƞǔȗȓȗǔƞǔǐ� ǩǿ� ƞǧǩș� ljȅǿƞǔπƞঀ� eǧǔșǔ� ǔаǔljƞș� λǔȗǔ� also tested via likelihood-ratio test model comparison of intercept-only models and the results were mainƞƺǩǿǔǐঀ� �ǔȓȗǔșșǩȅǿ� șljȅȗǔș� ǐǩǐ� ǿȅƞ� ρǩǔǹǐ� șǩǡǿǩйljƺǿƞ� ǿƺǩǿ�ǔаǔljƞ�ȗǔǡȗǔșșǩȅǿ�ljȅǔгljǩǔǿƞș�ǟȅȗ�ƺǿρ�ȅǟ�ƞǧǔ�șǔǹǔljƞed emotions in the lmms. it is important to mention ƞǧƺƞॹ� ǟȅȗ� șƺǐǿǔșșॹ� ƺ� ǿȅǿেșǩǡǿǩйljƺǿƞ� șǿƺǹǹ� ȓȅșǩƞǩκǔ� ǔǟǟǔljƞ�ȅǟ�ǐǔȓȗǔșșǩκǔ� șρǿȓƞȅǿș�λƺș�ȅljșǔȗκǔǐ� শݾ�઀ࢱ�ঀࢵࢱॹ� p < 0.1, cohen’s d = 0.11, ci95% = [-0.02; -0.24]). � �ș�ǟȅȗ�ƞǧǔ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞșॹ�ƞǧǔ�ǿƺșƿॴǐǔȓȗǔșșǩȅǿ� șljȅȗǔ�ǩǿƞǔȗƺljƞǩȅǿ�λƺș�șǩǡǿǩйljƺǿƞ�ƺƞ�ƞǧǔࢶ�ઔ�ǹǔκǔǹ�ǟȅȗ�ǧƺȓȓǩǿǔșș�শݾ�઀�েࢱঀࢶࢱॹ�ȓ�ઃࢱ�ঀࢶࢱॹ��ȅǧǔǿঢ়ș�ǐ�઀�েࢱঀࢸࢱॹ��2ࢶࢺઔ� = [-0.13; -0.01]) but not for sadness or anger. the sigǿǩйljƺǿƞ� ǩǿƞǔȗƺljƞǩȅǿ�ljȅǔгljǩǔǿƞș�λǔȗǔ�ȓǹȅƞƞǔǐ�ƞȅ�ƺǹǹȅλ� ƺ� ljǔƞƞǔȗ� ǩǿƞǔȗȓȗǔƞƺƞǩȅǿ� ȅǟ� ƞǧǔ� ǔаǔljƞ� ƺǿǐ� ljƺǿ� ljǔ� șǔǔǿ� in figure 5. the model for happiness, including the mask, depression scores, and the interaction between the two produced a marginal r2 of 0.174 (calculated according to nakagawa & schielzeth, 2013). a modǔȗƺƞǩȅǿ�ƺǿƺǹρșǩș�ȅǟ�ǐǔȓȗǔșșǩκǔ�șljȅȗǔ� ǩǿ�ƞǧǔ�ǿƺșƿ�ǔаǔljƞ� was conducted with the help of simple slopes (with the ȓƺljƿƺǡǔ�ǩǿƞǔȗƺljƞǩȅǿș�ǩǿ�[ষ�ƺƞ�ƞǧȗǔǔ�ǐǩаǔȗǔǿƞ�ȓȅǩǿƞș�ȅǟ� the depression scale (-1sd, mean, +1sd). the mask ǔаǔljƞ�λƺș�șǩǡǿǩйljƺǿƞ�ƞǧȗȅȣǡǧȅȣƞ�ƞǧǔ�șȓǔljƞȗȣǿ�ȅǟ�ǐǔpressive symptoms (p < 0.001). however, the 95% conйǐǔǿljǔ�ǩǿƞǔȗκƺǹș�ȅǟ�ƞǧǔ�ljȅǔгljǩǔǿƞș�ǐǩǐ�ȅκǔȗǹƺȓॹ�ƞǧƺƞ�ǩșॹ� ƞǧǔ�șǩǿȓǹǔ�șǹȅȓǔș�λǔȗǔ�ǿȅƞ�șǩǡǿǩйljƺǿƞǹρ�ǐǩаǔȗǔǿƞ�ǟȗȅǿ� ȅǿǔ� ƺǿȅƞǧǔȗঀ�eǧȣșॹ� ƞǧǔ�ǿȅǐǔȗƺƞǩȅǿ� ǔаǔljƞ� ljȅȣǹǐ� ǿȅƞ� ljǔ� ǩǿƞǔȗȓȗǔƞǔǐ� ƺș� șǩǡǿǩйljƺǿƞঀ� �șƞǩǿƺƞǔș� ǟȅȗ� ƞǧǔ� ǔаǔljƞ� of mask at the three respective levels of depression λǔȗǔݾ��઀� েࢲঀࢲࢴ�λǩƞǧ��2ࢶࢺઔ�઀� মেࢲঀࢳࢷআ� েࢲঀࢱࢱয�ƺƞ� েࢲ^�ॹ� �ݾ ઀� েࢲঀࢸࢶ� λǩƞǧ� �ઔࢶࢺ�2 ઀� মেࢲঀࢺࢸআ� েࢲঀࢷࢴয� ƺƞ� ƞǧǔ� ǿǔƺǿ� ƺǿǐݾ��઀� েࢲঀࢵࢹ�λǩƞǧ��2ࢶࢺઔ�઀� মেࢳঀࢵࢲআ� েࢲঀࢴࢶয� ƺƞ�੼ࢲ^� emotion recognition.�eǧǔ�ǿƺǩǿ�ǔаǔljƞ�ȅǟ�ƞǧǔ�ǿƺșƿ�ǟƺljtor for emotion recognition can be observed in the descriptive bar plot in figure 3. a hit (=1) was registered when the intensity rating of the target emotion was higher than the intensity rating of all other emotions. a miss (=0) was registered when one of the distractor emotions was rated higher than or equal to the target emotion. the second outcome variable, emotion recognition, produced similar results to emotion intensiƞρ�ȗƺƞǩǿǡșঀ�eǧǔ�ǿƺǩǿ�ǔаǔljƞ�ȅǟ�ǿƺșƿ�শƺǟƞǔȗ�ljȅǿƞȗȅǹǹǩǿǡ� ǟȅȗ�ǐǔȓȗǔșșǩȅǿ�șljȅȗǔșষ�λƺș�ȓȗǔșǔǿƞ�ǟȅȗ�ǧƺȓȓǩǿǔșș�শݾ�઀� -0.17, p < 0.001, cohen’s d = -0.27, ci95% = [-0.34; েࢱঀࢱࢳযষ�ƺǿǐ�șƺǐǿǔșș� শݾ�઀� েࢱঀࢺࢲॹ�ȓ�ઃࢱ�ঀࢲࢱࢱॹ��ȅǧǔǿঢ়ș�ǐ� = -0.21, ci95% = [-0.26; -0.16]) but not for anger. model comparison tests were consistent with this șǩǡǿǩйljƺǿljǔ� ȓƺƞƞǔȗǿঀ� eǧǔ� κƺȗǩƺljǹǔ� ǐǔȓȗǔșșǩκǔ� șρǿȓƞȅǿș�ǐǩǐ�ǿȅƞ�șǩǡǿǩйljƺǿƞǹρ�ȓȗǔǐǩljƞ�ƞǧǔ�ǔǿȅƞǩȅǿ�ȗǔljȅǡnition of any of the emotions displayed in this study. 80 mazzaferro figures 2 (top) and 3 (bottom): emotion intensity rating and recognition for each emotion as a function of mask. error bars are ઔ�ljȅǿйǐǔǿljǔ�ǩǿƞǔȗκƺǹșঀࢶࢺ interactions between mask and depression scores also ǟƺǩǹǔǐ�ƞȅ�ρǩǔǹǐ�șǩǡǿǩйljƺǿƞ�ȗǔșȣǹƞșঀ�^ƞǩǹǹॹ�ǩƞ�ǩș�λȅȗƞǧ�ǿǔǿƞǩȅǿǩǿǡ�ƞǧƺƞॹ�ǩǿ�ƞǧǔ�ljƺșǔ�ȅǟ�ǧƺȓȓǩǿǔșșॹ�ƺ�ǿȅǿেșǩǡǿǩйljƺǿƞ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞ�ljȅǿșǩșƞǔǿƞ�λǩƞǧ�ƞǧǔ�ȅǿǔ�ǟȅȣǿǐ� in the emotion intensity rating variable was reported শݾ�઀�েࢱঀࢷࢱࢱॹ�ȓઃࢱঀࢲॹ��ȅǧǔǿঢ়ș�ǐ�઀�েࢱঀࢶࢱॹ��2ࢶࢺઔ�઀� [-0.12; 0.01]), which is plotted in figure 5. the model for emotion recognition of happiness including the mask, depression scores, and the interaction between the two produced a marginal r2 of 0.093 (calculated according to nakagawa & schielzeth, 2013). moderation analysis through simple slopes was conducted for this outcome variable and showed similar results to the one of emotion intensity rating, meaning that ƞǧǔ�ǔаǔljƞ�ȅǟ�ƞǧǔ�ǿƺșƿ�λƺș�șǩǡǿǩйljƺǿƞ�ƞǧȗȅȣǡǧȅȣƞ�ƞǧǔ� depression scale and tended to increase as particiȓƺǿƞș�ȗǔȓȅȗƞǔǐ�ǿȅȗǔ�șρǿȓƞȅǿșॹ�ljȣƞࢶࢺ�ઔ�ljȅǿйǐǔǿljǔ� ǩǿƞǔȗκƺǹș�ȅκǔȗǹƺȓȓǔǐ�șȅ�ƞǧƺƞ�ƞǧǔ�ǐǩаǔȗǔǿljǔ�ljǔƞλǔǔǿ�ƞǧǔ� simple slopes ljȅȣǹǐ�ǿȅƞ�ljǔ�ǩǿƞǔȗȓȗǔƞǔǐ�ƺș�șǩǡǿǩйljƺǿƞঀ��ȅǔгljǩǔǿƞș�ƺƞ� ƞǧǔ�ƞǧȗǔǔ�ȗǔșȓǔljƞǩκǔ�ȓȅǩǿƞș�λǔȗǔݾ��઀�েࢱঀࢴࢲ�λǩƞǧ��2ࢶࢺઔ� ઀�মেࢱঀࢺࢲআ�েࢱঀࢸࢱয�ƺƞ�েࢲ^�ॹݾ��઀�েࢱঀࢸࢲ�λǩƞǧ��2ࢶࢺઔ�઀� মেࢱঀࢲࢳআ�েࢱঀࢳࢲয�ƺƞ�ƞǧǔ�ǿǔƺǿ�ƺǿǐݾ��઀�েࢱঀࢱࢳ�λǩƞǧ��2ࢶࢺઔ�઀� [-0.26; -0.14] at +1sd. within the framework of the gesichter lesen project, this study utilized morphed face stimuli to assess ƞǧǔ�ǔаǔljƞ�ȅǟ� ǟƺljǔ�ǿƺșƿș�ƺǿǐ�ǐǔȓȗǔșșǩκǔ� șρǿȓƞȅǿș�ȅǿ� emotion recognition and emotion intensity rating. eǧǔ��аǔljƞ�ȅǟ�eƺșƿেvǔƺȗǩǿǡ in partial accordance with h1.1 and h2.1, the results suggest that mask-wearing has, according to cohen’s standards (cohen, 1988), small to medium figures 4 (top) and 5 (bottom): regression slopes of emotion intensity rating and emotion recognition of happiness by depression score grouped by mask (0: without mask, 1: with mask). error bars are sds. 81 mask-wearing and facial emotion recognition ǔаǔljƞș�ȅǿ�ljȅƞǧ�ȗǔljȅǡǿǩƞǩȅǿ�ƺǿǐ�ǩǿƞǔǿșǩƞρ�ȗƺƞǩǿǡ�ȅǟ�ǧƺȓȓρ�ƺǿǐ�șƺǐ�ǟƺljǔșॹ�ljȣƞ�ǿȅ�șǩǡǿǩйljƺǿƞ�ǔаǔljƞș�λǔȗǔ�ǟȅȣǿǐ� for angry faces. this pattern could, at least partially, be explained by the notion that, in comparison to happy and sad faces, the diagnostic face region of anger tends to be in the upper half of the observed face (bassili, 1979). on a similar note, calvo et al. (2018) evaluated eye movement patterns of participants looking at ǐǩаǔȗǔǿƞ�ǟƺljǩƺǹ�ǔǿȅƞǩȅǿș�ƺǿǐ�ǟȅȣǿǐ�șǩǡǿǩйljƺǿƞǹρ�ǿȅȗǔ� йπƺƞǩȅǿ�ȅǿ�ƞǧǔ�ǔρǔ�ȗǔǡǩȅǿ�ǟȅȗ�ƺǿǡȗρ�ǟƺljǔșঀ�eǧȣșॹ�ƺ�ǟƺljǔ� mask that covers only the lower region of the face may not impair the recognition of anger at all. however, it is important to point out that the fact that our study ǐǩǐ�ǿȅƞ�йǿǐ�ƺ�ǐǩаǔȗǔǿljǔ�ljǔƞλǔǔǿ�ƞǧǔ�ǿƺșƿǔǐ�κșঀ�ȣǿmasked condition for anger does not mean that this ǐǩаǔȗǔǿljǔ�ǐȅǔș�ǿȅƞ�ǔπǩșƞঀ�2ǿ�ƞǧǩș�șǔǿșǔॹ�ǿȅȗǔ�ȗǔșǔƺȗljǧ� with larger samples is needed to further investigate the role of masks in the facial expression of anger. still, considering that the mask may, for example, also impair the understanding of speech (mheidly ǔƞ� ƺǹঀॹ� �ষॹࢱࢳࢱࢳ ȅȣȗ� йǿǐǩǿǡș� ǟȅȗ� ǧƺȓȓǩǿǔșș� ƺǿǐ� șƺǐǿǔșș� may have important consequences for social interactions that include face masks. social interaction partners may have to express their sadness or happiness in less ambiguous ways to avoid being misunderstood, for example, by speaking louder and incorporating gestures and body language when displaying these ǔǿȅƞǩȅǿșঀ� kǿǔ� ƞρȓǔ� ȅǟ� ǩǿƞǔȗƺljƞǩȅǿ� ƞǧƺƞ� ljȅȣǹǐ� șȣаǔȗ� ljȅǿșǩǐǔȗƺljǹρ�ǟȗȅǿ�ƞǧǔșǔ�ǐǔйljǩƞș�ǩșॹ�ǟȅȗ�ǩǿșƞƺǿljǔॹ�ƺ�ǹǩκǔ� psychotherapy session in which the client and the therapist are wearing face masks. psychotherapists should pay attention to these impairments when trying to read the facial expression of patients and when expressing emotional reactions themselves. failure in accounting for this shortfall may worsen interpersonal communication and hinder therapeutic progress. the relevance of depressive symptoms the analysis of a possible�ǿƺǩǿ� ǔаǔljƞ� ȅǟ� ǐǔȓȗǔșsive symptoms on emotion recognition and intensity rating as postulated by hypotheses h1.2 and h2.2 ǐǩǐ�ǿȅƞ�ρǩǔǹǐ�ƺǿρ�șǩǡǿǩйljƺǿƞ�ȗǔșȣǹƞșঀ�eǧǩș�йǿǐǩǿǡ�ǡȅǔș� against some of the literature presented in the theoretical background of the present study. we could speculate in the following ways about the non-emergence ȅǟ�ƺǿ�ǔаǔljƞঀ�'ǩȗșƞॹ�ljȅǿșǩǐǔȗǩǿǡ�ƞǧƺƞ�λǔ�λǔȗǔ�ǔπȓǔljƞǩǿǡ� șǿƺǹǹ�ǔаǔljƞșॹ�ƞǧǔ�șƞȣǐρ�ǿƺρ�ǧƺκǔ�ǹƺljƿǔǐ�ƞǧǔ�ȓȅλǔȗ�ƞȅ� йǿǐ� ǩƞঀ� /ȅλǔκǔȗॹ� ƺ� ȓȅλǔȗ� ƺǿƺǹρșǩș� ǟȅȗ� ǹǩǿǔƺȗ� ǿǩπǔǐ� models, which needs simulation studies, was beyond the scope of this article. second, our study did not apply psychiatric diagnostic of participants, and the number of participants presenting moderately severe to severe (>15) phq-9 scores was relatively low (11 ȅȣƞ�ȅǟࢲࢺ�ॹࢳࢲ�ઔষঀ�2ƞ�ljȅȣǹǐ�ljǔ�ƞǧƺƞ�ƞǧǔ�ǔаǔljƞ�ǩǿ�ȕȣǔșƞǩȅǿ� manifests itself in clinical depression cases, as observed for example by bistricky et al. (2011) and bourke et al. (2010) but disappears when evaluating the non-clinical spectrum of depressive symptoms. furthermore, ǿƺǿρ�șƞȣǐǩǔș�ƞǧƺƞ�ȅljșǔȗκǔǐ�'�[�ǐǔйljǩƞș�ǩǿ�ǐǔȓȗǔșșǩκǔ� patients utilized ambiguous or neutral facial stimuli (e.g., beevers et al., 2009; kan et al., 2004, bourke et al., 2010) whereas this study focused solely on a less ambiguous positive (happy) or less unambiguous negative (angry and sad) facial expressions. at the same time, it is relevant to note that there is still a debate in the literature as to whether facial emotion recognition biases are indeed a characteristic of depressive disorders. wu et al. (2012), for example, reported normal performance by highly depressive patients when testing for accuracy in recognizing emotions. 2ǿƞǔȗƺljƞǩȅǿ�ȅǟ�eƺșƿেvǔƺȗǩǿǡ�ƺǿǐ��ǔȓȗǔșșǩȅǿ concerning h1.3 and h2.3, the data produced mixed results. for happiness, sadness, and anger, no ljȅǿșǩșƞǔǿƞ� șǩǡǿǩйljƺǿƞ� ǩǿƞǔȗƺljƞǩȅǿ� λƺș� ȅljșǔȗκǔǐ� ljǔtween the mask factor and depressive scores for any of the dependent variables. if at all, the pattern of the results was most suggestive in the case of happiness. given the simple slope pattern, there may be some inǐǩljƺƞǩȅǿ�ƞȅ�șȓǔljȣǹƺƞǔ�ƞǧƺƞ�ƞǧǔȗǔ�ljȅȣǹǐ�ljǔ�ƺ�șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔ�ȅǿljǔ�ƞǧǔ�șƺǿȓǹǔ�șǩφǔ�λƺș�ǹƺȗǡǔȗঀ��ρ�ƞƺƿǩǿǡ�ƺ� ljǹȅșǔȗ�ǹȅȅƿ�ƺƞ�'ǩǡȣȗǔșࢵ��ƺǿǐࢶ��ƺǿǐ�ƞǧǔ�ǩǿƞǔȗƺljƞǩȅǿ�ljȅǔгcients, it seems that the presence of a face mask triggers a depressive response to the evaluation of happiness. in other words, when happy faces are masked, depressive scores correlate negatively in a slightly stronger fashion with emotion recognition and emotion intensity ratings. however, it is imperative to note that moderation analysis with the help of simple slopes revealed ƞǧƺƞ�ƞǧǔࢶࢺ�ઔ�ljȅǿйǐǔǿljǔ�ǩǿƞǔȗκƺǹș�ȅǟ�ƞǧǔșǔ�ljȅǔгljǩǔǿƞș� λǔȗǔ�ǿȅƞ�șǩǡǿǩйljƺǿƞǹρ�ǐǩаǔȗǔǿƞ�ǟȗȅǿ�ȅǿǔ�ƺǿȅƞǧǔȗঀ�kǿǔ� could speculate that with increased power and more ȗǔǹǩƺljǹǔ�ǿǔƺșȣȗǔǿǔǿƞॹ� ƞǧǩș� ǔаǔljƞ� ljȅȣǹǐ�ljǔ� ǟȅȣǿǐ� șǩǡǿǩйljƺǿƞ� ǩǿ� ǟȣƞȣȗǔ� șƞȣǐǩǔș� ȅȗ� ƞǧǔ�ȅǿǡȅǩǿǡ�ȓȗȅǵǔljƞ�gesichter lesenঀ�^ƞǩǹǹॹ�ǔаǔljƞș�ƺȗǔ�ǔπȓǔljƞǔǐ�ƞȅ�ljǔ�șǿƺǹǹॹ�ƺǿǐ� no conclusions can be drawn from the present sample. 82 mazzaferro implications of findings 2ǟ�ȅǿǔ�ǐǔƞǔljƞǔǐ�ƺ�șǩǡǿǩйljƺǿƞ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞॹ�ǟȅȗ� example, with a larger dataset, it could be interpretǔǐ�ǩǿ�ƺ�ǟǔλ�ǐǩаǔȗǔǿƞ�λƺρșঀ�'ǩȗșƞॹ� ǩƞ� ǩș�ȓȅșșǩljǹǔ�ƞǧƺƞॹ�ƺș� reported by leyman et al. (2008), participants with higher rates of depressive symptoms have more trouljǹǔ� йπƺƞǩǿǡ� ƞǧǔǩȗ� ǡƺφǔ� ȅǿ� ǧƺȓȓρ� ǟƺljǔș� ƺǿǐ� ƞǧǔȗǔǟȅȗǔ� ȓȗǔșǔǿƞ� ǿȅȗǔ� ǐǩгljȣǹƞρ� ǩǿ� ȗǔljȅǡǿǩφǩǿǡ� ƞǧǩș� ǔǿȅƞǩȅǿ� when the mask is present. duque & vázquez (2015) also observed attentional bias in depressed patients, in the sense that positive emotions attracted less attention than negative ones. the eye-tracking methodology could be utilized with the presence of a mask in future studies to further investigate this rationale. second, one could argue that the mask may act as a social signal that triggers pandemic-related psychological burdens, and therefore impacts emotion interpretation performance. it is noteworthy to mention that the second explanation does not clarify why the interƺljƞǩȅǿ�ǔаǔljƞ�λȅȣǹǐ�ljǔ�ǿǩșșǩǿǡ�ǟȅȗ�șƺǐǿǔșș�ƺǿǐ�ƺǿǡǔȗঀ�� � eǧǔ�йǿǐǩǿǡ�ȅǟ�ƺǿ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞ�ȅǿ�ǧƺȓȓǩǿǔșș� and other emotions would have especially important implications. many recently published studies highlight how pandemic-related safety measures interact with the mental health of vulnerable populations. one study conducted in germany by benke et al. (2020), for example, found that higher restrictions due to lockdown measures, a greater reduction of social contacts, and greater perceived changes in life were associated with higher mental health impairments. in italy, fiorenzato et al. (2021) found subjective cognitive functioning and mental health were strongly associated with enforcing social distancing measures. in china, lai et al. (2020) reported particularly bad mental health outcomes for front-line professions such as doctors and nurses, people that consistently use face masks and protective equipment in their daily tasks. in this context, this preliminary study is a further account of how the impairments in facial emotion recognition brought about by the wearing of face masks can have a distinctive impact on people with a disposition to depressive symptoms. the present investigation sheds light on one speljǩйlj� ȓǧǔǿȅǿǔǿȅǿ� ƞǧƺƞ� ljƺǿ� ǔπǩșƞ� ǩǿ� ƞǧǔ� ȣǿǩκǔȗșǔ� ȅǟ� interactions between psychopathology and the burdens produced by the current pandemic, namely, that ǿƺșƿেλǔƺȗǩǿǡ�ǿƺρ�șǩǡǿǩйljƺǿƞǹρ�ǩǿȓƺǩȗ�ȓǔȅȓǹǔঢ়ș�ƺljǩǹǩƞρ� to interpret happy and sad facial expressions and that this impairment may present itself more strongly for individuals scoring higher on a depressive symptoms scale. following the studies cited in this paragraph, the present data provides some evidence that the pandemic and the safety measures related to it do impact ȓșρljǧȅǹȅǡǩljƺǹ�ǟȣǿljƞǩȅǿǩǿǡ�ƺǿǐ�ǿƺρ�ǐȅ�șȅ�ǐǩаǔȗǔǿƞǹρ�ǩǿ� dependence on people’s mental health. governments ƺǿǐ� ȗǔșȓȅǿșǩljǹǔ� ƺȣƞǧȅȗǩƞǩǔș� șǧȅȣǹǐ� ƞƺƿǔ� ƞǧǔșǔ� йǿǐings into consideration when dealing with the spread of the coronavirus and planning future restrictions. limitations and outlook although one should consider the time and accessibility constraints under which this study was conducted and evaluated, there are a few strengths λȅȗƞǧ� ǿǔǿƞǩȅǿǩǿǡঀ� 'ǩȗșƞॹ� λǔ� ljȣǩǹƞ� ƺ� ƞǩǿǔেǔаǔljƞǩκǔ� online study that could be completed by anyone that spoke german and had a tablet or computer with upto-date software and a webcam. second, considering the complexity and time limitation usually associated with this investigation, this study conducted fairly sophisticated data analysis with the help of lmms and its possibilities within the statistical software r, which help prevent false-positive associations due to population or relatedness structure and increase ȓȅλǔȗ�ljρ�ƺȓȓǹρǩǿǡ�ƺ�ljȅȗȗǔljƞǩȅǿ�ƞǧƺƞ�ǩș�șȓǔljǩйlj�ƞȅ�ƞǧǩș� structure. in addition, the preliminary character of ƞǧǩș� ǩǿκǔșƞǩǡƺƞǩȅǿ�ƺǹǹȅλș� ǟȅȗ� ǟȣȗƞǧǔȗ� șljǩǔǿƞǩйlj� ǩǿȕȣǩȗρ� of the psychological processes addressed in this paper, both within and outside of the gesichter lesen project. nonetheless, the present study contains several limitations worthy of critical evaluation. because of the short period of time within which the data had to be collected for this thesis, we conducted the analysis on a relatively small and homogeneous șƺǿȓǹǔঀ� /ƺκǩǿǡ� ǔπȓǔljƞǔǐ� șǿƺǹǹ� ǔаǔljƞ� șǩφǔșॹ� ƺ� ǹƺȗǡer and more heterogeneous sample could account ǟȅȗ� ǿȅȗǔ� ȗǔǹǩƺljǹǔ� ȗǔșȣǹƞș� ƺǿǐ� ȓȅșșǩljǹρ� йǿǐ� ǔаǔljƞș� that remained undisclosed in the present sample. dealing with the phenomenon of emotion perception and processing, the fact that this study was based solely upon psychological rating data is also a limitation. including other forms of measurement to assess response to stimuli, such as psychophysiological data, can increase validity and further contribute to the understanding of the psychological response to emotions. the gesichter lesen project is already in the process of collecting and analyzing this type of data. in a relat 83 mask-wearing and facial emotion recognition ed online experiment, kastendieck et al. (2021) have found that facial mimicry the perceiver’s imitation of the other’s emotional display was reduced or absent in response to happy but preserved for sad mask-covered expressions. in the future, it would be interesting to see how mimicry and other physiological processes such as skin conductance and heart rate relate to psychopathology in emotion processing. for that, a study set up in laboratory settings would be the better approach. because of the covid-19 pandemic, university facilities and therefore laboratories had their access restricted and did not allow studies to take place. in order to increase standardization (for example, using electromyography instead of openface3 video analysis), future studies should utilize superior methods for mimicry assessment and, if possible, go back to being conducted in laboratory environments. as a last point, one could argue that there is still room for improvement in the quality of the stimuli. here, we utilized morphed videos composed of static photos from neutral faces to faces displaying full emotions and added a face mask to it. to increase ecological validity, future stimuli should consist of recorded videos of people wearing face masks and expressing their respective emotions. conclusion in summary, the present study found evidence that masks impair facial emotion recognition and bias the ǩǿƞǔǿșǩƞρ�ȗƺƞǩǿǡ�ȅǟ�ǧƺȓȓρ�ƺǿǐ�șƺǐ�ǟƺljǔș�ljȣƞ�ǧƺκǔ�ǿȅ�ǔаǔljƞ� on angry faces. depression scores were not associated λǩƞǧ�ƞǧǔ�ȅȣƞljȅǿǔș�ǩǿ�ƞǧǩș�șƺǿȓǹǔঀ��ǿ�ǩǿƞǔȗƺljƞǩȅǿ�ǔаǔljƞ� between mask-wearing and depressive symptoms may ǔπǩșƞ�ǟȅȗ�ǧƺȓȓρ�ǟƺljǩƺǹ�ǔπȓȗǔșșǩȅǿșঀ�eǧǔ�йǿǐǩǿǡș�ǩǿȓǹǩcate that social interaction partners wearing face masks should pay additional attention to facial expressions to avoid misinterpreting emotions. in light of the results of this preliminary study and the relevance of precaution measures to contain the spread of covid-19 at the current moment, authorities should consider ƞǧǔ� șȣǡǡǔșƞǔǐ�ǐǔйljǩƞș� ǩǿ�ǔǿȅƞǩȅǿ�ȗǔljȅǡǿǩƞǩȅǿ�ƺǿǐॹ� ǩǿ� particular, how they associate with psychopathology when planning future pandemic-related public policy. 3 3 the the gesichter lesengesichter lesen project is currently analyzing mimicry data using the openface software. for more information on openface, see baltrusaitis et. al., project is currently analyzing mimicry data using the openface software. for more information on openface, see baltrusaitis et. al., (2016). 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(2010). internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. plos one, 5(6), e10939. https://doi.org/10.1371/ journal.pone.0010939 world health organization (2017). depression and other common mental disorders. global health estimates. geneva: world health organization.retrieved from: https://apps.who.int/iris/ handle/10665/254610 licence: cc by-nc-sa 3.0 igo. the graduate student journal of psychology is a publication of the department of counseling and clinical psychology, teachers college, columbia university. editors jesse a. metzger karin g. coifman clinical psychology program teachers college, columbia university editorial board ben adams samantha boris karpel kathleen m. lalande joseph marasia lisa sara rosenzweig traci stein liat tsuman-caspi elizabeth watson design editor liat tsuman-caspi department advisor barry a. farber, ph.d. director of clinical training program coordinator, clinical psychology program, department of counseling and clinical psychology aims and scope. founded in 1998, the graduate student journal of psychology (gsjp) is a peer-reviewed publication devoted to clinical and counseling psychological research and practice. the gsjp is published annually and includes original empirical research articles, case studies, theoretical articles, and brief reports in the areas of adult and child psychopathology, the psychotherapeutic process, community mental health, multiculturalism, assessment, child development, ethics, and professional development. articles on other topics, such as psychophysiology, school psychology, and social psychology, may be accepted if they have a clear relationship to research or practice in clinical or counseling psychology. manuscripts. the manuscript submission deadline for next year’s volume is december 10, 2005. submit manuscripts via mail according to the submission guidelines printed in this issue. please submit 3 copies of the manuscript, along 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university, 525 west 120th street, new york, ny 10027. dear reader, we are pleased to present the seventh edition of the graduate student journal of psychology. this year we have continued our expansion of the journal’s scope and reach, inviting submissions from clinical and counseling programs in the tri-state area and beyond. we have also worked to maintain the highest standard of quality, and this year’s volume, we think, contains a particularly outstanding and diverse group of works. we would like to take this opportunity to highlight a very special contribution to this year’s volume: an invited paper by shefali tsabary, a doctoral student in the clinical psychology program here at teachers college. her paper, which is based on a presentation she gave at a recent program colloquium, details her experience of leading workshops for trauma survivors in the indian islands following the december 2004 tsunami disaster. we feel privileged to be able to share her moving account with our readers. finally, we would like to express our sincerest gratitude to professor barry farber for his mentorship and ongoing support of the journal, and to the editorial staff for their tremendous efforts over the past several months. much work has gone into this year’s volume, and we hope you will be pleased with the outcome. sincerely, jesse a. metzger karin g. coifman editor editor 5 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 experiencing michael: sullivan’s modes of sentience a. jordan wright teachers college, columbia university harry stack sullivan proposed a developmental model of sentience, of “any…primary data of experience” (sullivan, 1953, p. 28). this article uses theory and case study examples to explore sullivan’s developmental model in two ways. first, the scope of applicability of the model is extended to everyday experience. second, using sullivan’s other developmental theories as analogy, extension of his theory of sentience is drawn to a natural conclusion, incorporating the more contemporary notion of intersubjectivity. harry stack sullivan proposed a developmental model of sentience, of “any…primary data of experience” (sullivan, 1953, p. 28). the experience of something is not simply the event that occurs or in which the person participates, but the meaning that the individual attaches to that event. sentience itself is the data from which we come to have information, to know experience. in his model, sullivan proposes three modes of experience which develop as a function of both the quantity and quality of the elaboration of which one has had contact with events in one’s life. his model was proposed as a development that progresses over time; in his model, infants operate primarily in the first mode of sentience, and with experience over time, progress through to the highest mode of sentience. the present paper will illustrate and then elaborate on sullivan’s theory of sentience using case examples from the writer’s own work of how an adult man named michael is experienced. sarah looks up at michael, who to her is not quite a person, not anything but an overwhelming feeling of warmth and relaxation. the calmness that overwhelms sarah is like sunlight, the calm soothing warmth and safety of the sun’s light and warmth enveloping her little body. she experiences michael in terms of nothing but this overwhelming feeling he brings over her. sullivan termed the first mode of sentience the protaxic mode. the earliest and simplest of the modes of experience, the experience of early infancy, the protaxic mode “may be regarded as the discrete series of momentary states of the sensitive organism” (sullivan, 1953, p. 29), undifferentiated and unintegrated feelings. all that sarah knows when expecorrespondence concerning this article should be addressed to a. jordan wright, gouverneur healthcare services, behavioral health department, 227 madison street, 3rd floor, new york, ny 10002; 212-238-7335; e-mail: ajwright79@hotmail.com riencing michael are momentary states, with no integration of time involved. not an entity separate from the world, sarah is experiencing michael only as a sense, only as the global impact he has on her. sarah’s “felt experience is all of a piece, undifferentiated, without definite limits” (mullahy, 1948, p. 286). in general, sarah’s experience of michael is based solely on her sensitivity, that is, her capacity for sensation in her body. this earliest phase of sentience quickly gives way to the subsequent stages, however, by which it is “overlaid” (sullivan, 1972, p. 37). rachel sees michael and experiences him first and foremost as a male figure with predominantly feminine qualities, a seeming paradox to her. his ambiguous gender and sexual nature impacts rachel in a way that makes her feel she can connect to him, relate to him on a female level. with jet-black hair, michael looks mixed-race, beautiful but small. his small stature and demeanor strikes rachel in his overwhelming lack of aggression and masculinity. she experiences michael as a man, small and feminine, not unlike her own mother, with whom she can connect deeply. sullivan’s second mode of experience, predominating the child’s experience, is the parataxic mode. also crude, like the protaxic mode, the parataxic mode is the state “about which something can be known, but which is somewhat harder to discuss” (sullivan, 1953, p. 29). based on crude categorizations and broad stereotypy, rachel’s experience of michael is based on his categorization: his gender, his stature, his appearance. as a man, he would most likely be threatening, but his effeminate qualities liken him to other females, with whom she has an easier and freer time connecting. still without a clear continuity, rachel’s experience progresses in time but is unconnected and still poorly formulated. the distinction of michael as a man does not encroach upon her experience of his feminine qualities. to rachel, michael is wholly a woman, even though a moment wright 6 passed when he was a man. these “‘parts,’ the diverse aspects, the various kinds of experience are not related or connected in a logical fashion” (mullahy, 1948, p. 288). her experience of michael is based completely on how she relates to others with whom michael shares his categorizations of stature and quality, and to a lesser degree gender and race. victoria relates to michael as an individual. beyond his race, gender, and stature, she experiences his impact on her, his talkative, “like a girl” nature, his interest in her and her interests. victoria feels he is insightful, analytical, and extremely friendly toward her. she feels that he is “just like one of [her] girlfriends,” those with whom she shares her most intimate thoughts, who understand and will not judge her. victoria experiences michael as a friend, a distinct individual with individual characteristics in relation to herself. sullivan’s final mode of sentience, the syntaxic mode, represents the point where the child can finally understand the “‘consensually validated’ meaning of language—in the widest sense of language” (mullahy, 1948, p. 291). the child begins to be able to discern the finer distinctions between people. victoria experiences michael truly as an individual, though always in relation to herself, how he relates to her. relating to him beyond crude categorizations and assumptions, victoria is able to symbolize michael in terms of more individualized language, able to describe him beyond global feelings (i.e., protaxic) and gross associations (i.e., parataxic). victoria’s characterization of michael is completely understandable by others and often consistent with others’ understanding of him—“consensually validated symbol activity involves an appeal to principles which are accepted as true by the hearer” (mullahy, 1948, p. 291). sullivan’s theory of sentience ends with this mode of experience. maria knows michael quite differently than the other three; she experiences him as a true subjective other, in terms of his own experience, rather than just his impact on her. a true friend to her, she is also a true friend to him, listening to his problems. michael knows that maria is studying psychology, so he supports her with mutually beneficial results, by offering his problems for her to help him understand. they have a friendship and a bond that is understood only by the two of them. maria experiences michael in terms of not only what he means to her, but also what she means to him and what they mean together. although sullivan never added a fourth phase to his developmental theory of sentience, the experience of intersubjectivity seems to describe a further development in experience and sentience. intersubjectivity, reflecting a contemporary, postmodern view not addressed in sullivan’s time, incorporates the idea that two individuals in a relationship share more than just the two individuals bring to the interaction; two subjects co-create a reality that is shared only between them, in which they are both agents, both subjects (aron, 1991). beyond experiencing michael as only an object, understood only in terms of what he means to her, only experienced in globally consensually validated language, maria and michael share an intersubjective bond, an experience in a language that cannot be fully understood by anyone else. this language is intersubjectively consensually agreed upon (i.e., formulated), only between the two of them. their relationship (which is the primary way maria experiences michael) is “continually established and reestablished through ongoing mutual influence in which both…affect, and are affected by, each other” (aron, 1991, p. 33). beyond maria and michael existing only as individuals to whom the other is merely an object, their relationship, the “intersubjective analytic third” (ogden, 1994, p. 4), has become an entity unto itself, with its own language. sullivan’s stages of sentience ended at the ability to use and understand globally consensually agreed upon language; this proposed fourth stage adds the ability to integrate both global and interpersonal consensual languages. non-developmental development the above case studies of michael and how girls of different ages and different developmental stages experience him is actually not a collection of four different children at different ages. in fact, the vignettes above were taken from a single interview with an adult woman (i will call her julie), who was asked to recall the process of meeting and getting to know a single person, michael. although sullivan intended his theory as a macro-level, stage theory of development (the primacy of the earlier modes “tend[s] to disappear” [sullivan, 1972, p. 33] with the development of the later modes), it seems that the “development” process through these four modes occurs consistently throughout life, on a micro-level. the process julie went through with michael is typical of the process she (as well as most other people) goes through when meeting and getting to know anyone. although the idea of sentience may not have been intended toward the micro-level social and interpersonal realms, its practical applicability is precisely to those realms to which sullivan was dedicated in the majority of his work. extension of theory sullivan proposed several developmental stage theories in his writings. because of the parallel nature of his theories (he presented many of them as analogous), his theory of sullivan’s modes of sentience 7 sentience development can be placed in the context of his other theories to be evaluated. whereas his developmental theory of sentience only had three stages (modes), each of his other major developmental theories contained four distinct stages. the extension of sentience into the intersubjective realm is a logical extension when comparing his theory of sentience to his other developmental theories. biological development: analogy biologically, sullivan was interested in the characteristic behaviors of organisms, developmentally enumerated. the behaviors he equates with different organisms, though they can be seen in higher organisms, are those behaviors which are predominant in each organism’s existence. lower behaviors predominating in higher organisms are a sign of pathology. beginning with unicellular organisms, the lowest form of biological behavior is associated with protista (protophyta and protozoa). protista maintain “functional activity with and within a relatively very simple environment” (sullivan, 1972, p. 29). all behavior is based on biological needs, and energy is mostly expended in a conservative manner. in humans, pathological autism and psychomotor slowing are evidence of the pathological nature of this protista activity predominating higher organisms. sullivan was less clear and specific about the nature of the behavior that predominates plant life, the second biological state of development. in humans, plant behavior can be seen in “phenomena that occur in the borderline conditions which we speak of variously as ‘light sleep,’ sleep with dreams, panic states, night terrors, and the like” (sullivan, 1972, p. 29). seemingly, the behavior that predominates in plants is one of fantasy. the third phase of biological development can be seen in animals, which have “relative freedom from spatial limitations” (sullivan, 1972, p. 30). vocalization is a predominant tool of use in animal communication. sullivan’s final biological stage of development is human, characterized by both “‘consciousness’” and “‘selfconsciousness’” (sullivan, 1972, p. 30). able to think abstractly, learn by representation, and understand their own part within a system, humans have the capacity to be both adjustive and creative. sullivan wrote of humans’ ability to perform “self-conscious acts” (sullivan, 1972, p. 31) as their overt characteristic activity. what he may also have accounted for had he incorporated intersubjectivity (had he been writing several decades after he was) is humans’ ability to perform intersubjectively-conscious acts, to consider not only the consequences to oneself, but also to the other and to the relationship between them. skill development sullivan posited a theory of the evolution of humans’ “central integrative apparatus” (sullivan, 1953, p. 20), which basically consists of a development of cognitive skills. beginning with no skills except sensation, without a sense of agency, and without the ability to attach meaning to sensations, this first stage represents a point at which no skills have been learned. a relatively short period (because, as sullivan asserts, even without the influence of culture humans would most likely “be an exceedingly gifted member of the biological series” [sullivan, 1953, p. 20], able to learn and adapt relatively quickly to the environment), this first stage of skill development contributes significantly to the second stage. the second stage of skill development, entirely dependent on the success of the first stage (i.e., without any sensation, this second stage would not be able to form), is the integration of sensation and motor skills in response to that sensation. this second skill phase represents an acquisition of agency, the ability to react to positive or negative sensations. specifically, sullivan emphasizes the importance of a single relationship, “the interrelation of vision and the prehensile hands” (sullivan, 1953, p. 20). because of the communicative nature of the hands (in preverbal children, the hands are one of “the greatest tools of interrelation” [sullivan, 1953, p. 20]), as well as their distinctly human nature, this relationship between hands and vision is one of the most agentive acquisitions in children. this motoric agency constitutes the second milestone in the development of the central integrative apparatus. the third stage of skill development is “the interrelation of hearing and the voice-producing apparatus” (sullivan, 1953, p. 20), which ultimately gives rise to the capacity for language. a prerequisite for understanding consensually agreed upon language, this integration of hearing and vocalizing represents the next major milestone in agency and communication. the final stage, “the interrelation of these and all other receptor-effector systems in an exceedingly complicated forebrain, which permits operating with many kinds of abstracts of experience” (sullivan, 1953, p. 20), is the point at which humans gain the capacity of abstraction and representation. the most complex cognitive abilities constitute what sullivan felt to be the most advanced, “human” activities possible. these include the ability to anticipate outcomes, the cognitive “testing” of situations before their actuation, and the application of similar situations to others. internal experience development sullivan proposed a development of the predominant internal experience as another meaningful developmental theory. beginning with “primitive implicit processes” (sullivan, 1972, p. 33), to which sullivan refers as the exclusive content of thought in early infancy, the human child quickly progresses to fantasy and fantastic mentation. this fantasy is as difficult to define and even imagine as the primitive processes, because of both the lack of memory of very early infancy and the relative infrequency of primitive processes after infancy. thus, sullivan only defines fantasy (or “revery”) as “all those lying between the primitive and the wright 8 highest type of implicit process, which [is] ‘externally controlled’” (sullivan, 1972, p. 34). the third stage, which sullivan defines as “reality controlled” (sullivan, 1972, p. 32), is the capacity for adjustive thought. sullivan proposes this stage as “a conscious eduction of relations discriminated on multiple bases of experience with other people and things” (sullivan, 1972, p. 35). this capacity to adjust one’s associations from personal to globally consensually validated is the essence of adjustive mentation. the final stage, also consciously chosen and influenced by reality, is the capacity for creative mentation. a seeming merger between the fantastic and the realitycontrolled, creative thought is novel, individual thought that “can be subjected to preparation for consensual validation” (sullivan, 1972, p. 36). this final stage of development is not wholly dependent on reality and the environment, but is productive toward that reality and environment. external action development a developmental theory that closely parallels his development of internal mentation and experience is sullivan’s developmental theory of external action, those skills that predominate action in different developmental stages. the first stage is purely reflexive, innate impulsive acts, which sullivan calls “total reflexes” (sullivan, 1972, p. 33). again, relatively quick to learn, humans acquire the second stage rather quickly. this second stage is constituted of action that is impulsive. highly “plastic” (sullivan, 1972, p. 33), these impulses are modified by experience, unlike reflexes, which are innate and enacted without association. the third and fourth stages of external action development are the capacity for consciously conditioned acts and the capacity for self-conscious acts, respectively. the latter much more reflective, both represent actions that are consciously chosen. consciously conditioned acts are associated with adjustive mentation; self-conscious acts represent an understanding of the role of the self within a larger system, as well as the system on the self, associated with creative thought. this last stage of action development is indicative of the uniquely intersubjective nature of humans. comparison and extension table 1 shows a comparative schematic formulation of sullivan’s five developmental theories. comparing sullivan’s developmental theory of sentience to each of his other developmental theories reveals a significant shortcoming in the elaboration of modes of experience. the analogies of the biological stage of man, the skill development stage of abstraction and representation, the internal experience of creative thinking, and the predominance of self-conscious acts imply that experience develops beyond an understanding of the globally consensually validated meaning of language, the syntaxic mode. table 1 sullivan’s developmental stage theories biologya skillsb internal experiencea external actiona sentienceb protista sensory primitive processes reflexive protaxic plants integration of sensory and motor—agency fantasy impulsive parataxic animals integration of hearing and vocalization adjustive thinking consciously conditioned acts syntaxic man abstraction and representation creative thinking self-conscious acts (intersubjective) a taken and adapted from sullivan, 1972. b taken and adapted from sullivan, 1953. sullivan’s modes of sentience 9 the analogy of humans as a “step up” from animals implies a “step up” from consensually agreed upon forms of communications, which have been empirically shown to be present in many species of animals. the augmentation would be not only to know, understand, and use communication that can be globally understood, but to be able to convey thoughts and feelings that cannot be understood fully via the use of conventional language (“unformulated experiences” [stern, 1997, p. 33]) to others. the only “language” that would be effective is an intersubjectively created (formulated) language, in which words have a specific meaning to the dyad involved that would not translate easily to the globally consensually agreed upon form of language. similarly, the analogies of cognitive skill development and internal experience seem to demand a mode beyond understanding consensually agreed upon language. the third phase of skill development, the integration of hearing and vocalization, is the prerequisite for this understanding. adjustive thinking is defined in terms of adjusting one’s understanding of language to fit the language of the world. the final stages of each, the capacity for representation and abstraction and the capacity for creative thought, necessarily go beyond globally consensually agreed upon language. the ability for the creation of intersubjectively agreed upon meanings and language is absolutely dependent on the capacity for creativity and abstraction by the dyad involved. moreover, the development of predominant external action supports an additional stage of sentience, progressing from consciously conditioned acts, which are adjustive by nature (such as altering one’s own language system to match “reality’s” language), to self-conscious acts, which necessitate representation and creative thought. because sullivan’s theories of development are so intertwined and dependent upon one another, his theory of sentience needs slight revision to parallel his other theories. had sullivan theorized somewhat later in the century than he did, it is likely that he would have taken into account the notion of intersubjectivity into his theory of experience. julie’s experience of michael went far beyond what could be expressed with consensually agreed upon language, beyond the syntaxic mode of sentience. intersubjectivity seems to offer sullivan’s theory a convenient, congruent resolution in the context of his other theories of development. references aron, l. (1991). the patient’s experience of the analyst’s subjectivity. psychoanalytic dialogues, 1, 29-51. mullahy, p. (1948). oedipus, myth and complex. new york: hermitage press, inc. ogden, t. h. (1994). the analytic third: working with intersubjective clinical facts. international journal of psychoanalysis, 75, 3-19. stern, d. b. (1997). unformulated experience: from dissociation to imagination in psychoanalysis. hillsdale: analytic press. sullivan, h. s. (1972). personal psychopathology. new york: norton. sullivan, h. s. (1953). the interpersonal theory of psychiatry. new york: norton. microsoft word ptsdfinal version.doc 18 graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 posttraumatic stress and substance use disorders: a biological and clinical summary david a. fazzari teachers college, columbia university the comorbidity of post-traumatic stress disorder (ptsd) and substance use disorders (sud) has been established in a number of studies, however treatment programs have historically focused on one disorder without considering the other. in addition to the growing clinical awareness of the comorbidity, there has been increased interest in its biological underpinnings and treatment options. this paper seeks to briefly review the biological processes involved, the interplay between symptoms, and examine two of the recent attempts at integrative treatment. the comorbidity of post-traumatic stress disorder (ptsd) and substance use disorders (sud) has been established in a number of studies (breslau, davis, andreski, & peterson, 1991; kessler, sonnega, bromet, hughes, & et al., 1995; kulka et al., 1990; resnick, kilpatrick, dansky, saunders, & et al., 1993). for example, in studies of combat veterans with ptsd, alcohol abuse or dependence was the most common comorbid diagnosis. other substance abuse or dependence also occurred at high rates in this population (kessler et al., 1995; kulka et al., 1990). in one study the comorbidity between alcohol abuse and ptsd was as high as 75% (kulka et al., 1990). with growing awareness of the comorbidity, there has been increased interest in both its biological underpinnings and treatment options. this paper seeks to briefly review the biological processes involved and the interplay between symptoms, as well as examine two of the recent attempts at integrative treatment. diagnostic criteria substance use disorders (sud) vary in their presentation from substance to substance, but share certain common features. in this paper, sud will include both substance abuse and substance dependence. substance abuse is defined as meeting one of the following criteria in a year: failure to meet obligations at work, school, or home as a result of use, engaging in dangerous behaviors while intoxicated (such as drunk driving), recurrent substance use related legal problems, and continued substance use despite recurrent social or interpersonal problems (american psychiatric association, 2000). criteria for dependence involve meeting at least three of the following criteria: tolerance to the substance, withdrawal effects, taking the substance for correspondence concerning this article should be addressed to david a. fazzari. e-mail: damf11@yahoo.com longer or in larger amounts than intended, inability to control or reduce use, spending large amounts of time procuring, using, or recovering from a substance, giving up major life activities in favor of substance use, and continued use despite the awareness of negative physical or psychological effects caused by or exacerbated by the substance (american psychiatric association, 2000). ptsd, by definition, is precipitated by either a direct threat to one’s life or physical integrity or witnessing such an act and is marked by feelings of fear, helplessness, or horror (american psychiatric association, 2000). ptsd symptoms consist of three clusters. the first is reexperiencing symptoms such as flashbacks, nightmares, or intrusive recollections that may be caused by environmental cues associated with the trauma. the second group is characterized by avoidance of thoughts, feelings, or places associated with the trauma, as well as dissociation, restricted affect, and social withdrawal. the final symptom group involves increased arousal; which includes hypervigilance, difficulty concentrating, sleep dysfunction, or increased startle response. war veterans and rape and incest survivors are grouped together in this discussion. though there may be differences in their specific experiences, both trauma types must meet dsm-iv-tr criteria and both involve a “violation of pre-existing schemata of the self and the world, such as, that one is a good person and that the world is a safe and fair place where bad things do not happen to good people without reason” (dye & roth, 1991, p. 104). biological similarities on a biological and neurological level, a number of similarities have been found between ptsd and sud. these disorders share two major systems: the hypothalamic-pituitary-adrenal (hpa) axis and the noradrenergic system (though other systems are involved to a lesser extent). these two systems work simultaneously in response to stress during both substance use and ptsd (jacobsen, southwick, & kosten, 2001). in the hpa system, stress comorbid ptsd and substance abuse 19 leads to an increased turnover of norepinephrine in the locus ceruleus and the discharge of the corticotropin-releasing hormone (crh) in the pituitary portal system. these processes lead to the discharge of adrenocorticotropic hormone (acth, also referred to as corticotropin) in the pituitary, which in turn leads to a release of cortisol from the adrenal glands. cortisol then in turn inhibits the production of crh, creating a negative feedback loop (see figure 1; austgen, bowen, & rouge, 2003). there is growing evidence that increased crh is associated with anxious withdrawal symptoms and is a mediating factor in substance relapse (jacobsen et al., 2001). increased levels of crh also have been shown to lead to a startle response, as seen in ptsd. blocking the effects of crh, on the other hand, prevents the development of withdrawal associated behaviors related to anxiety. for example jacobson et al describe a study which found that injecting crh “reinstated heroin seeking after extinction in rats trained to self-administer the drug” (jacobsen et al., 2001, p. 1186). the growing consensus at this time around the effects of chronic stress or ptsd on hpa axis function is that the “glucocorticoid negative feedback loop is enhanced in ptsd,” (jacobsen et al., 2001, p. 1186) thus elevating crh. this is of interest because crh in the amygdala has been linked with fear-related behaviors such as the startle response. in addition, as mentioned earlier, elevated crh has been implicated in stress related relapse. therefore, crh may be related to both hyperarousal and relapse. interestingly, elevated crh “enhances the euphorigenic properties of certain drugs, such as stimulants, and may worsen the severity of withdrawal symptoms, thereby prompting patients to relapse to drug use” (jacobsen et al., 2001, p. 1187). the opposite could also be true: that high levels of crh caused by withdrawal may increase ptsd symptoms such as hyperarousal, which negatively effects mood and increases the chance of relapse. the second major system involved in ptsd and sud is the noradrenergic system. when an individual experiences chronic, uncontrollable stress, there is increased norepinephrine turnover in the brain (jacobsen et al., 2001). the regions of the brain affected most are the locus ceruleus, hypothalamus, amygdala, and cerebral cortex. this scenario has also been observed in individuals withdrawing from alcohol and opiates. the noradrenergic and hpa systems also interact with one another. for example, stress increases both crh and norepinephrine via the amygdala and hypothalamus (jacobsen et al., 2001). there has been some evidence that these two systems may increase one another, causing an increasing spiral of anxiety and hyperarousal related to ptsd, withdrawal, or both. clinical interaction the biological interplay between ptsd and sud affects the client and treatment in a number of ways. for example, treating one disorder does not resolve the other, and often makes it worse (najavits, 2002). clients frequently abuse substances in an attempt to reduce ptsd symptoms and when an individual stops taking the substance, one of the major coping mechanisms is taken away. furthermore, withdrawal symptoms are similar to and can exacerbate ptsd symptoms such as hyperarousal (jacobsen et al., 2001; najavits, 2002). figure 1. s t r e s s increased turnover of norepinephrine corticotropin-releasing hormone (crh) locus ceruleus hypothalamus acth released cortisol released pituitary glands adrenal glands cortisol inhibits crh fazzari 20 in addition, sud clients are at increased risk for trauma and ptsd sufferers are more susceptible to repeated abuse than someone who has not been traumatized in the past (messman-moore & long, 2003; najavits, 2002; roodman & clum, 2001). these and other factors can lead to a “downward spiral” for the client. ptsd clients are at increased risk to develop a sud and sud clients are at increased risk for trauma. as a client uses substances in response to ptsd symptoms, their sud develops further. when entering treatment, the already difficult process of withdrawal is compounded by ptsd symptoms (najavits, 2002). integrative treatments seeking safety this paper seeks to compare two of the recent empirically supported integrative treatments that have been developed: substance dependence ptsd therapy (sdpt; triffleman, carroll, & kellogg, 1999) and seeking safety (najavits, 2002). seeking safety’s title is derived from the author’s belief that safety is the most urgent and important need of people recovering from ptsd and sud. “safety” encompasses behaviors, thoughts, friends, and places in the client’s life. there are five central ideas underlying the seeking safety treatment. first, as stated above, safety is the priority of treatment. second, the treatment is integrative, not merely an addiction treatment added on to a ptsd treatment. treatment of the two disorders is simultaneous, regardless of which is predominant in the presenting complaint. third, there is a strong focus on creating meaning and living up to ideals. the fourth is that treatment consists of four areas: cognitive, behavioral, interpersonal, and case management. lastly, the process of therapy and the therapist are as important as the techniques that are implemented. this includes attention to the dynamic issues in the relationship between therapist and client. therapy is expected to last approximately six months. as mentioned above, four areas are targeted for intervention. the cognitive techniques focus on relapse prevention, such as problem solving and cognitive restructuring. in addition, there is a strong emphasis on compassion for self and others. behavioral interventions include techniques such as activity scheduling, self-care, and behavioral experiments. the goal is to make concrete steps, however small, during each session. these techniques, which can be applied to both disorders, are familiar concepts from relapse prevention (marlatt & gordon, 1985) and general cognitive behavior therapy (beck, 1995). seeking safety also focuses on interpersonal issues. this is especially salient because the violence involved in ptsd is often interpersonal in nature and self-perpetuating. for example, an individual may be in an abusive relationship (interpersonal situation) which may be a pattern that has been repeated since an initial childhood trauma (messman-moore & long, 2003). furthermore, substance abusers are at higher risk for interpersonal violence (najavits, 2002). the last area of focus is case management. because clients are often in need of a wide variety of services, it is important they have case management to help reconnect them to their communities and to take care of urgent needs such as food and shelter. other case management needs may include medication management, vocational counseling, and domestic violence counseling. the treatment is also specific in which elements it does not include, such as prolonged exposure therapy (pe; foa, hembree, & dancu, 1999). najavits (2002) states that the treatment is focused on current life issues and does not dwell on the precursors that led to the diagnoses. there is also the additional concern that pe could trigger relapse, especially due to the time-limited nature of the treatment. in order to stay focused on the present symptom picture, this treatment does not recommend psychodynamic interpretations of the disorders. substance dependence posttraumatic stress disorder therapy another recent empirically supported cognitive behavioral approach is sdpt (triffleman et al., 1999). the primary goals of treatment are abstinence through cognitive behavioral and coping skills treatment (cbcst), continued abstinence during ptsd treatment, and reduced ptsd symptoms. it is a two phase treatment lasting approximately five months. the first phase, lasting 12 weeks and covering 9 topics, is called “trauma-informed, addictions-focused treatment” (triffleman et al., 1999, p. 4) and focuses on abstinence, ptsd psychoeducation, ptsd symptoms, and the interaction between the two diagnoses within each participant. five of the topics have been adapted specifically for this dually-diagnosed population. the second phase, called “trauma-focused, addictions-informed” (triffleman et al., 1999, p. 5), focuses on an adaptation of pe and stress inoculation training (sit; foa, rothbaum, riggs, & murdock, 1991). phase ii is divided into two parts. the first section involves stress inoculation training, which uses cognitive and behavioral strategies to learn how to approach avoided stimuli, how to confront it, ways to cope when overwhelmed, and how to deal with any after-effects of the confrontation. the second portion continues the sit while conducting in vivo exposure. in vivo exposure is carried out much like foa et al’s (1999) manualized treatment. special attention is paid to developing the hierarchy of feared situations and implementing exposure in a slow and measured way so as to reduce the risk of relapse. sdpt allows for clinical judgment in transitioning an individual from phase i to phase ii. abstinence is preferred, but not mandatory, as long as progress has been made in the sud treatment. the client must also be evaluated as to whether they are stable enough to endure the additional stress involved in phase ii. comorbid ptsd and substance abuse 21 comparison of treatments both sdpt and seeking safety are strong empirically based treatments of ptsd and sud. though their format varies, the majority of the components overlap. seeking safety contains 25 topics, but several, such as compassion, recovery thinking, and create meaning, could be condensed under a single heading of cognitive restructuring and core beliefs. the benefit of separating these topics may be to make them more palatable to the client (and clinician) and more easily absorbed, though this is not explicitly stated. psychodynamic issues such as transference, countertransference, defenses, and projections are considered in both therapies. because of the strong (often contradictory) feelings that traumatized and substance-abusing clients evoke in therapists, awareness of dynamic issues is critical (daskovsky, 1998). however, both make the distinction that dynamic interpretations are not appropriate or productive for this type of treatment. in other words, awareness of the transference and countertransference is important for the clinician’s objectivity, but the analysis of such issues with the client is beyond the scope of these short-term treatments. the role of case management is highlighted to varying extents in both treatments. while seeking safety considers it one of the four core approaches, it is still well accounted for in sdpt. both recognize that many clients who enter treatment are in need of a wide range of services that therapy alone cannot provide. there are, however, a number of differences between treatments. first and most notably is the issue of in vivo exposure. seeking safety states that the risk of relapse due to the stress is too great to consider exposure treatment in this time limited format. though similar in duration, sdpt makes in vivo exposure a core component of its program. sdpt allows for clinical judgment in deciding when to proceed, but the assumption is that the majority of clients can and will benefit from in vivo exposure. seeking safety does allow for in vivo exposure as an adaptation that can be undertaken by individual clinicians in longer-term treatment. future research may indicate whether patients treated with sdpt experience significant relapses or drop out more frequently when compared to other treatments that do not include exposure. another difference between the two therapies is seeking safety’s emphasis on interpersonal issues. while sdpt includes interpersonal elements, seeking safety considers it tantamount in importance with cognitive and behavior methods. a third of the topics covered address interpersonal issues (najavits, 2002). an additional variation is that seeking safety borrows some techniques from the growing psychological field of mindfulness treatment (kabat-zinn, 1990). seeking safety’s “grounding” techniques ask clients to notice everything they can about the world around them. increasing one’s awareness of the world around them and “decentering” oneself from one’s emotions is a central theme of this buddhism-derived therapy (lau & mcmain, 2003). while both of these protocols advance the treatment of comorbid ptsd and sud, they are still in the early stages of empirical testing. sdpt cites unpublished clinical trials that guided its development, but had no published clinical trials to date. seeking safety’s author, najavits, has undertaken studies to provide an empirical basis for her treatment (najavits, 2000, 2002; najavits, weiss, & liese, 1996; najavits, weiss, shaw, & muenz, 1998; zlotnick, najavits, rohsenow, & johnson, 2003). for example, in a sample of 17 incarcerated women diagnosed with both ptsd and sud 53% no longer met criteria for ptsd by the end of treatment (zlotnick et al., 2003). data on substance use was not very meaningful due to the reduced access to drugs in prison. in a study of 100 low-income women, seeking safety significantly reduced substance use and ptsd symptoms when compared to a control group receiving the ‘standard’ outpatient treatment (najavits et al., 1998). however, a third group in this study was treated with relapse prevention techniques (marlatt & gordon, 1985) and made similar gains to seeking safety, raising the question of whether seeking safety offers something above and beyond other current treatments. this initial research on the integration ptsd and sud treatments has spurred other clinicians to develop empirically tested treatments. most notable are concurrent treatment of ptsd and cocaine dependence (ctpcd; back, dansky, carroll, foa, & brady, 2001), which includes imaginal exposure in their treatment, and transcend (donovan, padin-rivera, & kowaliw, 2001) which is a more intensive, partial hospitalization program developed for veterans. while many techniques are effective, prolonged exposure (pe), which includes both in vivo and imaginal exposure, has the greatest long term effect on reducing ptsd symptoms (foa et al., 1991; hembree, rauch, & foa, 2003; taylor, 2003; taylor et al., 2003; van etten & taylor, 1998). it would seem useful to incorporate pe into a truly integrative treatment in order to fully address the ptsd symptoms, however, as mentioned before, this may increase the risk of relapse and drop out. it is necessary to have these treatments tested by other clinicians in other settings to settle issues such as this. in addition, the author suggests that a component analysis be undertaken to elucidate which factors are most important for the reduction of symptoms. conclusion the difficulties clients face from sud and ptsd are enormous. either disorder alone can be serious and debilitating. when combined, they complement each other in what appears to be a synergistic manner, with one disorder driving and reinforcing the other and vice versa. there is a strong comorbidity of these two separately formulated diagnoses that until relatively recently was overlooked. however, the anecdotal connection has been strengthened by biological and psychological research findings. fazzari 22 both treatments are relatively new, though many of their components have been proven effective with other disorders. while future research may indicate one is more efficacious than the other, it seems that they hold much in common. the most significant difference, in this writer’s opinion, is the presence or absence of the pe component. however, because both treatments stress their flexibility, it seems that therapist preference and client presentation may be the best guide as to which treatment to choose at this point. references american psychiatric association. 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(1993). prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. journal of consulting & clinical psychology, 61(6), 984-991. roodman, a. a., & clum, g. a. (2001). revictimization rates and method variance: a meta-analysis. clinical psychology review, 21(2), 183–204. taylor, s. (2003). outcome predictors for three ptsd treatments: exposure therapy, emdr, and relaxation training. journal of cognitive psychotherapy, 17(2), 149-161. taylor, s., thordarson, d. s., maxfield, l., fedoroff, i. c., lovell, k., & ogrodniczuk, j. (2003). comparative efficacy, speed, and adverse effects of three ptsd treatments: exposure therapy, emdr, and relaxation training. comorbid ptsd and substance abuse 23 journal of consulting & clinical psychology, 71(2), 330338. triffleman, e., carroll, k., & kellogg, s. (1999). substance dependence posttraumatic stress disorder therapy: an integrated cognitive-behavioral approach. journal of substance abuse treatment, 17(1-2), 3-14. van etten, m., & taylor, s. (1998). comparative efficacy of treatments for posttraumatic stress disorder: a metaanalysis. clinical psychology and psychotherapy, 5, 126145. zlotnick, c., najavits, l. m., rohsenow, d. j., & johnson, d. m. (2003). a cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: findings from a pilot study. journal of substance abuse treatment, 25(2), 99-105. 24 june 2006 – volume 8   june 2006 – volume 8                issn 1088‐4661      published annually    by the department of   counseling & clinical psychology  teachers college, columbia university      graduate student  journal of psychology      lotus blossoms  traci r. stein      jesse a. metzger        editors graduate student journal of psychology copyright 2 graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 the relationship between children's beliefs about the stability of traits, rumination, and negative affect lisa d. dancho fordham university this study examined the relationship between children’s beliefs about the stability of personality and physical traits, their style of introspection, their attributional style, and their mood. in addition, gender differences were examined. data was collected from fifth grade students in a suburban public elementary school in the northeast and analyzed using correlation analyses. significant correlations were found between rumination style and mood scale, attributional style, and stability of traits. moreover, when analyzed by gender, a significant correlation was found between rumination style and mood. and their relationship with depression has been a major focus of research (beck, l987; ingram, miranda, & segal, l998). at some point in many people’s lives, clinical depression affects their mental and physical well being, causing the world to seem a bleak and hopeless place. indeed, depression is much more common than once believed, with nearly eight percent of all americans experiencing a severe depressive episode that leaves them unable to function for weeks, or even months (rutter, 1986). depression is a debilitating disorder, affecting all aspects of a person’s life as well as the lives of those individuals who are involved with the afflicted party. it is an even more critical issue for women as studies have shown that women are almost twice as likely as men to develop depressive symptoms (nolenhoeksema, 1990). this gender difference in depressive rates emerges during adolescence, making this developmental period an important area for study. one cognitive mechanism that may act as a protective factor against the development of depression is the tendency of children under the age of nine to view traits as more unstable than adults (seligman, 1990). if a person believes that he or she can change negative selfcharacteristics into positive characteristics, then that individual is less likely to feel hopeless. this could lead to a more optimistic view of the future and create the ability to overcome setbacks more easily because they are more inclined to see them as temporary problems that can be conquered. as the child matures mentally, emotionally, and physically, a more stable view of the traits they possess emerges, perhaps for evolutionary reasons or perhaps because the child gains more insight into the implausibility of specific mechanisms of change. more and more traits are now seen as permanent unchangeable states. this increase in stability can lead to the child adopting a more pessimistic worldview thus increasing susceptibility to depression. the existence of differing or compounding factors that impact an adolescent girl’s mental health to a larger degree than boys of a similar age holds the potential to, at least partially, explain the comparatively elevated state of depression in females. there are a variety of theories regarding gender differences in adolescent depression that cover a wide range of factors including hormonal/physical changes such as the onset of puberty, increases in the number of life stressors, and socio-cultural factors that make an adolescent's role in society difficult (nolen-hoeksema & girgus, 1994). there is, however, one area that has not received quite as much attention. with only a few exceptions (didgon & gotlieb, l983), the previous models have neglected the role that cognitive factors may play in providing a greater understanding of the change in incidence rates. during the past two decades the role of cognitive factors another impact of trait stability can be found in the child’s relationship to, and perception of, others. to the degree that the behavior of others is seen as a stable fixed response, the child might come to anticipate a greater consistency across varied situations as she grows older. that is, the developing child may begin to believe the behavior of others is predetermined. this may cause the child to make stable attributions when trying to understand the causes of negative events. in addition to viewing the self as a more stable entity as they mature, children also develop the ability to introspect about the causality of events. lockhart (l995) found that young children (5-6 years old) seldom use attribution information to adjust their affective response to a situation; instead the outcome and whether it is seen as positive or negative primarily determines their feelings. older chil correspondence concerning this article should be addressed to lisa dancho, 97 pond road, wilton, ct 06897. e-mail: lisadancho@aol.com. 24 relationship between stability and rumination the processes used by girls to cope with stressful situations can also be affected by learned helplessness. for instance, rumination, which is the passive, repetitive focus on negative emotions, is much more common among females than males. it is theorized that because girls have less control over their environment, they ruminate over their problems in an attempt to understand their mental distress. according to women’s health weekly (august 17, 1998), there are gender differences in the patterns of adolescents’ worrying. girls reported being more worried about their appearance, interpersonal relationships, acceptance, and safety, issues that are not totally under their control. boys however, reported being more concerned with “sports and other activities,” issues that they tend to have more personal control over (women’s health weekly, august 17, 1998). since, in general, the worries of teenage girls focus on those items over which they do not have total control they ruminate in order to deal with these problems emotionally. this constant fixation on stressful problems can arguably be a major contributor to depressive symptoms in young girls. dren, however, are more likely to use attribution information, including stable trait information, to exacerbate or attenuate their emotional response to an event. this could lead the older child to seek out reasons for feeling badly, ruminate about them, and use negative attributional information to determine a response to particular events. although these changing beliefs do not necessarily make one depressed, this cognitive framework may act to make one more vulnerable to hopelessness in the face of negative life events and lead to depression. if cognitive changes are a factor in the increase in vulnerability to depression, then it would be expected that older children with an increased negative mood should exhibit a pessimistic attributional style, view traits as being stable, and be high in rumination. similarly, because the appearance of sex differences in depression begins to emerge in older children, females should exhibit higher rumination, have a more pessimistic attributional style, and possess a greater belief in the stability of traits. earlier studies by nolen-hoeksema (1990) among college students found evidence that rumination is linked to persistent negative mood states and that women as a group spend more time ruminating than men. these apparent sex differences in rumination style could account for the emerging gender difference found in depression and could be an important indicator of future depression. similarly, worchel (1987) suggested from her research that females have a tendency to internalize their difficulties in life, whereas males have a tendency to externalize their difficulties. it is debatable as to which method of coping is healthier, but perhaps, because females have been trained to feel unable to control their problems, they do not know how to cope in ways that could better their situation. learned helplessness could result from all of the previous theories mentioned and from a constant buildup of feeling out of control in life. one socio-cultural explanation for differing cognitive processes in females may be provided by the concept of learned helplessness. in the 1960’s, seligman and his associates performed experiments in which dogs were given either a controllable or uncontrollable shock. the dogs in the “controllable shock” group quickly learned that they could turn off the shock by jumping over a short barrier. however, dogs in the “uncontrollable shock” group did not have any control over escaping the shock. furthermore, even when the latter group was put into a situation where they could control the shock, they were unable to learn how to do so. seligman and his associates coined this behavior “learned helplessness” (overmier & seligman, 1967). they also identified certain characteristics that symbolized the response of organisms to uncontrollable situations, such as decreased motivation, an inability to learn new responses to control the environment, passivity, and sadness (seligman, 1975). interestingly, many of these same characteristics are also indicators of clinical depression. the objective of this research is to explore the cognitive factors discussed above. this study represents the baseline of an ongoing longitudinal investigation of the hypothesis that, as children mature, they will spend more time looking inward as to the specific reasons for events, especially negative ones, and this internal introspection, or rumination, will then be related to negative mood states. specifically, the primary goal of this study is to explore whether the sex differences that occur in rumination style are already apparent in fifth grade children and whether such tendencies are related to increased negative affect in females. additionally, this study will evaluate the hypothesis that fifth grade children who view negative traits as more stable will be more likely to show negative mood states than older children who do not will. it is also predicted that those children who see traits as stable and who also have a tendency to ruminate over sad feelings will be the most likely to show negative affect. the theory of “learned helplessness” can be used to support the findings of increased depression levels in teenage girls. evidence suggests that female socialization is more likely than male socialization to lead to a feeling of learned helplessness, because females are taught helplessness and dependence rather than self-reliance and selfassertion (lips, 1997). therefore, females do not learn that they have the ability to control their environments. according to radloff (1980), males are more strongly socialized to believe that their responses to a situation make a difference in the outcome. further, the study will explore the relationship between the subject’s beliefs about stability of traits and their attribution style. studies by nolen–hoeksema (1990) and seligman (1995) have found that children who have a stable global attribution style are more susceptible to negative moods. it is hypothesized that a stable global attribution style is likely to be correlated with the child's belief about stability of traits. that is, those children who are more 25 dancho likely to see traits as unchangeable will be more likely to make stable attributions about events and children who view traits as more changeable will be more likely to make unstable attributions about events. in summary, this study seeks to explore the possible relationship between beliefs about stability of traits, children's attribution style, and negative mood states. it also hopes to examine the degree to which children in this age group engage in ruminative behavior when sad and if there is a significant sex difference in rumination within this age group. this study will help contribute to our understanding of the role cognitive factors might play in the increased incidence of depressive disorders in older children as compared to younger age groups. method participants thirty-one children in the fifth grade, ages 10 and 11, participated in this study. included in the study were 13 males (mean age 10.61) and 18 females (mean age 10.27). the children were recruited from an elementary school in southwestern connecticut and were predominantly caucasian. procedure consent forms were obtained from each participant’s parent. each participant was given eight different stories in random order. the protagonist in each story was the same gender as the participant. the participants were told that the main character in each story had the trait when they were both five and ten years old. the character was then described at 21 years of age and the participant was asked if the trait has changed and were asked the reasons for their responses. children were then asked to fill out the cesdc, the children’s attributional style questionnaire, and the rumination questionnaire. each child was interviewed individually by the data collector in a quiet room and the interviews lasted approximately 20 minutes. measures demographics. participant’s grade level, date of birth, and ages were collected. stability of traits. each child was presented with the stability of traits index (lockhart, 1995). this index consists of eight short stories about boys or girls who would like to change the following traits that they possess: being a slow learner, being clumsy, being unusually short, being very mean, being shy, being ugly, being overweight, and being overly aggressive. in each story, the negative trait was present when the main character was both five and 10 years old. the character was then described at 21 years of age and the child was asked to surmise whether or not the trait had changed. in each story the participants were told that the character had never had an operation and that they did not take medicine on a regular basis. these last statements were meant to rule out the possibility of changes being attributed to external interventions. on the traits questionnaire, responses were given a score of one, two, or three. a score of one was given to participants who said that the trait would not change, a score of two was given to participants who thought an average change would occur, and a score of three was recorded for responses that predicted an extreme positive change. the responses for each question were then totaled to give the participants their overall score. the range of possible scores was eight to 24 and higher scores indicated lower levels of the construct. the traits questionnaire had a moderate internal consistency (α = .67) for this sample. rumination. next, the participants were given a rumination questionnaire which included 26 likert style, forced choice questions. the rumination questionnaire was developed for this pilot study to explore the participant’s introspection style and included questions such as “when i’m sad, i like to listen to sad music.” for the rumination questionnaire, responses were given a likert scaling of one to five, with a one representing never ruminating and a five representing always ruminating. the positive questions were reverse scored and the responses were then totaled to give the participant their overall score. the range of possible scores was 26 to 130 and higher scores indicated a higher level of the construct. the rumination questionnaire had a high internal consistency (α = .73) for this sample. attributional style. also, the participants were given a subset of the children's attributional style questionnaire—revised (casq-r; seligman et al., 1984) which was used to assess optimistic and pessimistic explanatory style. the casq-r consists of 24 items with six subscales providing internal, stable, and global attribution scores for both positive and negative events. each item consists of a hypothetical event for which participants are required to choose the most likely explanation from two alternatives. a composite positive event score is calculated by adding the internal, stable, and global attribution scores for positive events. similarly, a composite negative event score is calculated by adding the internal, stable, and global attribution scores for negative events. the overall composite score used in the present study was calculated by subtracting the composite negative event score from the composite positive event score, with lower scores indicating a more depressive attributional style. the psychometric properties of the casq-r have been shown to be acceptable, but not strong, with moderate internal consistency (α = .50–.73), and fair test-retest reliability (α = .71–.80). each questionnaire consisted of 18 forced choice questions. on the attribution questionnaire, responses were given a score of zero or one. the questionnaire consisted of 18 questions. nine of the questions were positive attribution style questions and nine were negative attribution style questions. each of the positive and negative scores was totaled and the negative score was subtracted from the posi26 relationship between stability and rumination tive score to give the participant their overall score. the range of possible scores was negative nine to positive nine, with higher scores indicating lower levels of the construct. included as part of the negative score for the attributional questionnaire, the hopelessness score was determined by adding two subsets (pervasive bad events and permanent bad events) of the negative score to get the overall hopelessness score. the range of possible scores was zero to six and higher scores indicated lower levels of the construct. negative affect. finally, each participant was given the center for epidemiological studies–depression child (ces-dc) test created by weissman and orvaschell (1980). the original, 20-item ces-d was validated in a twocommunity survey that included both general and clinical populations. it was found to have high internal consistency (α = .85 in the general population and α = .90 in the patient sample), adequate test-retest reliability (between .45 and .70), and high convergent validity with established selfreport and clinical ratings of depression (radloff, 1977). in addition, both the ces-d and a 20-item youth version (ces-dc; weissman, orvaschell, & padian, 1980) have demonstrated good reliability and construct validity with child and adolescent populations (doerfler, felner, rowlison, raley, & evans, 1988; faulstich, carey, ruggiero, enyart, & gresham, 1986; garrison, jackson, marstellar, mckeown, & addy, 1990; roberts, andrews, lewinsohn, & hops, 1990). for the ces-dc, responses were given a score of zero, one, two, or three. a score of zero was given to participants who expressed not having any depressive symptoms, a score of one was given to those participants who expressed having slight depressive symptoms, a score of two was given to those participants who expressed having some depressive symptoms, and a score of three was given to those participants who expressed having a lot of depressive symptoms. the positive questions were reverse scored. the response scores were then totaled to give the participant their overall score. the range of possible scores was zero to 42 with higher scores indicating higher levels of the construct. results descriptive statistics. the mean age for the sample was 10.42 years. the mean age for the boys sample was 10.62 years and the mean age for the girls sample was 10.28 years. sixteen percent (n = 31) of the participants' scores on the mood scale were above 20, the cut-off for significant negative mood symptoms (seligman, l995). four of the five participants who scored above 20 were females, however, this was not significant (z = 1.11, n.s.). also, there was no significant gender difference for overall scores (t = 0.20, d.f. 29, n.s.). nineteen percent (n = 31) of participants scored below nine on the attributional style questionnaire, exhibiting a pessimistic attributional style. male participants were significantly more likely to be pessimistic than females (t = 2.82, d.f. 29, p. <.001). hopelessness was measured by adding participants' scores on the pervasive bad events and the permanent bad event items. none of the scores fell in the hopeless range. no significant difference was found between genders (t =0.01, d.f. 29, n.s.). three percent (n = 31) of participants scored above 78 on the rumination scale, the cut off for high levels of rumination. overall, participants believed that traits would change in only an average positive direction over time, if at all. 57 percents (n = 31) of participants' responses indicated that negative traits would change in an average direction over time; only 15% (n = 31) of responses indicated a belief that extreme positive change was possible. 28 percents (n = 31) of participants' answers endorsed the belief that negative traits would remain stable over development. no significant gender differences were found in beliefs about changeability of traits (t = -0.23, d.f. 29, n.s.). analysis of variance revealed a significant difference between traits and their perceived stability, (f (2, 31) = 4.01 = p < .001). generally, participants were less likely to believe that traits such as short, fat, and ugly would change over time than traits such as meanness, aggressiveness, and clumsiness. associations with mood. as shown in table 3, rumination scores were found to be significantly related to scores on the mood scale, attributional style scale, and beliefs about stability of traits. when analyzed by gender, a significant correlation was still found between rumination and mood (females, r = .486, d.f. = 29 p<.01; males, r = .839, p<.01). table 1 descriptive statistics for study measures boys girls n = 13 n = 18 m sd m sd depression 11.38 6.13 11.94 8.43 hopelessness1 1.62 .87 1.61 1.14 attribution2 9.38 2.57 11.77 2.16 rumination 65.30 11.20 62.06 8.92 stability of traits1 14.77 3.11 15.00 2.37 1 higher scores indicate lower levels of the construct. 2 higher scores indicate lower pessimism. 27 dancho table 2 score and standard deviation for perceived stability of specific traits. n=31 trait m sd short 1.51 .57 aggressive 2.25 .56 fat 1.74 .63 ugly 1.74 .63 clumsy 2.03 .71 slow 1.80 .70 shy 1.94 .68 mean 2.00 .52 table 3 correlations between participants' scores on the various measures mood attributional hopelessness rumination mood attributional -.12 hopelessness -.26 -.20 rumination .59** -.44* -.09 stability of traits -.04 .10 .13 -.43* * correlation is significant at the .05 level (2 – tailed) ** correlation is significant at the .001 level (2 – tailed) n = 31 discussion the findings from this study suggest that gender differences in negative affect may not be present as early as the fifth grade. overall, no significant difference was found between the scores of boys and girls on the mood scale at this age. this finding is consistent with other studies that have also found no significant gender differences in depression among pre-adolescents (essau & peterman, l999). sixteen percent of pre-adolescent children in this sample did exhibit significant negative mood symptoms. it is interesting, moreover, that more females than males scored above the cut-off score of twenty (22% vs. 7%). although again this difference was not significant, it might be an indication of emerging gender differences. it would be interesting to follow up this sample of boys and girls in to adolescence to see if significant gender differences do develop. since the mood scale only measures negative affect during the past week, it is not clear how stable the negative mood symptoms are. in this sample, increased negative mood was found to be significantly correlated with ruminative behavior for both males and females. past research by nolen-hoeksema (l990) has found that passive ruminative behavior maintains negative mood. it is possible therefore that those children showing high levels of negative mood and ruminative behavior would be the most vulnerable to developing a depressive disorder. one of the few significant gender differences found in this study was in attributional style: males were more pessimistic overall than females. a similar finding has been reported by seligman (1995). boys and girls did not differ from one another, however, on the hopelessness measure taken from the casq. since this measure looks at attributions made for pervasive and permanent bad events, it seems that the difference between males and females may center on the attributions they make for good events. that is, males may be less optimistic about seeing good events as stable, pervasive, and due to their own actions. one might have expected females to show a more pessimistic attributional style since a pessimistic attributional style has been associated with negative mood states and since females generally are more at risk for depression. further research should investigate whether attributions for negative events are more predictive of depression than attributions for positive events. indeed, pessimistic attributions for the occurrence of positive events might help protect one from being disappointed if they do not occur. the pessimism shown by males for good events might actually be a defense against depressive reactions. as stated earlier, a more pessimistic attributional style has been found to be related to depressive symptoms in children (nolen-hoeksema, et. al., 1991). in this study, a significant relationship was not found between a pessimistic attributional style and negative mood. attributional style was negatively correlated with rumination. that is, those children who ruminated more were more likely to have a pessimistic attributional style. attributional style and rumination might be risk factors for these pre-adolescent children, indicating a predisposition to developing depression following negative life events. no gender differences were found on the rumination measure. based on previous work by nolen-hoeksema it was expected that females would engage in more rumination than the males. results of this study however, seem to be consistent with those found by lockhart and levy (personal communication, l998) who found no gender differences in self reported rumination. lockhart and levy found that although both male and female adults engaged in rumination, females tended to share their concerns with others while men kept their negative thoughts to themselves. in this study also, the boys who ruminated wanted to be left alone with their sadness and expressed the desire to withdraw from family, friends, and social activities. perhaps this could be caused by their concept of what typical, or stereotypical, male behavior should consist of. several males stated that when they are sad they do not want to talk to their friends about their sadness. conceivably, they be28 relationship between stability and rumination lieve that discussing their sadness is a sign of weakness and opens them to criticism from their peers. girls however may be more likely to share their worries with other girls. perhaps this sharing with others, however, gives validity to their worries and concerns and further exacerbates them, worsening their mood state. the participants in this study were less optimistic about changing negative traits than younger children. lockhart et al. (in press) found that young children generally believe that negative traits can change in the extreme positive direction over development. this has been found to be true for both physical and psychological traits. the pre-adolescent children in this study, however, believed that only average change, if any, was possible. as in other studies, certain traits were seen as more malleable than others. interestingly, negative traits relevant to the self image of girls were seen as the most stable, e.g. fat and unattractive, whereas the negative trait of clumsiness or poor athletic ability, a trait of importance to boys' self image, was perceived as very malleable (lockhart et al., in press). pre-adolescent girls' beliefs about the stability of such traits as attractiveness and weight might make them more vulnerable to negative mood states if they possess negative instances of those traits. in the present study, no significant relationship was found between negative mood state and a belief in the stability of traits. again, seeing traits as more stable is probably only a risk factor for depression that comes into play when a person believes they possess negative traits, a belief that may be triggered by negative life events. there was a significant correlation between rumination and belief in stability of traits. that is, those children who spent more time thinking about their problems were more likely to view traits as stable. since belief in the stability of traits is characteristic of adults, this correlation may simply reflect the fact that those people who are more cognitively mature are more likely to worry or ruminate. a study that examines the relationship between these two variables in an adult population would be able to shed further light on this. overall, the rumination scale was the measure most strongly related to negative mood as well as other measures of pessimism (casq and stability of traits). without other comparison groups, it is unclear whether the level of rumination shown by this pre-adolescent group is similar or different from that of other age groups. further research should be conducted with other age groups to better understand developmental differences. similarly, assessments should be taken of subjects across time and with other measures in order to examine the reliability and validity of this scale. future studies with the exception of the rumination scores, most of the scores showed only slight interrelationships. however, the relationship between these measures may become stronger with age and a higher rumination style may lead to later development of a pessimistic style. therefore, further investigation, by conducting a longitudinal study with this same sample of children should be conducted. the study should strive to determine if those who were high in rumination, low in attributional style, and had a belief in the stability of traits were the same individuals that exhibit depressive symptoms later in life. conclusion cognitive changes are factors that may increase an individual’s vulnerability to depression. children who have high rumination, have a pessimistic attributional style, and view traits as stable are more susceptible to negative mood. it is unclear as to the exact age where gender differences emerge. additional studies are necessary in order to develop a deeper insight into developmental differences. historically, children were not considered candidates for depression (whitley, 1996). mostly due to freudian notions about the unconscious, depression had been viewed as a condition that only affected adults. today, childhood depression is widely recognized and health professionals see depression as a serious condition effecting both adolescents and young children (whitley, 1996; lamarine, 1995). one of the factors that make depression so difficult to diagnose in adolescents is the common behavioral changes that are normally associated with the hormonal changes of this period (lamarine, 1995). it has only been in recent years that the medical community has acknowledged childhood depression and viewed it as a condition that requires intervention. it is obvious that the added pressures, stresses, and societal norms placed on today’s adolescents make them much more susceptible to depression than ever before. the financial, emotional, and physical impact of depression represents an enormous burden on humanity. society, as a whole, needs to be educated as to the detrimental effects of depression on adolescents’ health, as well as take steps to develop the means to treat and eventually prevent this debilitating disorder. it is important that we endeavor to understand the causality of all factors. if adults are to notice, and hopefully treat adolescent depression, it is necessary to know which factors contribute to the decline in mental well being in the first place. references allgood-merten, b. & lewinsohn, p., & hops, h. 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(1987). new perspectives on child and adolescent depression. journal of school psychology, 25(4), 411-414. dancho 32 running head: relational and physical aggression graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 relational versus physical aggression: an overview debra henninger fordham university there is much neurological and cognitive research contributing to explanations of physically aggressive behavior. the brain’s activity and functioning are significant in the determination of reasons for this form of aggressive behavior. relational aggression is another form of aggression, however, and most research in this area focuses on the social or peer relationship side of relational aggression. little, if any, research has been done on the neurological contributions to relational aggression. since relational aggression and overt aggression both hold the same intention of inflicting harm on another person, it is reasonable to compare these two forms of aggression and their possible similarities. this review focuses primarily on neurological differences and cognitive deficits. individuals may be at high risk for numerous adjustment difficulties including feelings of rejection, loneliness, depression, and isolation (crick & grotpeter, 1995). a relationally aggressive individual might have difficulties with peer relations, and over time might lose friends, miss out on opportunities, and develop low self-esteem. the lack of a support system and deteriorating feelings of self-worth can easily heighten the risk of depression, anxiety-related issues, or even a personality disorder. much of the research on aggression deals with neurological components as contributing factors (lyvers, m., 2000; pihl, r. o., & peterson, j. b., 1993; raine, a., 2002; seguin, j. r., pihl, r. o., harden, p. w., tremblay, r. e., & boulerice, b., 1995; spoont, m. r., 1992), and mainly focuses on violent behavior or overt aggression. there is much less research regarding another form of aggression called relational aggression. in fact, there is little or no information on neurological components of relational aggression. it is because of this gap in the literature that this paper focuses on relational aggression and it is because both forms of aggression have the same intention – namely, to cause harm that this paper addresses potential similarities between the two. the goal is to compare physical aggression and relational aggression in an attempt to share insight on a neurological and cognitive basis for future research on relational aggression. crick (1996) found that relational aggression is stable over time and is predictive of future social maladjustment. if this behavior is stable over time, the individual is not forming new patterns of behavior, and may be at risk for future behavior problems. it could be that the relationally aggressive individuals are not aware that their behavior is causing any aversive reactions, which would suggest possible cognitive impairments. also, in a sample of girls, crick found negative changes in adjustment as the behavior persisted, meaning that the relationally aggressive individuals became more rejected by peers over time. this confounds the issue because, if social relationships are considered important to an individual, than the individual should notice when the relationships are faltering, and adjust their behaviors accordingly. since relational aggression appears to be stable over time, it is as if these individuals are either not concerned with social relationships, or they lack the cognitive abilities, such as an executive functioning or problem solving ability, to both be aware of the rejection of their peers, and/ or change their behavior patterns. relational aggression relational aggression is an attempt to “harm others through purposeful manipulation or damage to their peer relationships (e.g., using social exclusion as a form of retaliation)” (crick, 1996,). and so, relational aggression deals mainly with social issues and damage related to interpersonal relationships. this form of aggression can be just as destructive to an individual as overt aggression, particularly when one puts a great emphasis on their social interactions and relationships. since the intention is to inflict harm on another, and is purposefully chosen to inflict the most damaging kind of harm, relational aggression is just as serious an issue as overt aggression. clinical and research literature highlights frequent cases of impairments in executive functioning and problem solving ability in physically aggressive individuals. these impairments usually involve the frontal regions of the brain. the following sections address the neurological and cognitive components of physical aggression, and suggestions are made for potential similarities with relational aggression. research suggests that relationally aggressive correspondence concerning this article should be addressed to debra henninger, department of psychology, fordham university, 441 east forham road, bronx, ny 10458. e-mail: debra_henninger@yahoo.com 13 henninger neurological contributions to aggression in general, damage to the frontal lobe of the brain has been shown to result in a disruption of “aspects of autonomy, (such as) self-control, delay of gratification, drive inhibition, and the anticipation of future consequences, as well as selective attention and certain kinds of abstract problem-solving” (lyvers 2000,). research has also shown that limits in one’s problem solving abilities in social situations leads to physically aggressive behavior. a possible explanation for aggressive behavior is that individuals that are violently aggressive tend to use aggressive behavior in adverse conditions because they lack appropriate problem solving abilities (spoont, m. r., 1992). raine (2002) suggests that damage to the prefrontal cortex results in the inability to use reasoning skills adequately and difficulties making appropriate decisions, which contributes to behaviors such as impulsivity, recklessness, and irresponsibility. also, “the prefrontal cortex is part of a neural circuit that plays a central role in fear conditioning and stress responsivity… and individuals who are less autonomically responsive to aversive stimuli… would be less susceptible to socializing punishments, and hence become predisposed to antisocial behavior” (raine, 2002). it is also thought that the prefrontal cortex regulates arousal and since there are deficits in arousal in aggressive individuals, they try to compensate by acting in a stimulation-seeking behavior (e.g. aggression, impulsivity, etc.). all of these findings suggest one’s ability to solve problems and deal with social situations contributes to their behavior. because individuals who exhibit physically aggressive behavior appear to be deficient in these abilities, they behave in an aggressive manner. interestingly, “damage to areas of the prefrontal cortex reduces inhibitions and self-concern, causing an indifference to the consequences to one’s behavior. thus, areas of the prefrontal cortex are thought to modulate social skills” (fishbein, 2000). also, damage to the prefrontal cortex is related to posttraumatic violent behavior (fishbein, 2000) and people with this damage “often exhibit impairments in ability to make rational decisions in personal and social matters, in addition to difficulties in the processing of emotion” (fishbein, 2000). not only are people shown to behave in a more violent manner, but their ability to make decisions is impaired, which suggests they are thinking differently about violence and the repercussions involved and their mental processes are lacking. this is all due to an alteration in the brain, specifically the prefrontal cortex, which indicates there is a distinct cognitive change. furthermore, “impaired executive cognitive functioning (ecf) compromises the ability to interpret social cues during interpersonal interactions, which may lead to misperceptions of threat or hostility in conflict situations. ecf impairment may further undermine the ability to generate alternative socially adaptive behavioral responses and to execute a sequence of responses necessary to avoid aggressive or stressful interactions” (fishbein, 2000). and so, when an individual perceives something or someone as a threat, they are more likely to react violently if they are ecf impaired. these functions are different from a nonviolent person and the differences result in a misinterpretation of intentions being threatening, which leads to violent defensive actions. “particular regions of the prefrontal cortex (e.g. the orbitofrontal region) appear to play a role in forethought, behavioral inhibition, and capacity to learn from experience” (fishbein, 2000). if violent individuals are not able to experience the same levels of forethought and learning from experience than nonviolent individuals, then they are not cognitively processing information the same way a nonviolent person would. furthermore, “there is recent speculation that a poor connection between functions of the prefrontal cortex and structures within the limbic system may be responsible for disinhibited behavior, inability to act on an assessment of costs versus benefits, and poor emotional regulation” (fishbein, 2000). these are biological differences in individuals that affect cognition which indicate not only a better understanding of why they behave the way they do, but an idea that the root of this behavior lies in the structures of the brain. since relationally aggressive individuals would need higher level social skills to manipulate social situations, it is possible that when they perceive someone as a threat, they do not react with physical violence, but emotional violence. conflict situations are still instigating an aggressive behavior, albeit a non-physical form of aggressive behavior. physically aggressive behavior also appears to be linked to the limbic system in the forebrain, which holds the hypothalamus and amygdala. stimulation of the hypothalamus or amygdala has been shown to lead to aggressive behavior (clemente, c. d. & chase, m. h., 1973). zagrodzka, hedberg, mann, and morrison (1998) emphasized the role of the amygdala with aggressive behavior by looking at cats with and without lesions in their amygdala. the cats were observed both while awake and during rapid eye movement (rem) sleep. in either state, the cats did not display any aggressive behavior, but when the cats were exposed to aggression provoking situations, the cats with amygdalic lesions did not act aggressively. also, the cats with lesions did not show normal predatory tendencies when mice were placed in their environment. the results show that the amygdala may play a role in aggressive behavior and dysfunction or deficit in this area leads to a lack of aggressive behavior. glucocorticoid hypofunction or glucocorticoid plasma levels are also associated with physically aggressive behavior. halasz, liposits, kruk, and haller (2002) used c-fos protein immunocytochemistry to study the effects of implanting low-release glucocortoid pellets into rats. when the rats were exposed to an intruder, the level of c-fos activation was induced in the brain areas related to aggression, 14 relational and physical aggression including the amygdala and hypothalamus. when glucocortoid hypofunction was induced, there was an increase in attacks, especially to vulnerable parts of the intruder, and there was a dramatic increase in the activation of brain centers involved with stress response such as the hypothalamus and fear reactions such as theamygdala. thus, glucocortoid hypofunction is related to stress sensitivity and fear and leads to physically aggressive behavior. further examination of the amygdala’s role in aggressive behavior leads to consideration of the neurotransmitter serotonin. serotonin is regulated through the work of the forebrain, an area important in executive functioning. this suggests that serotonin levels influence a threshold function in information processing and behavioral reactions. therefore, physically aggressive behavior may be linked to limits in problem solving abilities in social situations because of the influence of serotonin’s regulation from the forebrain. serotonin regulates chemical processes in the brain, such as response to pain, body rhythms, and sexual behavior. reduced serotonin levels are associated with heightened aggression, and higher levels of serotonin are associated with reduced aggression in animals (higley 1992; popova 1991). in humans, “reduced brain serotonin function is associated with heightened vulnerability to depression, increased risk of violent suicide, propensity to exhibit aggressive or impulsive behavior, and susceptibility to alcohol abuse both among persons with psychiatric disorders and among the general public” (phil, r. o. & peterson, j. b., 1993). brain imaging has shown violent offenders have functional deficits in anterior regions of the brain, particularly in the frontal region. (raine, 2002). explanations for the deficits include reduced glucose in the frontal cortex, reduced frontal regional cerebral blood flow, and lower prefrontal concentrations of n-acetyl asparate and creatine phosphocreatine (raine,2002). interestingly, individuals who have received damage to the prefrontal region of the brain “proceed to acquire an antisocial, psychopathic-like personality. these patients also show autonomic arousal and attention deficits to socially meaningful events” (raine, 2002). in general, the structures of the brain most often associated with physical aggression are in the frontal regions. these structures appear to be related to self-control, problem solving behavior, inhibition, and aggression. if the same issues of executive functioning and problem solving ability apply with regards to relationally aggressive individuals, the same regions of the brain would be important focal points of future research. cognitive contributions to aggression impairment in executive functioning is related to physically aggressive behavior. a study by seguin, pihl, harden, trembley, and boulerice (1995) investigated the relationship between cognitive deficits and physical aggression. they looked at four factors: verbal learning, incidental spatial learning, tactile-lateral ability, and executive functions. the results showed that the aggressive boys had difficulties in executive functions, but not the other factors. executive functions were defined as: “capacities for the initiation and maintenance of efficient attainment of goals. they are typically derived from tests that assess primarily programming and planning of goal-oriented motor behavior skills, modulation of behavior in light of expected future consequences, anticipation of events in the regulation of behavior, learning of contingency rules and the ability to use feedback cues, inhibition of response set and flexibility (vs. perseveration), abstract reasoning, problem solving, sustained attention, and concentration” (seguin, et al., 1995). this explanation of executive functioning encompasses a wide range of abilities, and relational aggression can be attributed to the same abilities. as discussed previously, relationally aggressive individuals did not change their behavior over time even when rejected by peers. this relates to an apparent deficit in executive functioning in that behavior is not altered or modified in the apperent absence or ineffectiveness of feedback cues. problem solving ability is associated with physically aggressive behavior. a longitudinal study by seguin, phil, harden, tremblay, & boulerice (1995) found that cognitive executive functions were poor on performance among physically aggressive males. in the words of seguin et al: “poor performance on several verbal abilities, such as reasoning, planning, and problem solving in the verbal modality (which are associated with antisocial behavior), theoretically rely as much on executive abilities as nonverbal executive tests… the executive functions tests used in the present study required active formation of representations in working memory that needed to be temporarily stored, accessible, and free of interference as they were continually monitored and scanned according to goals and rules” (seguin et al., 1995). if an individual has difficulty using these cognitive functions, they are more likely to exhibit physically aggressive behavior. this suggests “an association between history of aggressive behavior and impairment in executive functions most probably reflects an inability to organize several parameters simultaneously, uncover complex rules, anticipate consequences of choices and actions, and reflect abstractly (verbally or otherwise) in order to solve interpersonal and social problems. the capacity to reflect in impaired individuals may quickly be overwhelmed or their abilities poorly activated when they are in a motivational situation that calls for a more adaptive social response” (seguin et al., 1995). therefore, the tendency to exhibit aggressive behavior may be a result of a lack of ability to use cognitive processes such as working memory or reasoning skills. the executive functions may be hard to access or use because of 15 henninger hitting or punching anyone (obviously explicit signs of harmful agression), the aggressor and others might not perceive the behavior as being problematic. obstructions of these functions or they may be overloaded easily. the working memory of these individuals may not be as large or smooth as non-aggressive people, which would make it harder for them to organize their thinking and formulate and understand the best action to take. in support of this point, a study by shahinfar, kupersmidt, & matza (2001) focused on social-cognitive and social information processing. individuals that were victims of severe violence had significant levels of the measures of social information processing, including approval of aggression, hostile attributional bias, and social goals; witnesses to violence were more likely to perceive a positive outcome from violence (shahinfar et al., 2001). a possible explanation is relational aggressive individuals may also have difficulty with problem solving abilities because of their inability to resolve a conflict in a non-aggressive way (i.e. talking about a problem and proactively expressing their feelings or dismissing the conflict). their ability to use reasoning skills might also be lacking due to a personal conflict that may or may not actually exist. sometimes the relational aggressors simply perceive conflict when it is not actually there. “that having been a victim of violence enhances children’s perceptions of threat in the world, which affects appraisal of the social environment and the interpretation of the behavior of others. having been a victim of severe violence may also accentuate the need for revenge and dominance of others as a response to one’s own experience” (shafinfar et al., 2001). in a different light, problem solving skills and information processing might alter the way an individual views behavior. a study by slaby and guerra (1988) selected adolescents that were incarcerated in a maximum-security facility for having committed at least one violent criminal act and compared them with public high school adolescents. it was found that individuals with high levels of aggression also had low levels of problem solving skills and they generally felt that aggressiveness was a positive way to behave. this is thought to be somewhat related to information processing, although, the exposure to violence, whether it is as a victim or as a witness, appears to result in a particular form of cognitive thinking about violence in general. this relates to the phenomenon of thinking that the world and other people are a threat, which was previously suggested to result from a biological difference in the brain, whereas shanfinfar et al suggests this results from experience. and so, exposure to violence actually appears to change the way individuals think about violence. “it is unclear whether this hostile bias represents a deficit in processing information whereby aggressive children merely assume that others’ intentions would be similar to their own, presumably hostile, intentions, or whether this hostile bias reflects a more general set of “paranoid” beliefs about others’ motivations that might affect processing and interpretations of cues” (slaby & guerra, 1988). this mechanism may be the same for relationally aggression individuals. if an individual is a victim of relational aggression, that individual might exhibit relationally aggressive behavior for revenge or because they might simply see the aggression as a way to get what they want. this relates to cognition and how the aggressive individual is thinking and understanding information. there is a difference in the way these individuals are processing information and it results in aggressive behavior. slaby and guerra illustrate how an individual “generates consequences”. slaby and guerra explain that “an individual must generate or draw from an existing repertoire of available responses. if he or she holds the belief, for instance, that heightened self-esteem is a consequence of aggression, this response might be available for consideration during the responseevaluation step of information processing. however, this particular belief might also directly lead the individual to seek out opportunities to aggress” (slaby & guerra, 1988). it is possible that aggressive individuals have a limited cognitive pool of responses and if those responses are all related to aggression, then they are bound to behave in an aggressive manner and furthermore, find situations to engage in such behavior. intelligence is also linked to violent behavior. a study by sigurdsson, gudjonsson, & peersen (2001), administered psychological tests to young juvenile offenders who had plead guilty to a criminal offense and then were given a conditional discharge. sigurdsson et al found that “as far as cognitive abilities were concerned the desisters (temporary or situational offending) scored significantly higher than the re-offenders (stable and persistent offenders) on the standard progressive matrices and had better verbal memory recall on the gss 1”. the standard progressive matrices specifically measured intellectual ability, but does not translate to i.q. scores. the individuals who continually committed violent offences had lower intelligence scores than the individuals who committed violent offences on a temporary or situational basis. this suggests that cognition affects whether or not an individual will act in a violent manner. the results also suggest that low intellectual capacity may result in an inability to understand repercussions, socially acceptable behavior, or that these individuals are simply thinking on a different level that non-violent individuals. relationally aggressive individuals might not realize their behavior is “wrong.” a contrubiting factor of this may be that authority figures tend not to recognize relationally aggressive behavior or punish individuals for it (simmons, 2002). it may be that because the individual is not 16 relational and physical aggression conclusion relational aggression and physical aggression are similar in that they both hold the same intention of inflicting harm on another person. research on relational aggression mainly focuses on the social or peer relationship component of relational aggression. little, if any, research has been done on the neurological contributions to relational aggression, which leaves this report to speculate on the similarities between neurological aspects involved with overt aggression and relational aggression. it is possible that individuals who exhibit relationally aggressive behaviors have neurologically related deficits and/ or cognitive differences that contribute to this behavior. there are numerous contributions from the neuroscience literature explaining aggressive behavior from a biological perspective. the brain and its activity and functioning are predominantly significant in the determination of reasons for aggressive behavior. an underlying theme suggests the behavior is a result from limits in interpreting social situations adequately and lacking appropriate problem solving abilities. since relationally aggressive behavior is stable over time and predictive of future social maladjustment (crick, 1996), impairments in executive functioning and problem solving skills are possible. considering the social nature of relational aggression, these individuals probably have some of the same differences in brain activity and functioning as physically aggressive individuals. future research should focus on neurological and cognitive components of relationally aggressive behavior. due to the breadth of information regarding these issues in physically aggressive individuals, and the underlying intention of harm that both forms of aggression share, components related to physical aggression should be considered as a starting point to further understand relational aggression. references clemente, c. d., & chase, m. h. 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(2002). annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. journal of child psychology and psychiatry and allied disciplines, 43 (4), pp. 417-434. seguin, j. r., pihl, r. o., harden, p. w., tremblay, r. e., & boulerice, b. (1995). cognitive and neuropsychological characteristics of physically aggressive boys. journal of abnormal psychology, 104 (4), pp. 614-624. shahinfar, a., kupersmidt, j. b., & matza, l. s. (2001). the relation between exposure to violence and social information processing among incarcerated adolescents. journal of abnormal psychology, 110(1), 136-141. sigurdsson, j. f., gudjonsson, g. h., & peersen, m. (2001). implications for human psychopathology. psychological review, 112 differences in the cognitive ability and personality of desisters and re-offenders: a prospective study among young offenders. psychology crime & law, 7, 3343. simmons, r. (2002). odd girl out: the hidden culture of aggression in girls. new york, harcourt, inc. slaby, r. g., & guerra, n. g. (1988). cognitive mediators of aggression in adolescent offenders. developmental psychology, 24(4), 580-588. spoont, m. r. (1992). modulatory role of serotonin in neural information processing: (2), pp. 330-350. zagrodzka, j., hedberg, c. e., mann, g. l., & morrison, a. r. (1998). contrasting expressions of aggressive behavior released by lesions of the central nucleus of the amygdala during wakefulness and rapid eye movement sleep without atonia in cats. behavioral neuroscience, 112 (3), pp. 589-602. 17 29 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 child and adolescent depression: should antidepressants be used in treatment? erica saypol teachers college, columbia university this paper examines the controversy over the use of selective serotonin-reuptake inhibitors (ssris) in the treatment of children and adolescents. arguments for and against the use of ssris with pediatric populations are evaluated. supporting ssri treatment are findings that ssris are effective, the potential accessibility of medication, and findings that ssris have played a role in the overall decline in adolescent suicide rates. arguments against the use of ssris among child and adolescent populations include findings of associated increases in suicidality and of potential impulsivity and violence in response to the medication. arguments against treating children and adolescents with ssris also include the complications of side effects, dosage, and duration of treatment, and concerns over an approach limited to the neurobiological level. the role of psychotherapy, both alone and in combination with ssri treatment is discussed. the controversy over the use of antidepressants in the treatment of children and adolescents has received a great deal of media attention following the food and drug administration’s (fda) september 2004 decision to require a “black-box” warning label for the use of these medications with pediatric patients. while such a decision does not contraindicate the treatment of pediatric patients with such medications, the black box represents the most serious type of warning label, cautioning strongly about the risks associated with a medication. in the case of antidepressant use in children and adolescents, the risk involves a potential increase in suicidality (i.e., suicidal ideation and behavior). many of the same arguments for and against the blackbox warning can serve as arguments for and against the use of antidepressant medications in children and adolescents. the goal of this paper is to address the specific question of whether or not a particular class of antidepressant medications, selective serotonin-reuptake inhibitors (ssris), should be used in the treatment of children and adolescents with depression1. research evidence supporting the efficacy correspondence concerning this article should be addressed to erica saypol, box 102, department of counseling and clinical psychology, teachers college, columbia university, 525 west 120th street, new york, ny 10024. 1 the scope of this paper is limited to an examination of the treatment of children and adolescents with ssris and excludes the other major class of antidepressants that has been used in the treatment of this population, including tricyclic antidepressants (tcas). research on the latter suggests that they are no more effective than placebo in the treatment of children and adolescents (carr & boyd, 2003), and that they are associated with danger of overdose (mahler, 2004). of ssris in reducing the symptoms of depression among children and adolescents represents the strongest argument in favor of their use in pediatric treatment. in addition, greater accessibility to these medications (as compared to psychotherapy) among children and adolescents may also support their role in treatment. finally, findings that suggest that ssris are associated with a decrease, rather than an increase, in completed suicides among children and adolescents lend support to their use in reducing actual incidences of suicide among depressed children and adolescents. although the evidence supporting the treatment of children and adolescents with ssris is persuasive, so too are the arguments against the use of this medication with pediatric populations. the most powerful evidence against the use of these medications in the treatment of children and adolescents comes from research demonstrating that the medication is associated with an increase in suicidality (e.g., jureidini et al., 2004; newman, 2004). furthermore, there are findings that ssris may be linked to an increase in agitation, impulsivity, and violence among pediatric patients (e.g., glass, 2004). those who argue against the use of ssris in children also point out that the findings supporting their efficacy are quite small in magnitude as compared to the increased risks of suicidality. pharmacological treatment of depression in general also brings concerns over side effects, questions of dosage and length of treatment, and treatment decisions for relapses, which are of heightened concern in the treatment of growing and developing children. another argument against the treatment of children and adolescents with ssris lies in the limitations of approaching a psychological disorder solely on the neurobiological level. in other words, even if ssris are highly effective, pharmacological treatment of depression fails to address the feelings of depression on a psychological level and to foster the development of coping mechanisms. such erica saypol 30 mechanisms can play a critical role as patients wait for medication to become effective, as they face future major depressive episodes, and as they grapple with the vicissitudes of life. this limitation of pharmacological treatment will be discussed and evaluated along with recent evidence supporting the efficacy of psychotherapy among child and adolescent patients. evidence supporting the treatment of children and adolescents with ssris efficacy a number of recent studies offer support for the effectiveness of ssri medications in the treatment of child and adolescent depression (e.g., wagner et al., 2003; treatment for adolescents with depression study (tads) team, 2004). although small when compared to the number of studies of antidepressant treatment among adult patients, the recent research findings offer persuasive evidence of the efficacy of ssris among child and adolescent patients. wagner et al. (2003) demonstrated that depressed children and adolescents treated with sertraline (zoloft) showed significantly greater improvement than did those treated with a placebo. specifically, wagner et al.’s research involved two identically designed studies conducted at multiple hospital, practice, and academic settings in the us, india, canada, costa rica, and mexico. participants included 376 children and adolescents between the ages of 6 and 17, who were randomly assigned to the double-blind sertraline or placebo treatment conditions. prior to treatment, participants’ diagnoses of major depressive disorder were confirmed and their symptoms were evaluated using the children’s depression rating scale-revised (cdrs-r) and the clinical global impression of severity of illness (cgi-s). participants received medication for a period of 10 weeks, with some adjustments permitted to attain effective dosages. the cdrs-r and cgi-s assessments were given multiple times throughout the duration of the study to evaluate responses to the medication. significantly higher levels of improvement were found among patients treated with sertraline on both measures. on the cdrs-r, the sertraline group experienced a decrease in mean depression scores from week one to week ten of 22.84 points, whereas the placebo group experienced a mean score decrease of 20.19 points. on the cgi-s, the mean score decreases were 1.22 in the sertraline condition and 1.01 in the placebo condition. the findings of wagner et al.’s (2003) studies reveal a significant improvement among pediatric patients treated with sertraline as well as a large placebo effect. studies of antidepressant treatment of adults and the small group of other studies of children and adolescents also reveal similar, sizeable placebo effects. yet, the significant findings should not be discredited for a number of reasons. first, it is possible that in a number of ways, psychotherapy may also have played a role in the improvement of patients in both conditions. specifically, though not permitted to be treated with cognitive-behavioral therapy (cbt), participants were allowed to continue other types of psychotherapy in which they had been engaged prior to joining the study. in fact, 8 placebo condition participants were in psychotherapy during the study and 29 had been in psychotherapy prior to the study; for both groups, wagner et al. suggested that the benefits of extra-study psychotherapy may have been responsible for improvement in symptoms. additionally, wagner et al. pointed out that for all participants, because of the frequency of sessions for medication adjustment, monitoring, and symptom assessment (almost weekly throughout the study), an informal therapeutic interaction may have taken place between participants and investigators. varley (2003) posits that “these findings suggest that children may be more responsive than adults to nonspecific measures of support that are included in the placebo response, particularly because children and adolescents are in a more dependent and reactive developmental state” (p. 1092). it is important to recognize that a small significant effect of sertraline was found above and beyond these potentially psychotherapeutic effects. a second reason wagner et al. (2003) offer for the large placebo effect is the high level of variability within conditions; participants were treated in different types of treatment centers, by different investigators, in different countries, and within different cultural contexts. a third reason for the high placebo effect, which the researchers did not mention, is that patients may have been moving out of the depths of depression over time. a condition for participation was that criteria for a major depressive episode must have been present for at least 6 weeks prior to joining the study. the 6-week presentation of symptoms was followed by a 2-week screening period before the 10-week trials took place. in general, major depressive episodes can last 4 months or longer, if left untreated (dsm-iv-tr). this, combined with the fact that the length of the episode included a minimum of 18 weeks (and possibly longer, since 6 weeks of pre-participation symptoms was the minimum requirement), makes it seem possible that some participants may have begun improving naturally. despite the large placebo effect, the improvement of children and adolescents in the sertraline treatment condition was significant and supports the use of at least one ssri in the treatment of child and adolescent patients. studies of other ssris offer additional evidence of their efficacy in treating child and adolescent patients, but they also point out the need to assess these medications individually. although clustered together because of their known role in inhibiting the reuptake of serotonin, each medication appears to operate on a distinct pathway, as revealed in its effects on multiple neurotransmitters, side effects, and the differential responsiveness of patients. in addition to the above findings on the efficacy of sertraline, a recent major study by the treatment for adolescents with depression study (tads) team (2004) supports the use of child and adolescent depression and antidepressants 31 fluoxetine (prozac). this study (which will be discussed subsequently in more detail in the context of psychotherapy) revealed that fluoxetine was superior to both placebo and cbt alone, but that the best outcome (and the only statistically significant finding) involved the combination of fluoxetine and cbt. by contrast, several unpublished studies recently suggested that another ssri, paroxetine (paxil), was not significantly more effective than a placebo, and that the medication (now contraindicated for use with pediatric patients) may pose particular risk of suicidality (wooltorton, 2003; mathews & windham, 2004). although the body of research on ssri treatment of depression in children and adolescents is quite small, there are several important findings and implications. first, some studies have demonstrated significant levels of improvement among pediatric patients with depression (e.g., wagner et al., 2003). second, even in purely psychopharmacological studies, frequent interactions with a clinician may have psychotherapeutic benefits for adolescent and child patients (wagner et al., 2003); this finding commands greater research attention to psychotherapeutic treatment of depression among children and adolescents. furthermore, although large placebo effects and the therapeutic overlap were viewed as limitations in wagner et al.’s (2003) study, such limitations may have serendipitously offered greater insight into the nuances of the treatment. third, each ssri operates differently, and rather than drawing general conclusions about the efficacy of the class of drugs in treating pediatric cases of depression, critical evaluations of each individual medication are needed. the need for specific research is embedded within a larger need for more studies on the use of ssri medications with children and adolescents, to permit a better understanding of the efficacy and other benefits, and the risks associated with each of them. accessibility another consideration in this debate focuses on the accessibility of various treatments. pediatric patients are largely dependent on parents or caregivers for treatment approval and decisions, initial insight into their difficulties, and transportation to and from treatment appointments. when it comes to getting treatment for depressed pediatric patients, might parents be more likely to seek treatment involving ssris than psychotherapy? won tesoriero (2004) suggests that many children and adolescents suffering from depression may receive treatment from pediatricians or primary care physicians because such treatment is more readily available and less stigmatized than treatment with a psychiatrist or psychologist. the issue of accessibility appears to be a serious one, given that there are about 7,000 child and adolescent psychiatrists in the u.s. (compared to about 60,000 pediatricians), and that, in the early 1990s, there was a need for 33,000 child and adolescent psychiatrists (won tesoriero, 2004). the problems of accessibility appear to be exacerbated among children in families of low socioeconomic status, children without health insurance, african americans, and very young children (olfson, gameroff, marcus, & waslick, 2003). the possibility that accessibility factors and the stigma associated with having depressed children would lead parents to obtain prescriptions from a pediatrician, rather than transporting their child to numerous psychotherapy sessions, offers some support for the treatment of children and adolescents with medication to assure that they receive some form of help. through a collection of health-service use data, olfson et al. (2003) found that whereas more depressed children and adolescents received psychotherapy than antidepressant medication (about 75% and 60% of those treated, respectively), the number of psychotherapy visits attended was found to be quite low. while clinical trials suggest 15 to 25 sessions over a period of 6 to 16 weeks, children and adolescents being treated for depression averaged fewer than eight sessions a year, with many undergoing only one or two visits (olfson et al., 2003). thus, the possibility arises of parental disincentives towards psychotherapy, including both the stigma associated with child depression and the logistical difficulties of transporting a child to numerous appointments. however, won tesoriero (2004) points out that following the black-box warning given to antidepressants this past september, parents are finding that many pediatricians and primary care physicians are no longer willing to prescribe medications. thus, parents are finding it increasingly difficult to find one of an already small number of child and adolescent psychiatrists to prescribe the medication. although there may have been (and may still be) some advantages of treatment with ssris, there appears to be an important role for qualitative research to achieve an indepth understanding of the factors that influence the parents and caretakers of children and adolescents with depression. such research could lead to an understanding of their plight that goes beyond speculation and could guide practitioners and researchers in the development of and education about effective psychotherapeutic, psychopharmacological, or combined treatments. decrease in child and adolescent suicide in addition to the efficacy and accessibility of ssris, further support for the use of ssris in the treatment of children and adolescents with depression involves a potential association between treatments involving these medications and a decrease in suicide rates among adolescents. brent (2004) points out that after a long history of increasing rapidly, suicide rates among adolescents have been falling for the past 10 years. although a large part of the decrease can be accounted for by stricter gun control, brent suggests that corresponding improvements in the detection erica saypol 32 and treatment of depression and the use of ssris may have played a role. brent cautions that there is a relationship between suicidality and completed suicide and that the possibility of ssris causing increased suicidality presents an important risk. yet, he argues, such a risk suggests the need to carefully monitor adolescent patients being treated with ssris, rather than to avoid a form of treatment that appears to be effective in reducing depression and that may support an overall decrease in adolescent suicide rates. difficulty in evaluating the link between ssris and suicidality lies in understanding what the data can actually mean in practice. according to the former head of the fda division that examines psychiatric medications, “you don’t know whether the phenomena you’re looking at are good surrogates for actual suicide” (mathews & windham, 2004, d3). in particular, the confusion arises from research findings of an increase in suicidal ideation and attempts, but no incidences of completed suicide associated with treatment with ssris. the instances of completed suicide are revealed, not in research studies, but in individual case studies, often provided by parents who speculate after a child’s death that the ssri played a role. both brent’s (2004) reminder of the relationship between suicidality and completed suicide and features of the design of recent studies demand that the risk of completed suicide be further assessed. in particular, ethical limitations of research prohibit the inclusion of adolescents at the highest suicide risk as subjects in the research (glass, 2004). for example, in wagner et al.’s (2003) studies of children and adolescents treated with sertraline, “[p]atients who had previously attempted suicide or who were judged to pose a significant suicidal or homicidal risk” were excluded from participating in the study (p. 1034). the exclusion of such participants could lead to an underestimation of the suicidality risks associated with ssri treatment. the empirical data supporting the ssri-associated increase in suicidality and a case study involving a suicide following the initiation of ssri treatment will be presented below in a discussion of evidence against the use of ssris with children and adolescents. supporters of the use of ssris in children and adolescents portray the suicidality findings as evidence of a small but serious risk associated with the medication, as opposed to the perhaps greater risk of removing the ssri treatment option. specifically, boland and keller (2004, as cited in glass, 2004) state that “although some concerns about potentiating suicidal behavior may remain, these should be balanced over the clear risk of suicide in patients with untreated depression” (boland & keller, 2004, p. 856, as cited in glass, 2004, pp. 861-862). similarly, brent (2004) concludes that an appropriate balance needs to be found “between the risk of suicidality and another, greater risk: the risk that lies in doing nothing” (p. 1601). the key element missing from these statements, which will be discussed below, involves the role of psychotherapy, both alone and in combination with ssri treatment and in specifically addressing the risk of suicidality. evidence against the treatment of children and adolescents with ssris suicidality the most powerful argument against the treatment of depressed children and adolescents with ssris lies in findings that these medications may lead to suicidality among pediatric patients. evidence from both clinical research trials and individual case studies reveals the potential that ssris may produce or exacerbate suicidal thinking and behavior. the seemingly paradoxical finding has been explained by the phenomenon of “rollback” (mahler, 2004). specifically, while in the initial depths of a major depressive episode, a person may have thoughts about wanting to die, but may be unable to elaborate on these thoughts or to act on them given the decreased energy associated with the depression. as the ssri begins to work (but before the person’s mood has reached pre-episodic levels), the person may experience enough of an increase in his or her energy level to think seriously about, or act on, a plan to commit suicide. the case against the use of ssris with pediatric patient populations can be made in part by an examination of some of the same research trials used to demonstrate the efficacy of ssris. for example, jureidini et al. (2004) point out that analysis of the data in wagner et al.’s (2003) study reveals the problematic increase in suicidality associated with sertraline. in particular, 9% of children and adolescents in the sertraline condition (as compared to 3% in the placebo condition), experienced adverse effects serious enough to lead them to withdraw from the study. further analysis of the individual adverse events was not reported, but might be informative in confirming the extent to which they included suicidal ideation or attempts. additionally, jureidini et al. draw attention to wagner et al.’s findings involving adverse events among patients who remained in the study, which included more instances of serious adverse events involving suicidality. among patients in the sertraline condition, two suicide attempts and three instances of suicidal ideation were revealed as compared to two suicide attempts and no instances of suicidal ideation among patients in the placebo condition. the numbers are small and the conclusions unclear, but the possibility that sertraline caused an increase in suicidal ideation among these patients (and among those who withdrew participation) remains. newman (2004) presents an argument supporting the black-box warning for ssri use with pediatric patients. specifically, newman describes findings from an analysis of unpublished studies coordinated by the fda and reviewed by suicide experts at columbia university. these experts blindly evaluated a series of narratives about adverse events that took place during clinical trials and made determinations as to whether or not each should be coded as an instance of suicidality. without knowing whether they were reading narratives involving participants receiving child and adolescent depression and antidepressants 33 antidepressant medication or placebo pills, these raters found over twice as many incidences of suicidality among participants taking antidepressants versus those in placebo groups. however, a main criticism of this analysis was that the studies supplying the original data were not uniformly designed, were not specifically designed to study suicidality, and were not required to be of high quality. for newman, however, this makes the findings all the more convincing, given that the probability of their chance occurrence would be 1 out of 20,000 (p = 0.00005) by his calculation (newman, 2004, p. 1596). newman argues further that such a finding stands in stark contrast to the efficacy data on ssris, in which significant effect sizes are small and sizeable placebo effects are revealed. newman cites the small effect size in the tads (2004) study of fluoxetine, in which the reduction of cdrs-r scores among patients receiving fluoxetine was 22.6 points versus 19.4 points among those receiving a placebo. these findings were similar to those of wagner et al. (2003) (i.e., 22.84 in the sertraline condition and 20.19 in the placebo condition). as in wagner et al.’s study, the tads study left more information to be desired regarding the implications specifically related to suicidality. again, the numbers are small, and drawing conclusions is difficult. looking at the suicide-related events that did occur, no significant differences were revealed between the treatment groups. however, harm-related adverse events, a category broader than suicidality and including “any self-harm or harm to another person or property” revealed a difference: patients taking fluoxetine experienced more harm-related adverse events than did patients not receiving ssris (glass, 2004, p. 862). the research studies, especially those involving experts’ blind ratings of adverse events, suggest a potentially sizeable risk of suicidality associated with the treatment of children and adolescents with ssris. however, the data are limited by questionable research design and by the small number of data points (perhaps in part due to exclusion of high-risk patients from participation). clearly, more research is needed to clarify whether or not the findings of increased suicidality among child and adolescent patients in a few trials can be generalized to the broader population of depressed children and adolescents. further evidence supporting the potential risk of suicidality posed by ssri treatment of pediatric patients comes from the testimonials of relatives of those who have committed suicide following the initiation of ssri treatment. according to newman (2004), numerous individuals offered public testimony about such incidences to the fda committee charged with the black-box label recommendation for these medications. furthermore, newman reports that “several of these cases involved patients who had shown no hint of suicidality before beginning treatment with the drugs” (newman, 2004, p. 1596). the details of the case of matt miller, a 13-year-old boy who committed suicide a week after beginning treatment with sertraline (zoloft), seem to suggest an association between the medication and suicide (mahler, 2004). matt did not appear to be at high risk for suicide; he had indicated on the children’s depression inventory one week earlier that although he thought about killing himself, he would not actually do it. matt’s parents are convinced that the medication led to matt’s suicide. matt may have experienced rollback, getting enough energy back to convert suicidal ideation into a suicide. alternatively, the medication may have induced a broader pattern of impulsivity and violence in the young patient, leading to his suicide (mahler, 2004). impulsivity, violence, and hostility matt miller’s parents reported additional changes in matt’s behavior during the week he began taking sertraline. he became visibly agitated and seemed to have experienced a burst of energy, which he released through activities such as frequent bike riding. searching for answers about his son’s death, matt’s father came across …a phenomenon known as akathisia, or activation, a state of extreme agitation that can be induced by some psychotropic medications and can cause patients to behave in an uncharacteristically violent manner, which seemed to describe perfectly matt’s condition before his suicide. (mahler, 2004, p. 62) matt’s agitated behavior coupled with the violent means by which he chose to commit suicide (i.e., by hanging himself), suggested that beyond rollback, impulsivity and violence may have led to his decision to commit suicide (mahler, 2004). keeping in mind matt’s case, the findings of the tads (2004) take on heightened significance. specifically, the study’s finding of a general increase in the broader category of harm-related adverse effects (glass, 2004) might be consistent with a risk of activation among pediatric patients taking ssris. the possibility that pediatric patients taking ssris might develop a pattern of impulsivity that can manifest itself in suicidality may have neurobiological underpinnings. begley (2004) outlines findings related to the effects of ssris on the brains of children and adolescents. specifically, treatment with ssris stimulates neurogenesis (the growth of new neurons), which may be more problematic to the child’s developing brain than to that of an adult taking the medication. for example, this neurogenesis appears to restore the shrunken hippocampus (a brain region associated with emotion and memory) of the depressed adult’s brain back to its original size (begley, 2004). by contrast, the hippocampus does not show this shrinkage in the brains of depressed children and adolescents and therefore, “some scientists wonder whether the new neurons could destabilize fragile brain circuits in kids suffering from mental illness” (begley, 2004). furthermore, researchers are looking into differences in images of depressed children’s prefrontal cortices (the region responsible for inhibition and impulse control) as compared to that of adults. the prefrontal cortex is still maturing in children and adolescents, and ssri treatment may result in difficulties with impulse control. erica saypol 34 thus, ssri medications may put children and adolescents at particular risk for impulsive and violent behavior, which among depressed children and adolescents seems likely to include suicidal behavior. other limitations of psychopharmacological treatment beyond the potential risks of an increase in suicidality, or a general increase in violence and impulsivity, there are several additional arguments against treating children with ssri medications. first, general considerations of psychopharmacological treatments, such as side effects (ranging from the minor headache to suicidality), determination of dosage, and duration of treatment, require careful riskbenefit analyses for which the limited body of research may fall short of supplying sufficient data. second, ssri or psychopharmacological treatment of child and adolescent depression approaches the disorder only on the neurobiological, rather than the psychological level. as a result, ssri treatment does not offer a child coping mechanisms or support, which may be of critical importance in the face of a recurrence. unfortunately, the likelihood that children or adolescents experiencing major depressive disorder will experience further major depressive episodes is two to four times that of children and adolescents without depression (wagner et al., 2003). assuming a diathesis-stress model of depression, a child or adolescent with depression has some genetic predisposition or vulnerability to develop depression in the face of particular stressors. according to such a model, it would appear that treatment should take into consideration the exposure to the stressors that trigger the depression for a child or adolescent. given their youth and the difficulties associated with adolescent development, it appears that treatment should address both current and potential future episodes. in such a treatment approach, ssris, in the absence of psychotherapeutic interventions that can foster coping skills, seem quite limited. combined treatment of ssris and psychotherapy the recent research on the treatment of depression among adolescents reveals the efficacy of combination treatments including both ssri medication and psychotherapy. in particular, the tads (2004) demonstrated the efficacy of such combined treatments. the study involved 439 patients between 12 and 17 years of age who were randomly assigned to one of four conditions: fluoxetine alone, cbt alone, fluoxetine and cbt, and placebo. the outcome measure involved a reduction in symptoms of depression as measured by the change in cdrs-r scores over a 12-week treatment period. the most improvement came from the combination of fluoxetine and cbt, followed by the fluoxetine-alone group, then the cbt-alone group, and then the placebo. the only effect that obtained significance was the combined treatment over the placebo. the value of psychotherapeutic treatment revealed by tads (2004) went beyond the finding of the combined efficacy of cbt and fluoxetine. a more subtle effect was revealed in terms of the potential role of psychotherapy in reducing the risks of suicidality and generally impulsive and dangerous behaviors among adolescents treated with ssris. in particular, as compared to the fluoxetine plus cbt treatment group, the fluoxetine-alone group experienced more harm-related adverse events, including any selfharm or harm to the person or property of another (glass, 2004). according to glass, the tads findings suggest the possibility of a protective effect of psychotherapy. such a protective effect is a particularly important finding given concerns about the potential for ssri treatment to induce suicidality and general impulsivity. again, the numbers are small and thus, definitive conclusions are difficult to draw from this early research, including conclusions about whether findings about psychotherapy with adolescents generalize to the treatment of younger children. there appears to be a great need for future research clarifying whether or not there is indeed a causal association between ssri treatment and suicidality and impulsive behavior. there is also a need for research on the potential benefits of the development of coping skills, support, and protection against suicidality offered by different forms of psychotherapy for depressed children and adolescents. discussion there are no straightforward answers in the literature to the question of whether or not depressed child and adolescent patients should be treated with ssri medications. supporting such treatments are findings that ssris are effective in reducing or eliminating depression, potential issues of accessibility of medication over psychotherapy to children, and findings that ssris have played a role in the overall decline in adolescent suicide rates. arguments against the use of ssris among child and adolescent populations come primarily from research and case study findings of associated increases in suicidality and findings of potential impulsivity, violence, or agitation in response to the medication. furthermore, arguments against treating children and adolescents with ssris include the complication of an array of side effects of varying severity, issues of dosage and duration of treatment, and concerns over an approach limited to the neurobiological level, which provides no room for the development of coping skills or support. the controversy over the use of antidepressant medications has been heightened by ethical concerns regarding unpublished data. of particular concern was the discovery of internal documentation at a drug company instructing the withholding of data demonstrating that a particular ssri, paroxetine (paxil), was ineffective in the treatment of adolescents (kondro & sibbald, 2004). furthermore, by conducting a meta-analysis of published and unpublished data on the use of ssris with children, whittington et al. (2004) child and adolescent depression and antidepressants 35 found that, with the exception of fluoxetine (prozac), the inclusion of unpublished data altered the overall findings such that the risks outweighed the benefits of treatment with several medications. considering the overall limitations of small effect sizes in this growing area of research, and the potential suicidality risk, the disclosure of all findings appears critical. another interesting, recent development in the debate came in a recent revision to the fda’s warning about these medications (polk, 2005). specifically, in early february, 2005, the fda removed a statement establishing a causal link between these medications and increased suicidality from its website and replaced it with a statement that reported an increase in suicidality found in short-term studies of these medications with children and adolescents. the replacement sentence was also placed in boldface in the black box warning on the medication insert, with the original (causal) sentence moved into a later section of the text that discusses suicide risk in more detail. such a change in language serves to qualify the original fda warning, and to point out that further research is needed to assess the true safety of the medication for children and adolescents. at this time, the research data from studies of children and adolescents are few and there is a great need for further study to better understand child and adolescent depression, and to understand the relationship between the medication and possible outcomes of suicidality and impulsive or violent behavior. the case studies provided by the parents of children who have committed suicide during ssri treatment demand a more in-depth, research-based evaluation of the treatment of children and adolescents with these medications. the question of whether or not ssris should be used in the treatment of children also sheds light into the range of opinions of clinicians based both on experience and training. as a graduate student in clinical psychology, i have attempted to address the topic of the controversy surrounding the treatment of children and adolescents with ssris. in contrast, in his review of tads (2004), which provided support for the role of psychotherapy in the treatment of depressed adolescents, glass (2004) suggests that an “area of lingering controversy is the role of psychotherapy in the treatment of psychiatric disorders, including major depression” (p. 863). the depiction of child and adolescent depression as either a psychiatric or a psychological disorder, with different points of view and treatment implications of each, should not pose a threat to finding the most effective help for depressed children and adolescents. if anything, the early studies appear to suggest that the combination of psychotherapeutic and psychopharmacologic treatment may offer the most hope to patients. wilens, spencer, frazier, and biederman (1998) offer a six-step framework for evaluating the treatment of children and adolescents with psychotropic medication. first, psychotropics should only be prescribed following a thorough diagnostic evaluation. second, when used, pharmacotherapy should be integrated with other forms of treatment, such as psychotherapy, rather than suggested as an alternative form of treatment. third, the severity and type of symptoms and the age of the child should be considered. fourth, both the family and the child should be educated about treatment alternatives and the risks and benefits associated with the medication. fifth, the child or adolescents’ dosage should be kept as low as possible and treatment should be tapered if not effective and reevaluated after the child or adolescent has improved. sixth, multiple practitioners (e.g., psychologists and psychiatrists or pediatricians) should work collaboratively in managing the psychopharmacologic treatment. such a framework should guide the treatment of children and adolescents with ssris. for now, a primary goal should be collaborative, interdisciplinary research to assess the true safety and efficacy of ssris in pediatric patients and to identify effective forms of psychotherapy. until more research has clarified the safety of ssri mediation for use with children and adolescents, they should continue to be prescribed only in severe cases of depression and after the parents, child, and clinician have learned about, understood, and considered other alternatives. ideally, such medication would be prescribed and patients closely monitored by psychiatrists with specialization in the treatment of children and adolescents. however, as won tesoriero (2004) pointed out, there are simply too few of such professionals (with some 7,000 child and adolescent psychiatrists in the u.s. currently, versus an estimated need in 1990 for 33,000 such professionals). won tesoriero suggests that this shortage is associated with the limited federal funding for hospitals to offer the training this specialty requires. because of the heightened concerns over the safety of antidepressant treatment of children and adolescents, it seems critical to address this shortage of child and adolescent psychiatrists. perhaps this could be addressed by increasing the opportunities for psychiatrists to specialize, by offering training to the pediatricians who prescribe the medication, or by increasing collaboration between child and adolescent psychologists and those writing the prescriptions in an attempt to improve diagnosis, treatment plans, and monitoring of young patients. furthermore, when treating children and adolescents with ssris, concurrent psychotherapy should be strongly encouraged for several reasons. first, psychotherapy becomes critical to monitor risks related to suicidality and impulsivity. second, psychotherapy can offer depressed children and adolescents support as they wait for the inhibition of enough serotonin-reuptake to occur and an improvement in mood to result. the support and development of coping skills offered by psychotherapy can be equally important throughout psychopharmacological treatment, during the tapering and removal of medication, and in the future as children and adolescents face other major depressive episodes and cope with everyday life stressors. for proponents of ssri use in children who are exclusively focused on examining depression and treatment on the neurobiological level, the potential role of psychotherapy in treatment remains a powerful one. studies comparerica saypol 36 ing interpersonal therapy and ssris have demonstrated that psychotherapy produces similar (and possibly longerlasting) brain changes to those produced by ssri treatment (friedman, 2002). finally, the research so far on the treatment of child and adolescent depression reveals the benefits of psychotherapy both directly and indirectly. tads (2004) demonstrated significant improvement among depressed adolescents only from the combination of an ssri and psychotherapy, and a possible protective effect of psychotherapy related to impulsivity and suicidality. wagner et al’s (2003) work revealed the more subtle possibility that even in a study limited to psychopharmacological treatment, the informal, frequent psychotherapeutic interactions between investigators and pediatric patients may have led to substantial improvement. together, such findings offer powerful evidence of the importance of psychotherapy in the treatment of depressed children and adolescents. references american psychiatric association. 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(2003). efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. the journal of the american medical association, 290, 1033-1041. whittington, c. j., kendall, t., fonagy, p., cottrell, d., cotgrove, a., boddington, e. (2004). selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. the lancet, 363, 1341-1345. wilens, t. e., spencer, t. j., frazier, j., & biederman, j. (1998). child and adolescent psychopharmacology. in t. h. ollendick & m. hersen (eds.), handbook of child psychopathology (pp. 603-636). new york: plenum press. wooltorton, e. (2003). paroxetine (paxil, seroxat): increased risk of suicide in pediatric patients. canadian medical association journal, 169, 446. won tesoriero, h. (2004, october 7). new drug problem: getting antidepressants. the wall street journal. retrieved november 18, 2004, from factiva database. graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 mindful parenting, affective attunement, and maternal depression: a call for research jeanette a. sawyer teachers college, columbia university this paper introduces the construct of mindfulness and highlights research findings on the benefits of mindfulness-based clinical interventions. drawing on the theoretical perspective of daniel stern (1985), mindfulness can be understood as a necessary prerequisite for the affective attunement that occurs within the intersubjective relatedness of mother and infant. the negative consequences of maternal depression are discussed, and the notion that maternal depression can prevent a mother from being mindful is suggested. the case is made that research is needed on child outcomes in existing mindfulness-based interventions for adult depression, and that such empirically validated interventions should be modified for specific use with women experiencing antepartum and postpartum depression. furthermore, mindfulness as a potential mechanism of change in dyadic interventions for this population should be examined. this paper also highlights the positive psychology view that interventions can focus on enhancing current strengths and need not focus solely on deficits. “mindful parenting calls us to wake up to the possibilities, the benefits, and the challenges of parenting with new awareness and intentionality, not only as if what we did mattered, but as if our conscious engagement in parenting were virtually the most important thing we could be doing, both for our children and for ourselves.” (kabat-zinn & kabat-zinn, 1997, p. 22). the study of mindfulness-based clinical interventions is an emerging area of interest for both researchers and clinicians (e.g., baer & kreitemeyer, 2006). mindfulness is considered “an enhanced attention to and awareness of current experience or present reality” (brown & ryan, 2003, p. 822) and “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment-by-moment” (kabat-zinn, 2003, p. 145). the state of nonjudgmental observation of an always-changing stream of thoughts has been called “bare attention” or “choice-less awareness” (kabat-zinn, 1982). mindfulness is also defined as “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (nyanaponika thera, 1972, p. 5) and as the experience of “keeping one’s consciousness alive in the present reality” (hahn, 1976, p. 11). it is important to differentiate mindfulness from that which is commonly meant by the notion of self-awareness. although a key aspect of the construct of mindfulness is the capacity for selfawareness, the two terms are not synonymous. generally, self-awareness refers to the acute awareness of internal states and is used to describe a process of correspondence concerning this article should be addressed to jeanette a. sawyer; email: jas2164@columbia.edu. self-examination by which one’s own cognitive operations (i.e., thinking) are focused on aspects of the self. one is, in essence, thinking about or reflecting on one’s own thoughts (see duval & wicklund, 1972; buss, 1980; and carver & scheier, 1981 for variations on the notion of self-awareness as knowledge about the self). in contrast, mindfulness encompasses awareness of both self and other, of both internal and external; mindfulness is more accurately conceptualized as awareness-centered rather than self-centered. brown and ryan’s mindful attention awareness scale (maas; 2003) further elucidates the construct of mindfulness with descriptions of the experience of not being mindful: “i find it difficult to stay focused on what’s happening in the present”; “it seems i am ‘running on automatic’ without much awareness of what i’m doing”; and, “i find myself preoccupied with the future or the past.” mindfulness: a promising intervention interventions that promote mindfulness through the use of mindfulness meditation have been shown to be effective in a variety of clinical domains, and approaches using meditation to treat individuals for a wide range of mental and physical health problems are receiving increasing attention and interest. this includes the use of meditation as an adjunct to more traditional cognitive-behavior therapy (cbt) with difficult to treat patients (linehan, 1993), as a depression relapse prevention strategy (teasdale, segal, & williams, 1995), as a relapse prevention program for alcohol and substance use disorders (witkiewitz, marlatt, & walker, 2005), and as central to a therapeutic program aimed at stress reduction (kabat-zinn et al., 1992). 3 sawyer 4 the most frequently cited mindfulness training approach (baer, 2003), mindfulness-based stress reduction (msbr), was developed for populations with chronic pain and a range of stress-related disorders in a behavioral medicine setting at the center for mindfulness at the university of massachusetts medical school (kabat-zinn, 1982, 1990). trained instructors teach the mbsr program as an 8to 10-week group course consisting of up to 30 participants who meet for 2-2.5 hours per week for instruction plus an additional daylong mindfulness session held during the sixth week. the groups are often composed of individuals with varying clinical complaints, though mbsr has been modified for work with specific populations. in the highly experiential sessions, participants practice mindfulness meditation skills and discuss stress and coping. each participant is asked to commit to completing daily homework assignments for at least 45 minutes per day, six days per week, and a large emphasis is placed on practicing mindfulness in daily life (baer & kreitemeyer, 2006). msbr has been shown to be an effective treatment for a variety of clinical conditions including anxiety and panic disorders (kabat-zinn et al., 1992), fibromyalgia (kaplan, golderberg, & galvin-nadeau, 1993), and chronic pain (kabat-zinn, lipworth, burney, & sellers, 1986). increasingly, researchers and practitioners are investigating mindfulness-based interventions for specific populations, such as mindfulness-based cognitive therapy (mbct) for the prevention of depressive relapse (e.g., teasdale, 1999). through the use of mindfulness training, mbct encourages individuals to “disengage from habitual (‘automatic’) dysfunctional routines, in particular depressionrelated ruminative thought patterns” (teasdale, segal, williams, rideway, soulsby, & lau, 2000, p. 618). a multisite study of 145 adult subjects in remission or recovery from major depression suggests that mbct can significantly reduce the risk of future relapse and recurrence in patients with mdd (teasdale et al., 2000). in a recent meta-analysis of research into the efficacy of mindfulness practice published in clinical psychology, ruth baer (2003) assessed the impact of mindfulness on problems such as depression and anxiety, and found that 74% of those individuals in groups receiving mindfulness training had better outcomes than those receiving another treatment or no treatment—a significantly large effect for these interventions. said one molecular biologist who participated in an eight-week experimental study on the impact of meditation: “i could tell i was less irritable. i had more capacity to take on more stressors. my wife felt i was easier to be around. so there were tangible impacts. for an empiricist, that was enough” (hall, 2003, p. 49). paul eckman, richard davidson, matthieu ricard and allan wallace, in an article on buddhist and psychological perspectives on emotions and well-being, described the results of mindfulness meditation training as follows: “as a result of such training, one perceives what is presented to the senses, including one’s own mental states, in a way that is closer to their true nature, undistorted by the projections people habitually mistake for reality” (ekman, davidson, ricard, & wallace, 2005, p. 60). mindfulness: necessary for parental attunement attunement refers to particular affective experiences that occur during developmentally achieved intersubjective relatedness—a period wherein the developmental focus shifts from the mutual regulation of behavior to the mutual sharing of experience. stern’s (1985) conceptualization of the infant’s developing theory of mind suggests that intersubjective relatedness occurs around the infant’s seventh to ninth month, when infants develop a sense of self as separate from other; self and other are now interfaceable separate minds (bretherton & bates, 1979). this experience of intersubjectivity is “crucial for creating experiences of being-with-other and for furthering individuation and autonomy” (stern, 1985, p. 127). the most important mode of sharing subjective experiences, stern proposes, is affective attunement. affective attunement is specifically defined as “the crossmodal matching of intensity, timing, and ‘shape’ (contour) of behavior, based on microdynamic micromomentary shifts over time, perceived as patterns of change that are similar in self and other” (beebe, knoblauch, rustin, & sorter, 2005, p. 47). when a parent is attuned to his or her child, moments of particular connectedness are possible, and the child feels understood and accepted (siegel & hertzell, 2003). preconditions for attunement include 1) a parent being able to read the infant’s feeling state and overt behavior, 2) the parent being able to perform a behavior that corresponds to the infant’s overt behavior and that is more than strict imitation, and 3) the infant being able to read the parent’s response as being related to the infant’s original feeling experience (stern, 1985). although an elaboration of the processes involved in attunement and crossmodal matching is beyond the scope of this paper (see stern, 1985; and beebe et al., 2005 for more), most relevant to this discussion is the understanding that attunement is a form of communing, rather than a communication, which refers to sharing without altering in order to maintain “the thread of feeling-connectedness” (beebe et al., 2005, p. 48). according to stern, during intersubjective relatedness, the subjective “state-sharing other [the mother] acts with her mental presence” (stern, 1985, p. 211; italics added). it follows logically that the mother (or parent) must be mentally present in order to relate intersubjectively with her infant; she cannot be authentically attuned if she is having difficulty staying focused in the present, if she is running on automatic, or if she is preoccupied with the future or past (see brown & ryan, 2003). in other words, attuned communications rely on a parent’s ability to be mentally present, or mindful; an ability to be mindful is a prerequisite for the possibility of authentic attunement. mindfulness can be understood as a necessary though not sufficient condition for this affective attunement. utilizing the language of mindful parenting 5 mindfulness, we can say that intersubjective relatedness is facilitated by the ability to hold the present moment with awareness and attention. in his discussion of intersubjective relatedness, stern illustrates, with case study examples, clinically relevant patterns of mal-attunement (e.g., non-attunement, selective attunement, and misattunement) as causally relevant to a child’s development of psychopathology. for example, a parent who selectively attunes to one aspect of the child’s emotional experience leads the child to utilize “that portion of inner experience that can achieve intersubjective acceptance with the inner experience of the other, at the expense of the remaining, equally legitimate, portions of inner experience” (stern, 1985, p. 210). this is the beginning of the development of a “false self” (see winnicott, 1960). in contrast, authentic attunement validates the child’s inner experience and allows the child to internalize a sense of acceptance. of course, no parent can be attuned all of the time— nor would the child benefit if this were the case. stern (1985) describes the notion of overattunement, or “psychic hovering,” which is experienced by the child as intrusive. the mindful parent, in contrast, is authentically attuned to the child such that he or she respects “the natural oscillating rhythms of the child’s need for connection,” because “attuned relationships give respect to the rhythm of these changing needs,” (siegel & hertzell, 2003, p. 68). maternal depression and the early mother-child relationship having explored the importance of intersubjective relatedness and understanding mindfulness as a prerequisite for the affective attunement that is central to the development of an infant’s intersubjective relatedness, we now turn to a brief examination of the impact of maternal depression on the mother-child relationship and suggest that depression interferes with a mother’s ability to be present in the moment with her child. there is a wealth of research literature examining the negative impact of parental psychopathology on young children’s well-being. specifically, maternal depression greatly affects the quality of the mother-child relationship. a meta-analysis of 46 studies (lovejoy, graczyk, o’hare, & neuman, 2000) found consistent differences between depressed and non-depressed mothers, and patterns linking maternal depression with less positive and more negative and disengaged behaviors. research on depressed mothers and their infants indicates that these infants are at increased risk for insecure attachments and compromised cognitive outcomes (murray & cooper, 1997). post-partum depression (pdd), with a prevalence rate of up to 15% in new mothers (o’hara, 1997), has been linked to impairments in parenting and to a high incidence of insecure attachment, cognitive delays, and dysregulation related to depressed affect, irregular sleep, higher norepinephrine levels and lower vagal tone in infants of ppd mothers compared to infants of non-depressed mothers (clark, tluczek, & wenzel, 2003). in a study conducted by the national institute of child health and human development (nichd; 1999), maternal depression was found to negatively affect parenting sensitivity, which was, in turn, uniquely associated with child outcomes such as school readiness, expressive language, and verbal comprehension. in this study, sensitivity was measured via a composite score created during motherchild play by observer ratings, and sensitivity scores encompassed ratings of the mother’s positive regard, lack of intrusiveness, supportive presence, respect for autonomy, and lack of hostility (nichd, 1999). these findings suggest that maternal depression limits a mother’s ability to be a sensitive, supportive presence for her child. studies using global assessments and clinical ratings have shown that the security of the child’s attachment to the parent is dependent on the emotional availability of the parent (see de wolff & van ijzendorn, 1997, for a review). mindfulness-based interventions for depressed mothers the negative consequences of maternal depression on the early mother-child relationship are well documented (e.g., insecure attachments, dysregulation, decreased maternal sensitivity; see above). this paper suggests that depression may prohibit a mother from being fully present, or mindful, when interacting with her infant, thus influencing her ability for authentic affective attunement during the developmental period of intersubjective relatedness. interventions aimed at maternal depression during the antepartum and postpartum periods are therefore vital to the wellbeing of both mother and child. although pregnant women may be unusually open to interventions directed at improving their own mental health before the birth of their child (cowan & cowan, 2000) and as such, pregnancy is known to be an opportune time for suggesting interventions (institute of medicine, 1996), many pregnant women refuse medication during this time, for fear of unknown consequences to their developing fetus. along these lines, many women are unwilling to take medication during the postpartum period, primarily when breastfeeding. there is therefore an urgent need to develop effective, non-pharmacological treatment alternatives to antidepressant medication (oren, james, & prince, 2002). interpersonal psychotherapy (ipt), a time-limited psychotherapeutic intervention that aims to relate depressive symptoms to an interpersonal context (weissman, markowitz, & klerman, 2000) may be an effective nonpsychopharmacological treatment for depressed women who are pregnant or suffering from postpartum depression (bledsoe & grote, 2006). however, a recent review of treatment approaches for postpartum depression concluded that when compared to interventions that treat the mother’s sawyer 6 depression symptomatically, mother-baby dyadic interventions are more efficacious in helping mothers with postpartum depressions and their babies (nylen, moran, franklin, & o’hara, 2006). abidi, sawyer, hoffman, & tower (2007) stress the importance of trying to understand the mechanisms of change in these dyadic interventions. it is plausible that dyadic interventions increase a mother’s ability to be present, or mindful, with her child, and that this increased mindfulness is an important mechanism of change. to date, this author is not aware of any research examining mindfulness-based cognitive therapy (mbct) as adapted for maternal depression. as discussed above, mbct can significantly reduce the risk of future relapse and recurrence in adult patients with mdd (teasdale et al., 2000). mbct for maternal depression might enhance the mother-child relationship (and therefore promote healthy child development) indirectly by reducing the recurrence of depressive episodes, which are known to have a negative impact on the relationship and consequently on the child’s development (e.g., nichd, 1999). mbct for maternal depression (and possibly dyadic interventions) might also impact the mother-child relationship more directly by increasing the mother’s mindfulness in daily interactions with her child and thus enabling a more attuned connection between them. research is needed on this and other mindfulness-based interventions that might enhance mother-child interactions and/or impact child outcomes. a modification of empirically validated mbct specifically aimed at ante and postpartum depression is also warranted, given the prevalence and severity of depression during these times and the need for non-psychopharmocological interventions. furthermore, examining mindfulness as a potential mechanism of change in existing dyadic interventions for mothers with postpartum depression and their babies may serve to uncover the active ingredients of a particular therapeutic strategy (see kazdin and nock, 2003, for a discussion of mechanisms of change in child and adolescent therapy). mindful parenting: a move into positive psychology although there is ample research literature examining the impact of maternal depression on children’s development, as a field we know little about the ways in which mindful parenting may positively impact children’s development. similarly, though the study of mindfulness-based clinical interventions is an emerging area of interest for both researchers and clinicians (e.g., baer & kreitemeyer, 2006), there is as yet limited research on the benefits of mindfulness training for non-clinical populations. working within a positive psychology framework (see seligman & csikszentmihalyi, 2000), this paper suggests that research is needed on interventions that enhance mindfulness in healthy mothers and that such research is timely. in what may become a significant contribution to the field of developmental psychopathology, lieberman, padron, van horn, & harris (2005) recently published an article that, while acknowledging the ghosts, allows room for ‘angels in the nursery.’ the authors argue that uncovering ‘angels’ as growth-promoting factors in the lives of parents is just as critical to the work of therapy as is the interpretation and exorcizing of ghosts. thirty years after the publication of frailberg, adelson, and shapiro’s (1975) classic paper, with the growing interest in positive psychology and resilience, the zeitgeist is shifting to enable the examination of factors that promote well-being, such as mindfulness. the time is now. the field is ready. further evidence that in-depth research into the benefits of mindful parenting is a timely pursuit can be found in popular culture. in 2005, a search for “mindful parenting” on the google internet search engine revealed approximately 358,000 results, many of which describe mindful parenting classes and workshops aimed at helping parents to stay focused in the moments shared with their child. the same search in march 2007 revealed 664,000 hits. popular books by kabat-zinn & kabat-zinn (1997), costello & haver (2004), kramer (2004), and siegel & hartzell (2003) suggest that being mindful will enhance the quality of the parent-child relationship. clearly there exists a pronounced gap between interest and personal experience as reflected in popular culture, and the lack of empirical evidence examining the relationship between mindfulness and parenting. the mindful parent authentic emotional relating requires a mindful awareness of one’s own internal state as well as an openness to understanding and respecting the other’s state of mind; the mindful parent would be aware of both the child’s needs and his or her own needs within the experience of intersubjective relatedness. if parents are not mindfully present in the moment, perhaps because they are distracted by thoughts or feelings related to the past or the future, they are not truly emotional available for their child at that moment. but “as every parent knows, your heart can’t always be in it, for all of the obvious reasons from fatigue through competing agendas to external preoccupations that fluctuate from day to day,” (stern, 1985, p. 217). to be mindful, therefore, is not to hold perfectionist ideals for parenting or life; rather, to be mindful is to non-judgmentally hold an awareness of current experience. the current experience will inevitably be, at times, that of the awareness of not being authentically attuned. in her book on buddhism for mothers, author sarah napthali aptly describes a mindful mother. this, of course, is an ideal, but one worth striving for nonetheless: imagine a calm, serene mother who accepts whatever life presents her with… she’s selfaware, but because she has fostered self-love, she is not self-conscious or self-absorbed when she mindful parenting 7 talks to others…. her children delight in her company for she makes them feel important and understood… (napthali, 2003, p. 9). conclusion to sum, the scientific study of mindfulness is a new and emerging field. mindfulness as a psychological construct, though beginning to gain empirical support, is not yet widely understood. to date there is a dearth of empirical research investigating the efficacy of parenting interventions that utilize mindfulness meditation as a means to foster positive child outcomes. while research findings demonstrate that maternal depression negatively impacts children’s well-being (lovejoy et al., 2000) and that mindfulness meditation can be an effective approach to treating depression (teasdale et al., 2000), there is no known empirical support for the use of mindfulness interventions targeting maternal depression and/or child outcomes. although child psychopathology is clearly multidetermined, we do know that parenting plays a major role. the theoretical literature (stern, 1985) proposes that adequate parental attunement positively impacts a child’s sense of self, whereas mal-attunement is implicated in the development of psychopathology (i.e., “false self”; winnicott, 1960). the ability to be mindful is a necessary (though not sufficient) condition for authentic parental attunement. if one is not present, one cannot attune. future research would do well to investigate the impact of mindful parenting on child outcomes in 1) existing mindfulness-based interventions such as mbct; 2) existing dyadic interventions that do not explicitly teach mindfulness; and 3) existing “mindful parenting” interventions that have not yet been researched. mindfulness is not a panacea, but in certain conditions or in conjunction with 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(2005). mindfulness-based relapse prevention for alcohol use disorders: the meditative tortoise wins the race. journal of cognitive psychotherapy, 19 (3), 221-228. 87 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university afraid to vomit? the relationship between temperamental fear, emetophobia symptoms, and the impact of sex jennifer a. petell1, molly e. wickenhauser,1 and danielle j. maack,1,2 1department of psychology, university of mississippi 2 delta autumn consulting emetophobia, the specific phobia of vomiting (spov), is an anxiety disorder associated with a persistent fear of emesis. the temperament of fear is evident in phobic and anxiety disorders, which behaviorally manifests through a sensitivity in the fight, flight, freeze system (fffs). the present study aimed to test specific associations between these constructs. undergraduate students (n= 186) completed self-report measures assessing symptoms of emetophobia, the fffs, and general anxiety. correlational analyses were used to test initial relations, followed by regression analyses to assess the unique contribution of temperamental fear to the emetophobia symptom experience. significant positive correlations were found between emetophobia symptoms with anxiety symptoms and the overall temperament of fear. however, only the fight response of the fffs was significantly associated with symptoms of emetophobia. further regression analyses demonstrated that the fight response did not uniquely predict emetophobia symptoms above and beyond anxiety. however, post-hoc analyses illustrated sex moderated the relationship between temperamental fear and emetophobia symptoms, such that the relationship was significantly stronger for male participants than female participants. results of this study expand upon the current conceptualization of emetophobia to incorporate underlying temperamental vulnerabilities and sex differences, which may function to exacerbate and/or maintain symptoms. keywords: emetophobia; specific phobia of vomiting (spov); fight, flight, freeze system (fffs); fight, flight, freeze questionnaire (fffq); sex differences the specific phobia of vomiting (spov), also known as emetophobia, is a specific phobia characterized by a marked fear of emesis (self or other). though symptoms have a mean age of onset occurring between 7.5 to 15.7 years, symptoms may develop and frequently persist beyond young adulthood (keyes & veale, 2018). in fact, symptoms are pervasive and persist for an average duration of 25.9 years before individuals seek treatment (keyes et al., 2017; lipsitz et al., 2001). although inconsistent (veale et al., 2015), prevalence estimates of emetophobia demonstrate a much higher occurrence in females (6-7%) than in males (1.8-3.1%; kirkpatrick & berg, 1981; van hout & bouman, 2012). those with emetophobia symptoms have severe, negative impairments in quality of life and may develop co-occurring anxiety disorders (e.g., generalized anxiety disorder (gad), obsessive-compulsive disorder (ocd), social anxiety disorder (sad); boschen, 2007; keyes et al., 2017). in addition to the core symptom of pervasive fear of vomiting, there are a variety of fear emphases that an individual may also hold. for example, 41-75% of individuals with emetophobia present with a primary fear of vomiting themselves; while 18-45% of individuals are primarily debilitated upon seeing others vomit in their presence (keyes & veale, 2018). other fears of vomiting surround the potential of choking on vomit leading subsequent to death, the act of vomiting in public (16-62%), and/or the physiological symptoms themselves associated with vomiting (keyes & veale, 2018). these impairing symptoms of emetophobia are supported through elaborate safety-seeking and avoidance behaviors, such as checking food expiration dates and avoiding contact with an ill person (simons & vloet, 2018; van hout & bouman, 2012). through these consistent responses with acute reinforcement, the phobia is actively maintained and exacerbated. though symptoms overlap, it is evident that anxiety and fear are both unique constructs and components observed in anxiety disorders (gullone et al., 2000; mcnaughton & corr, 2008; perkins et al., 2007; woody & teachman, 2000). the psychological constructs of anxiety and fear have been conceptualized using the revised reinforcement sensitivity theory (r-rst), a neuropsychological model of personality and motivation developed by gray and mcnaughton (2000). the r-rst consists of three motivational systems that work together to respond to threats: behavioral activation and inhibition systems (bis and bas) and the fight, flight, freeze system (fffs; corr & krupić, 2017; mcnaughton & corr, 2008). the bis and bas are predominantly used to conceptualize anxiety, which is posited to occur upon approaching of perceived danger (gray & mcnaughton, 2000; 88 mcnaughton & corr, 2008). the third motivational system, the fffs, is used to operationalize the temperament of fear, which operates upon active avoidance (i.e., leaving the vicinity) of perceived danger (gray & mcnaughton, 2000; mcnaughton & corr, 2008; walker & jackson, 2017). indeed, the bis and bas, and to a lesser extent the fffs (kimbrel et al., 2008), have been used in the conceptualization of anxiety symptoms and disorders (e.g., sad and ocd; bijttebier et al., 2009; katz et al., 2020). one area of limited research is the relationship of fffs with anxiety disorders (kambouropoulos et al., 2014; kimbrel et al., 2008). as the r-rst motivational symptoms are concurrently activated (corr & krupić, 2017; mcnaughton & corr, 2008), it stands to reason that the temperament of fear, as operationalized by the fffs, is implicated in the experience of anxiety symptoms, and likely emetophobia symptoms. the fffs is maintained through learned avoidance of aversive stimuli and is theorized to be highly sensitive to punishment (kimbrel et al., 2008), thereby reinforcing avoidance behaviors seen in anxiety disorders and likely emetophobia. specifically, the fight response is characterized by defensive aggression evoked in the presence of proximal, unescapable threats; while the flight response is conceptualized as a quick, direct escape from distal threats (walker et al., 2017). finally, the freeze response is considered a physiological panic response to distal threats involving physical immobility (walker et al., 2017). although the flight and freeze responses are classic avoidance behaviors seen in emetophobic responses to potential or distal fear (e.g., leaving the vicinity of an ill individual or shutting down mentally and physically upon the sight of vomit; keyes et al., 2017, veale et al., 2013), the fight response may also occur. for example, a threatening situation (e.g., the inability to vacate a room with ill colleagues) may provoke a fight response expressed as outright physical or verbal aggression or subtle nonverbal hostility. as is consistently demonstrated in phobic disorders, reinforcement and behavioral responses have a significant effect on the presentation and severity of emetophobia (keyes & veale, 2018; wu et al., 2015). the present study to date, the symptoms of emetophobia have not been assessed within the r-rst framework or the specific fffs motivational system. the primary aim of the present exploratory study was to assess the overall relationship between emetophobia symptoms, general symptoms of anxiety, and fight, flight, freeze tendencies (combined and individually) in an undergraduate, analog population. as fear is inherently involved in phobias and other anxiety disorders, the current study aimed to examine both symptoms of emetophobia and overall anxiety with the fffs motivation system. based on the r-rst theory and current conceptualization of emetophobia, it was hypothesized that emetophobia symptoms, general anxiety, and fffs would be positively associated. a secondary aim of the study was to investigate the unique contribution of fear in the experience of emetophobia symptoms when controlling for the known association of general anxiety symptoms (boschen, 2007). methods participants and procedures participants (n = 186; mage = 19.05 years, sd = 1.69) were undergraduate students, aged 18 to 36 years old, enrolled in an introductory psychology course at a large south-eastern university in the united states. participants were recruited via class announcements and through sona systems (an online participant recruitment portal). no other inclusion or exclusion criteria were present as this was an exploratory study assessing potential associations between temperamental fear and symptoms of emetophobia in an analog sample. further, symptoms of emetophobia may develop after the average age of onset and often persist through adulthood (keyes et al., 2017), the current sample of undergraduate students is consistent with individuals with emetophobia who may seek treatment for persistent symptoms. the majority of participants were female (74.9%; 25.1% male) and white (71.7%), though participants also identified as african american (21.2%), asian (1.6%), native american or alaskan native (0.5%), or multiracial (4.6%), and 5.2% identified as hispanic. as a part of a larger study, undergraduate students presented in person to the lab. prior to study commencement participants provided verbal and written informed consent, and then completed a series of self-report questionnaires (non-randomized). participants received research course credit for participation. the following three questionnaires were examined for the purposes of the current study. all procedures were petell, wickenhauser, maack 89 approved by the university’s institutional review board. instruments the specific phobia of vomiting inventory (spovi; veale, et al., 2013). the spovi is a short, 14item measure assessing fear of vomiting symptoms experienced within the last seven days. all items are rated on a likert-type scale from 0 (symptoms not at all experienced) to 4 (symptoms experienced all the time). scores are summed, with higher scores suggesting an increased experience of spov symptoms (range 0-35). a clinical cut-off of 10 has been previously proposed (veale, et al., 2013), which was endorsed by 9.14% of the current study sample (n = 17). the spovi has displayed good internal consistency (α = .89), good convergent and divergent validity in college samples, and has evidenced invariance across sex (maack et al., 2017). in the current study, the spovi also demonstrated good internal consistency (α = .82). the fight, flight, freeze questionnaire (fffq; maack et al., 2015). the fffq is a 21-item measure assessing the typical reaction of an individual to a threatening situation. all items are rated on a likert-type scale from 1 (experienced almost never) to 5 (experienced almost always). the measure results in a total fffq score as well as three subscale scores individually assessing fight, flight, and freeze. the fffq has demonstrated reliable internal consistency overall (α = .92) and with all subscale scores (fight: α = .91; flight: α = .94; freeze: α = .86; maack et al., 2015; walker & jackson, 2017). the current study found similarly good internal consistency for the overall fffq score (α = .93) and individual subscales (fight: α = .90; flight: α = .94; freeze: α = .91). the depression, anxiety, stress scale (dass21; lovibond & lovibond, 1995). the dass-21 assesses depression, anxiety, and stress symptoms experienced within the last week, consisting of 21 items. all items are on a likert-type scale from 0 (not applicable) to 3 (applicable much of the time). the 7-item anxiety subscale was used to assess anxiety as a potential covariate apart from overall temperamental fear. both the overall scale and anxiety subscale scores have demonstrated good internal consistency (α = .82 and α = .81, respectively; crawford & henry, 2003; osman et al., 2012). the current study showed acceptable internal consistency for the subscale of interest (anxiety subscale: α = .71) and overall scale (α = .74). statistical analysis all data analyses were conducted using spss version 27. data was cleaned prior to analyses. of the original sample (n= 194), three participants were removed for missing more than 10% of data, five multivariate outliers were removed using mahalanobis distance, and additional missing data was replaced with variable means. preliminary analyses of the final sample (n= 186) included descriptive statistics and zero-order correlations for all variables of interest. following this, a hierarchical regression analysis was run to assess the unique variance of predictors on the experience of emetophobia symptoms. post-hoc analyses, including correlations, independent samples t-tests, and a moderation analysis, examined the potential impact and interactional effects of sex on the relationship between temperamental fear and emetophobia symptoms. results descriptive statistics and intercorrelations among variables of interest are presented in table 1. as illustrated, spov symptoms were significantly related to anxiety (r = .20, p < .01) and both the overall temperament of fear (r = .17, p < .05) and the fight subscale (r = .15, p < .05). however, the subscales of freeze (r = .13, p = .08) and flight (r = .13, p = .08) were not significantly associated with spov symptoms. to assess the unique contribution of the temperamental fear response to the experience of emetophobia symptoms, distinct from general anxiety symptoms, a hierarchical regression analysis was run with spov symptoms as the dependent variable (see table 2). in the first step of the model, the fight subscale (the only significantly associated subscale of fear) was entered. this step of the model was significant (f[1, 184] = 4.03, p < .05, δr2 = .02), with fight accounting for 2.1% of the variance in the prediction of emetophobia symptoms. next, in the second step of the model, anxiety was added. the overall model was significant (f[1, 183] = 5.72, p < .01, δr2 = .03); however, the contribution of the fight subscale no longer added unique predictive ability. post-hoc analyses given the above unexpected findings and clear sex differences in the occurrence of emetophobia symptoms evidenced in previous studies (kirkpatrick & fear tendencies and emetophobia symptoms 90 berg, 1981; van hout & bouman, 2012), post-hoc analyses related to sex were conducted to elucidate potential unique contributions of sex in the present preliminary study. additionally, although using a non-clinical sample for an initial exploratory study, an assessment of clinical elevations of spov symptoms occurred. in the current study, 17 participants (9.14%) met or exceeded the threshold for clinical cut-off scores on the spovi (score > 10). consistent with the previously mentioned studies (kirkpatrick & berg, 1981; van hout & bouman, 2012), of the 17 participants who met the spovi clinical cut-off, 13 were females (6.99%), while only 4 were males (2.27%). point-biserial correlations demonstrated that sex was only significantly associated with the flight subscale (r = .17, p < .05) and was not significantly associated with spov symptoms, anxiety, overall temperamental fear, or the fight or freeze subscales. further, independent samples t-tests demonstrated no significant differences between sex among any of the variables (ps > .05). a simple moderation analysis using process 3.5 by hayes (hayes, 2018) was conducted to test if sex acted as a moderator among temperamental fear and emetophobia symptoms. temperamental fear was entered as the predictor variable, sex as the moderator, and spov symptoms as the outcome. anxiety was entered as a covariate. the overall model was significant (f [4, 178] = 3.66, p < .01, r2 = .08). more importantly, the interaction between temperamental fear and sex was also significant (f [1, 178] = 4.14, p < .05, r2 = .02). specifically, the relationship between temperamental fear and spov symptoms was significantly stronger for men compared to women (see figure 1). discussion the aim of the current study was to investigate the fight, flight, freeze motivational system and its relations with symptoms of emetophobia. results provided initial evidence for the impact of fear, specifically the fight tendency, on symptoms of the specific phobia of vomiting. however, further extrication of fear and anxiety is needed. consistent with theory and as hypothesized, the overall temperament of fear was found to be significantly associated with symptoms of emetophobia (harnett et al., 2013; keyes & veale, 2018; perkins et al., 2007; wu et al., 2015). however, contrary to the hypotheses, not all domains of the fffs behavioral responses were related. specifically, the flight and freeze responses, common reactions to potential threats across species (roelofs, 2017), were not significantly associated with emetophobia symptoms in the current study. notably, the fight response was the only fear domain significantly associated with spov symptoms. regarding the salient role of the fight response in the overall sample, individuals may respond differently in situations wherein active avoidance (i.e., escape from the immediate and proximal threat) of vomit is not available (mcnaughton & corr, 2008). the perceived urgency of threat and inaccessible escape in these situations may prompt the fight response to override other fffs reactions experienced more commonly among distal threats. however, upon further examination, the fight subscale did not add significant predictive utility above and beyond general anxiety symptoms. additional research may examine the unique impact of the remaining motivational systems of the r-rst, the bis and bas, which are operationalized as the anxiety response (mcnaughton & corr, 2008), and provide a further understanding of these results. it is possible that spov symptoms are more closely linked to a preparatory response in anticipation of future negative consequences from the act of vomiting as opposed to a defensive response to vomiting alone (barlow, 2002; lang et al., 2000). potential explanations for the aforementioned discrepancies observed in the fffs and emetophobia symptoms may involve documented hypervigilance regarding perceived vomit-related risks and threats (boschen, 2007; keyes & veale, 2018). the flight and freeze responses are implicated in response to perceived threats that are distal to the individual, while the fight response uniquely combats proximal threats (walker et al., 2017). given the significant association of emetophobia symptoms with the fight response, this suggests participants in the current study perceived a proximal, immediate threat wherein active avoidance was unattainable (mcnaughton & corr, 2008). however, this perception may have been overshadowed by the strong connection between emetophobia symptoms and general anxiety about potential future threats that could result from vomiting (e.g., difficulty breathing, choking, embarrassment). further research may benefit by clarifying the situational contexts unique to emetophobia which provoke the perception of proximal and distal threats and consequent arousal. petell, wickenhauser, maack 91 in addition to being impacted by assessed distance (i.e., proximal or distal) from threat (i.e., vomiting), sex differences have also been demonstrated to impact risk perception across species (gruene et al., 2015; gustafsod, 1998; jones & monfils, 2016). in the current study, the flight response was associated with being female, which suggests differential behavioral responses in the motivational system may occur. one possibility is that females may achieve more successful attempts of physically or mentally distancing from vomit. for instance, females experiencing emetophobia may employ flight responses (such as actively avoiding ill children at the local preschool or temporarily restricting food consumption) to avoid possible situations of vomit that may or may not occur in the distal future. additional research should examine the frequency of the specific motivational systems of the r-rst among males and females, and whether those systems were successful at avoiding the anxiety-provoking stimuli. negative affect, including experience of anger and irritability, may also account for differences in behavioral responses. emotions of negative affect (anger or irritability, anxiety, disgust, etc.) are expressed among various emotional disorders, such as anxiety and depression (hofmann et al., 2012; hundt et al., 2013) and have been linked to higher intensity in women (fujita et al., 1991). within the revised reinforcement sensitivity theory (r-rst), the experience of negative affect has also been demonstrated to negatively impact the perception of daily events (hundt et al., 2013). further, the specific emotion of anger has been positively associated with heightened sensitivity to reward and aggression, and it is further associated with an elevated fight response to threatening situations (hundt et al., 2013; roelofs, 2017). as such, the fight response may be perceived as resulting in a larger, more salient reward (to evade the proximal, immediate threat) than flight or freeze (to evade the distal, potential threat). thus, negative affect, particularly when accounting for sex differences, may alter the behavioral response of the fffs in individuals with emetophobia. given the inconsistencies between the current study’s findings and theory, post-hoc analyses were conducted to explore a potential missing link of the previous analyses: sex. results from the current study demonstrated clinical levels of emetophobia symptoms were three times more prevalent in female participants than males, consistent with prior research (kirkpatrick & berg, 1981; van hout & bouman, 2012). interestingly, the significant interaction effect found in the moderation model demonstrated a stronger relation among men for temperamental fear and emetophobia symptoms. that is, during moments wherein heightened fear symptoms are activated, men will likely experience increased severity of emetophobia symptoms. in comparison, this effect was not found in females in the current sample. elucidating whether this demonstration is unique to the fffs, as compared to the bis and bas, may provide further understanding regarding sex differences in emetophobia. it is possible, potentially as a result of societal differences and behavioral expectations among sex, that males and females may display and engage in emetophobia symptoms differently. sex differences have been evidenced across the lifespan among temperamental fear and anxiety symptoms (mclean & anderson, 2009). for example, disgust sensitivity, or the degree an individual regulates the emotion of disgust, has been found to be higher in females than in males (cisler et al., 2009; connolly et al., 2008). as disgust sensitivity promotes avoidance of perceived disease (connolly et al., 2008), this suggests females may engage in increased flight responses, as evidenced in the current study. future studies are needed to elucidate sex differences in the experience of emetophobia to provide additional contextual information to better inform treatment approaches. overall, the results of the current preliminary study add to the current conceptualization of emetophobia as its relationship with the temperament of fear combined with the impact of sex has not yet been documented in the literature. limitations although this preliminary study of temperamental fear and symptoms of emetophobia furthers the extant literature, it is not without limitations. specifically, data was collected from an undergraduate population with no formal diagnostic assessment of emetophobia or other psychiatric disorders. as the study was considered exploratory to first determine the potential of a relation between fear tendencies and symptoms of emetophobia, there were no exclusion or inclusion criteria. it is important to note that substantial variance nical sample although having good internal validity (α = .82 in this sample) may not be representative of external validity (i.e., true diagnostic status). moreover, rep fear tendencies and emetophobia symptoms 92 licating this study in a clinical sample with structured clinical assessments of emetophobia is needed to truly further the overall conceptualization of emetophobia. another limitation, as previously mentioned, was that the study relied upon self-report measures wherein the threat of immediate and proximal vomit was not present, thereby potentially impacting the innate behavioral responses of participants. despite these limitations, the current study provides a novel, initial understanding of the fffs and the impact of sex on emetophobia symptoms. to address such limitations in the future, studies employing behavioral avoidance tasks (bats) related to emetophobia stimuli may improve the understanding of natural behavioral responses across sex and in response to tangible vomit-specific threats. additionally, research examining the fffs in individuals formally diagnosed with emetophobia may contribute to a comprehensive conceptualization of this disorder. additionally, clarity on possible confounding variables related to fffs presentation may be provided by formal diagnostic assessment by a trained clinician and/or the addition of self-report measures. finally, based on previous literature indicating anger is associated with an increased sensitivity to reward, the emotion of anger in relation to the overall temperament of fear, individual response tendencies (i.e. fight, flight, freeze), and symptoms of emetophobia is worth exploration (hundt et al., 2013). conclusion the present study assessed the associations of temperamental fear (fight, flight freeze systems) with the experience of emetophobia symptoms. although symptoms of emetophobia were associated with the temperament of fear, specifically the fight subscale, none of the subscales offered predictive utility above and beyond general anxiety symptoms. interestingly, post-hoc analyses revealed that sex moderated the relationship between the overall fffs and emetophobia symptoms, such that this relationship was much stronger for male participants than for females. to advance the conceptualization of emetophobia, additional research is needed to first confirm the association between the fffs and emetophobia behaviors (i.e. using behavioral tasks) and then assess/identify these specific fear behaviors in a clinical sample. further, exploring whether the temperament of fear is generalized to vomit-specific stimuli and proximally threatening situations may provide information to assist with comprehensive treatment. importantly, the current study expands the literature in the area of emetophobia by assessing the specific underlying temperamental vulnerability of fear, the impact of sex, and how this relationship significantly affects symptoms of this phobic experience. references barlow, d. h. 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(2015). phenomenology, clinical correlates, and impairment in emetophobia. journal of cognitive psychotherapy, 29(4), 356-368. https:// doi:10.1891/0889-8391.29.4.356 petell, wickenhauser, maack 95 fear tendencies and emetophobia symptoms 96 petell, wickenhauser, maack 97 fear tendencies and emetophobia symptoms runninghead: social support graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 the role of social support and positive affect during conjugal bereavement brandon t. tatum teachers college, columbia university conjugal loss engenders a loss of connectedness that can lead to proliferated stress and the manifestation of depressive symptoms. however, these depressive symptoms and increased stress can be thwarted if one receives support from friends and family to compensate for the lost bond with one’s spouse. in addition, social contact and supportive relationships help to generate positive emotions, which are thought to increase well-being. the aim of this study was to investigate the relationship between social support from family and friends and positive affect on daily depression and stress after conjugal loss. the results indicate that family support acts as a buffer against daily stress and depressive symptoms. further, the results suggest that family support augments the experience of higher daily positive affect. it is noteworthy that the influence of positive affect on depression was evident primarily on days of elevated stress. one of the most stressful life events that humans can experience is the death of a spouse (amster & krauss, 1974; holmes & rohe, 1987; lang & stein, 2001). typically, the loss of a spouse is followed by a period of bereavement, which is defined as the emotional and physiological response to such loss (summers, 1998). during this period, many bereaved spouses experience negative emotions, a decrease in health, and an increase in depressive symptoms (marz, 1997;kendig & wells, 1997). conjugal loss often produces deleterious effects such as stress, depressive and anxious symptomatology, panic, and increased mortality (summers, 1998). though people take varying approaches to coping with these problems, studies show that across populations, the perceived amount of social support is an important factor in the coping process (aldridge, 2003). a supportive relationship can activate adaptive coping strategies that initiate the process of remoralization, thereby resulting in an increased sense of hopefulness, well-being, and personal efficacy (frank & frank, 1991). further, social support is essential in countering the bereaved individual’s often-held belief that others are hostile to the bereaved person’s continued symptoms and lack empathy. in general, social support and the opportunity to express one’s grief help mitigate the negative outcomes of bereavement. types of social support social support is a complex bi-directional construct the author was a student at the university of notre dame at the time he conducted the research. correspondence concerning this article should be addressed to brandon t. tatum, box 102, department of counseling & clinical psychology, teachers college, columbia university, 525 west 120 street, new york, ny 10024; email: btt2102@columbia.edu th referring to interpersonal dynamics between the identified individual and one or more family members or friends. measurements for social support generally fall into two categories: functional social support (fss) and structural social support (sss) (trunzo & pinto, 2003; wills, 1985). sss focuses on the presence of social support (e.g., friend, family), whereas fss focuses on the quality of support (e.g., feeling cared for and loved, expressing feelings, and discussing fears). this study investigates the relative influence of quantity of family and friends’ support (ie. sss) on daily stress and depressive symptoms. the influence of social support on stress & depression in general, social support is associated with superior mental and physical health and can moderate the negative consequences of exposure to stressful life events such as loss of spouse (cohen & wills, 1985; major, zubek, cooper, cozzarelli, & richards, 1997). social support and involvement in social activities promote well-being by acting as psychological buffers against stress, anxiety and depression (mayo, 2003). according to linville’s buffering hypothesis, social support is important when one is exposed to life stress because it helps to reduce undesirable effects on health (ystgaard, tambs, & dalgard, 1999). the theoretical underpinning for the buffering hypothesis is provided by the stress theory, which suggests that high levels of social support protect the individual against the deleterious impact of stress on emotional health (stroebe, stroebe, abakoumkin, & schut, 1996). hence, social support has been found to act as a moderater between stress and related depressive symptoms (chou & chi, 2001). typically, individuals who have greater amounts of social support experience lower levels of depression and psychological distress (geckova, van dijk, stewart, 24 tatum 25 groothoff, & post, 2003). a paucity of family and friends after a stressful event can contribute to feelings of depression and undermine an individual’s self esteem and self-efficacy (ornish, 1999). schraedley, gotlib, and hayward’s (1999) study revealed that levels of depression were higher among individuals who had no one to talk after a stressful life event (e.g. death of a spouse, loss of a friend) compared to those who had a confidant. among researchers who study the effects of stressful life events, a dominant perspective is that deficits in social support increase risk for depression (monroe, 1983; stice, ragan, & randall, 2004; windle, 1992). murphy and colleagues (2000) found that social support and adaptive coping methods were associated with both lower levels of depression and positive affect. in bertera’s (2001) study, lack of social support was associated with negative emotions in participants. positive affect and depression interaction with others is one important route to experiencing positive emotions (king, 2000). social contact, especially close and supportive relationships with friends and family, helps generate positive emotions (bertera, 2001; fredrickson, 2000). positive emotions help individuals mature, take positive action, solve problems, improve the quality of relationships, and increase emotional well-being (sharma, 2001). durable social resources (e.g. family and friends) help build positive emotions during stressful life events (fredrickson, 2001) and provide pathways out of traumas (keltner & haidt, 1999). for example, for a bereaved individual, positive emotions help develop meaning and lead to positive transformation (keltner & haidt, 1999). during bereavement, individuals with positive emotions tend to adapt more quick to loss, set new life goals, reconnect to survivors, and form new relationships (sharma, 2001). as noted earlier, after the occurrence of a traumatic event, individuals often experience an increase in depressive symptoms. positive emotions are particularly suited for preventing and treating problems rooted in negative emotions, such as depression and stress-related health problems (fredrickson, 2000). over time, positive emotions decrease depressive-related symptoms and trigger upward spirals to increase well-being (fredrickson, 2001). during bereavement, an increased number of positive emotions coincide with lower levels of depression (keltner and haidt, 1999) and attenuate both daily stress and depressive symptoms (ong, bergeman, & bisconti, in press). overview of the research previous research has found that social support and positive affect play strong roles in helping to determine, reduce, and alleviate stress and depression symptoms after a traumatic life event. however, there have been relatively few studies that have examined the link between these variables and their effect on individual levels of depression and stress after conjugal loss. thus, the purpose of this study was to investigate the relationship between social support and positive affect on daily depression and stress after conjugal loss. it was hypothesized that greater quantity of social support (i.e. family and friends) immediately following conjugal loss would be associated with higher daily positive affect and lower daily stress and depressive symptoms. it was predicted that the “undoing effects” of positive emotions on depressive symptoms would be evident primarily on days of elevated stress. it was also predicted that positive affect would be especially important to the well-being of widows low in quantity of social ties. method participants thirty-four elderly widows from the northern indiana/southwestern michigan area participated in the study. participants ranged from 61 to 83 years of age (mean=71.9, sd=6.11). all participants were european american females. the majority of participants had at least a high school education (41.2%). additionally, thirteen completed some vocational training or college courses (38.3%), four attained a college degree (11.8%), and two earned advanced degrees (5.8%). most of the participants reported an income between $15,000 and $24,999 a year (46.2%). five of the participants reported an income between $7,500 to $14,999 (19.2%), seven reported an income of $25,000 to $40,000 (26.9%), and two reported an income over $40,000 (7.7%). the vast majority of participants indicated that they lived alone (91. 2%), and three indicated that they lived with their children (8.8%). measures the questionnaire assessed several demographic characteristics: gender, martial status, date of birth, level of education, race/ethnicity, household income, and living arrangements. social support was measured using a subscale of the interview schedule for social interaction (henderson, duncan-jones, & bryne, 1980). the subscale consists of sixteen items that measure two constructs: family support and friend support. an equal number of items assessed both types of support. examples of the items are “how many people do you meet or talk to on the telephone in a typical week?” and “how many people can you share your innermost feelings with and confide in?” participants used a static checklist to indicate their answers (e.g. nobody, 1-2, 3-5, 6-10, and 11 or more). perceived stress was assessed using the fourteen-item perceived stress scale (cohen, kamarch, & mermelstein, 1983). this scale is widely used in studies of both mental and physical health (cohen, doyle, & skoner, 1999; cohen, tyrrell, & smith, 1993; ong, bergeman, & bisconti, in social support conjugal bereavement 26 press). the perceived stress scale was designed to assess the degree to which individuals appraise the situations in their lives as stressful and has a cronbach’s α of .86. a sample item is, “in the last month, how often have you been upset because of something that happened unexpectedly?” participants respond on a four-point scale (from 1, never to 4, always). the measure used to assess daily positive emotions, anxiety, and depressive symptoms was the mental health inventory (mhi; veit & ware, 1983). mhi is one of the most widely used mental health assessment inventories and is sensitive to intra-individual change (for reviews, see mchorney, ware, rogers, anastasia, & lu, 1992; ong, bergeman, & bisconti, in press; ware & gandek, 1994). participants were asked to indicate, on a four-point (from 1, not at all true to 4, completely true) scale, the extent to which they experienced positive emotions and depression/anxiety symptoms on a daily basis. positive emotions were assessed using the eleven-item subscale of the mhi. a sample item is “today i felt relaxed and free of tension.” anxiety and depressive symptoms were measured using the nine-item anxiety and four-item depression subscales of the mhi (veit & ware, 1983). sample items include the following: anxiety— “today, i felt lonely,” and depression—“today, i felt downhearted and blue. procedure initially, 266 recently widowed women were identified from the obituary sections of northern indiana and surrounding areas newspapers. the criterion for participation in the study was having recently lost a spouse who was at least sixty years of age. approximately seven days following the death of their spouses, the women were sent a letter describing the purpose of the study. after the letter was sent the women received a telephone call from the research interviewer. of the 266 women, 217 responded. seventy one widows expressed an interest in the study, however, eleven cancelled before the initial interview. the remaining 60 women participated in the interview, 18 to 42 days following their spouse’s death (mean=28.6 days, sd=6.41). of the 60 women, five had too much missing data for inclusion and 21 did not take part in the daily assessments; therefore, their data was not included in the present study. data on the remaining 34 participants was analyzed. one month following the death of their spouses, participants received a battery of self-report questionnaires. also, all kept a daily diary of their emotions and perceived stress. at the initial interview participants received a packet containing the measures and daily diaries, as well as a prestamped envelope addressed to the research team. the participants received a phone call every three weeks as a reminder to mail the assessments. each subsequent batch of daily diaries and measures was dated and mailed to the widows at bi-monthly intervals. in the event that a participant missed a day, they were instructed to leave the sheet for that day blank. participants received an incentive of fifty dollars for participation. results overview of analyses we tested our hypotheses using hierarchical linear modeling (hlm; bryk & raudenbush, 1992). the flexibility of multilevel modeling provided a number of advantages. first, hlm is appropriate for daily diary data. in the current study, the data had a hierarchical structure with 98 daily observations nested within each of 34 participants. second, hlm does not require that all individuals be measured at all occasions. thus, we were able to use the responses from participants who had missing data for some of the time points. finally, a multilevel modeling approach allowed us to estimate personand daylevel effects simultaneously. for example, we examined the separate and independent day-level effects of daily stress and positive affect on depression and then tested whether person-level variables (e.g., family support) moderated these effects. we developed hlm equations predicting daily depression to test our hypotheses. there were several common elements in each of our hlm analyses. first, following recommendations by bryk and raudenbush (1992), all day-level variables were centered on the individuals’ means, and all person-level variables were centered on sample means. second, variables that did not include a meaningful zero in the original scaling (e.g., day of study) were rescaled to include zero. predicting daily depression day-level depression was estimated by the following equation: depressiont = stresst + positive affectt + (stress x positive affectt) + dayt + et the equation refers to the intercept (i.e., a widow’s depression level on an average day) and represents the maximum likelihood estimates of the population slopes estimating daily depression from daily stress, positive affect, the positive affect by stress interaction, and time (in days) from loss, respectively; et is a random component of depression at time t. in the second portion of the model, person level effects were estimated as follows: = γ00 + γ01familyi + γ02friendi + u0 = γ10 + γ11familyi + γ12friendi + u0 = γ20 + γ21familyi + γ22friendi + u0 = γ30 + γ31familyi + γ32friendi + u0 = γ40 + γ41familyi + γ42friendi + u0 tatum 27 where each person’s level 1 intercept and level 1 slopes were predicted by an intercept, family support, friend support, and a random error component. the results of the hlm analyses predicting daily depression indicate that compared to widows who reported relatively high levels of social support, widows with chronically low levels of family support had higher intercepts (b = -8.312, se = .037, t = -11.021, p < .001), slopes for depressive symptoms (b = -.412, se = .044, t = 7.281, p < .01), and stronger daily stress-depression relationships (b = .405, se = .030, t = 8.285, p < .05). a similar pattern, albeit weaker, emerged for support from friends. importantly, higher levels of daily positive emotions were associated with lower symptom levels of depression (b = -.281, se = .041, t = -12.394, p < .001). further, the relationship was strongest among those low in family support (b = .284, se = .104, t = 6.125, p < .05). this interaction is depicted in figure 1. daily positive emotions highmeanlow d ai ly d ep re ss iv e s ym pt om s 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 .5 0.0 family support low mean high figure 1 for those high in family support, changes in positive emotions were not associated with changes in depressive symptoms. in contrast, those low in family support showed a strong inverse relationship between changes in positive emotions and depression symptoms. finally, the interaction between daily stress and positive emotions indicated that in the presence of positive emotions, there was a weaker relationship between daily stress and depressive symptoms (b = -.445, se = .028, t = -15.618, p < .001). this interaction is depicted in figure 2. there was a less manifest increase in depressive symptoms on days marked by greater stress when positive emotions were also high. notably, average positive emotions were not associated with daily depressive symptoms, suggesting that only elevations in positive emotions at the time of stress appear to reduce depressionrelated symptoms. daily stress highmeanlow d ai ly d ep re ss iv e sy m pt om s 4.0 3.5 3.0 2.5 2.0 1.5 1.0 .5 0.0 positive emotions low mean high figure 2 discussion the arc of positive and negative emotional states in later life is surprisingly complex, especially preceding the loss of a loved one. however, a significant proportion of the older adults in the present study managed to maintain positive affect, even through significant life challenge. positive emotions had beneficial effects on well-being when present during times of stress and depression. the results of the present study indicate that positive emotions reduce both feelings of daily stress and depressive symptoms. for instance, intra-individual analyses revealed that, when positive emotions were high, there was a less apparent increase in depressive symptoms on days marked by greater stress. this result suggests that positive affect maximizes resistance to stress and depression. in general, the results underscore the importance of building positive emotional experiences into our daily lives (frederickson, 2001). further, the results are consistent with the larger literature on positive and negative emotions (ong, bergeman, & bisconti, in press; watson et al., 1988; watson & tellegen, 1985), as well as tripartite models of depression (clark & watson, 1991; watson, clark, & carey, 1988; watson & kendall, 1989), which suggest that low positive affect is analogous to depression, even though general negative emotionality encompasses both depression and anxiety (ong, bergeman, & bisconti, in press). in the present study, discriminant validity of daily positive emotions is strongly supported. the hlm results indicate that the correlation between stress and depressive symptoms was significantly reduced on days in which positive emotions were high. thus, positive emotions appear to play a particular role in the regulation of ongoing depression during conjugal bereavement (ong, bergeman, & bisconti, in press). this test revealed that individuals who found a positive meaning during adversity and who ordinarily experienced positive affect may have had a greater ability to cope with adverse circumstances and bounce back quickly from them (sharma, 2001). social support conjugal bereavement 28 consanguinity of positive affect and social support in general, bereavement is considered to be a time of instability in which individuals cope with significant life changes. past research suggests that coping can either manifest in an adverse or positive manner contingent on the perceived amount of support and connectedness with others and the outside world (gale, 2005). the results from this study suggested that family support contributed to the improved adjustment to conjugal loss. the results also indicated that greater family support helped to maintain an individual’s stability throughout the course of the bereavement period. specifically, the results of this study emphasized the importance of perceived support, especially from family members, in experiencing positive emotions and having a positive outlook on life preceding traumatic life events (baarsen, 2002). widows low in social support showed a strong inverse relationship between changes in positive emotions and depression. limitations and directions for future research possible limitations of this study should be noted. despite the confidence of the correlations between the variables provided to us by using the daily measurements, causal conclusions cannot be made. also, since mood may vary during the course of an individual’s day, the time of day that the measurements were completed could have confounded the data. since participants completed the selfreport measurement at the end of the day an array of circumstances could have led them to answer in a particular manner. second, the participants of the study were all european american women. the findings of the study may not apply to bereaved men or individuals from different racial and age groups. third, the survey included no filter questions or measures to control for lying or providing answers that seemed to have greater social desirability. in addition, as implied in the literature, depression and anxiety often co-occur. thus, discriminating between the two constructs poses a problem (murphy, moscicki, vermund, & muenz, 2002). also, clinical diagnoses of participants’ depression were not obtained and may have been valuable in this study. finally, the quality of the social support received was not examined. quality of support might be a better predictor than quantity as it may be more reflective of the received benefits from relationships with family and friends. references aldridge. s. 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(1999). life stress, social support and psychological distress in late adolescence: a longitudinal study. social psychiatry, 34, 9-12. graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 patient predictors of response to interpersonal psychotherapy (ipt) for depression jessica a. keith teachers college, columbia university researchers in the past 20 years have identified a number of patient-specific variables that appear to moderate response to ipt for depression. these factors include length of the depressive episode, biological sleep profile, baseline social functioning, adult attachment profile, level of perfectionism, presence of personality disorder, level of somatic anxiety, and expectations about treatment. the therapeutic alliance is also important to consider, as it may interact with patient characteristics to influence outcome. the evidence for each of these factors is presented in order to begin to create a profile of patients who are more likely to respond to ipt for depression. implications for clinical practice and future research directions are discussed. the psychotherapy treatment literature provides evidence that a single treatment is not appropriate for all patients with the same disorder. interpersonal psychotherapy (ipt), a time-limited, manualized treatment that focuses on the relationship between depression and current interpersonal problems (weissman, markowitz, & klerman, 2000), is no exception. having established that ipt is a generally efficacious treatment for major depressive disorder (e.g., elkin et al., 1989), researchers have begun examining the characteristics of depressed patients for whom ipt is most appropriate. though the literature in the area of patientrelated moderators of response to ipt is in the early stages, some predictors of response have emerged. this research is important to consider for several reasons. perhaps most valuable is this information’s clinical utility in the selection of depressed patients suited to receive ipt. if certain characteristics of depressed patients can serve as markers of more likely ipt response, treatment decisions can be enhanced from the outset. an increased focus on response predictors may also further understanding about the mechanisms through which ipt exerts its ameliorative effects, thereby leading to enhancements in this valuable treatment. in comparing results of the studies reviewed, it is important to consider the definition of “response” to ipt that is used. many studies define response as “complete recovery” from the presenting depressive episode by the termination of treatment, operationalized via a cut-off score less than or equal to 6 or 7 on the 17-item version of the hamilton rating scale for depression (hrsd), an established, clinicianadministered measure of depression symptoms (hamilton, 1960). other studies define response as remission from the current depressive episode, operationalized as a score of 7 correspondence concerning this article should be addressed to jessica a. keith, box 102, department of counseling and clinical psychology, teachers college, columbia university, 525 west 120 street, new york, ny 10027; e-mail: jak208@columbia.edu. th or below on the hrsd for a number of consecutive weeks (usually 3 or 4). in addition to response to ipt, outcome is addressed in the research, defined as the continuous hrsd score at termination. other studies include number of weeks to remission as an outcome variable of interest. overview of studies reviewed many of the findings reviewed in this article are based on the national institute of mental health (nimh) treatment of depression collaborative research program (tdcrp), a randomized, multi-site clinical trial comparing the efficacy of ipt, cognitive behavior therapy (cbt), imipramine hydrochloride plus clinical management (imipramine-cm), and pill-placebo plus clinical management for non-bipolar, non-psychotic depressed patients (elkin et al., 1989). subjects were adult outpatients with a diagnosis of a current major depressive episode and scores of 14 or higher on the hrsd. treatment in each condition consisted of 16 to 20 sessions conducted over 16 weeks by experienced psychologists and psychiatrists trained to deliver treatment in accord with detailed manuals. two hundred fifty subjects were randomized, 239 entered the treatment, and 162 completed the 16-week trial. all four treatments were effective in reducing depressive symptoms and improving functioning, with ipt and cbt as effective as imipramine-cm. ipt and imipramine-cm were significantly more effective than placebo in reducing depression severity as measured by the hrsd (elkin et al., 1989). other findings reviewed here are from studies of outpatient maintenance ipt for recurrent unipolar depression conducted by frank and colleagues (feske, frank, kupfer, shear, & weaver, 1998; cyranowski, et al., 2002). subjects were experiencing at least a second episode of major depression and had scores of over 14 on the hrsd. subjects received 12 to 24 weeks of ipt, ending when remission 3 keith 4 (defined as 3 consecutive weeks with hrsd <= 7) was achieved, at the end of 24 weeks, or at patient dropout (the later two groups were classified as non-remitters). additional findings in this article are taken from brown and colleagues’ randomized controlled trial of ipt, nortriptyline, or usual care for patients with dsm-iii major depression recruited from internal medicine clinics and family health centers (brown, schulberg, madonia, shear, & houck, 1996; brown, schulberg, & prigerson, 2000). subjects had scores of 13 or higher on the hrsd. all treatments lasted 8 months; ipt included 16 weekly sessions followed by 4 monthly continuation-phase sessions. findings from several other studies of ipt are described as they appear in the review below. note that studies of ipt used in combination with pharmacotherapy (e.g., dew et al., 1997; greenhouse, kupfer, frank, jarrett, & rejman, 1987; reynolds et al., 1996) are not included in this review, as the impact of ipt versus the drug treatment on response is unclear. key patient predictors of ipt response researchers in the past 20 years have identified a number of patient-specific variables that appear to predict response to ipt for depression. these factors include the severity, onset, and duration of the patient’s depression, depression of the endogenous type, social functioning, marital status, adult attachment profile, perfectionism, personality disorder, anxiety, and expectations about treatment. the evidence for each of these factors is presented. features of depression features of a patient’s depression, such as severity, duration, and onset may impact response to treatment. examining the role of depression severity in the tdcrp study, elkin and colleagues (1989) found that patients classified as having more severe baseline depression (hrsd >= 20) and more impaired baseline functioning defined via the global assessment scale (gas <= 50) had significantly lower depression scores and a greater chance of recovery (hrsd <= 6) at termination in the ipt and imipramine-cm conditions compared to placebo. in contrast, feske and colleagues (1998) found that greater baseline depressive severity and gas functional impairment predicted non-response to ipt. brown, schulberg, and prigerson (2000) similarly found that baseline depression severity and functional impairment did not predict recovery (hrsd <= 7) at 8-month termination for the ipt group. regarding duration of the current depressive episode, sotsky and colleagues (1991) observed that across all tdcrp treatment groups episodes of 6 months duration or more were correlated with greater post-treatment depression severity. feske and colleagues (1998) similarly found that longer duration of the index episode of depression was associated with non-remission. depression with greater acuteness of onset (less than 3 months) predicted less depression severity at termination for patients treated with ipt or imipramine-cm in tdcrp (sotsky et al., 1991). endogenous depression—that is, depression that is less situational and more innate or biological in nature—has long been thought to respond better to somatic treatments than to psychotherapy (prusoff, weissman, klerman, & rounsaville, 1980). however, the findings regarding ipt’s effect on endogenous depression are mixed. in a study of 96 acutely depressed ambulatory patients, prusoff and colleagues (1980) found that subjects with endogenous depression defined by research diagnostic criteria (rdc) responded poorly to ipt alone, but positively when ipt was combined with pharmacotherapy. patients not meeting criteria for rdc endogenous depression responded well to ipt. in contrast, sotsky et al. (1991) found that rdc endogenous depression predicted reduction in depression severity in the ipt group. feske et al. (1998) similarly found that subjects who failed to remit with ipt were more likely to meet rdc criteria for non-endogenous depression. an additional analysis of tdcrp data by sotsky in 1997 found that subjects with symptoms of atypical depression (mood reactivity, hypersomnia, hyperphagia, or weight gain) responded better to ipt and cbt than to imipramine-cm or placebo (cited in weissman, et al., 2000). commenting on the disagreement in the literature about the role of endogenous depression in moderating ipt response, thase and colleagues (1997) noted a general lack of consensus about the features that best define endogenous depression. they proposed that eeg sleep information could more accurately identify patients with biological disturbances characteristic of endogenous depression. in a study of 91 subjects with unipolar or bipolar ii depression, they examined the predictive utility of eeg sleep profiles to outcome from ipt. subjects received two nights of eeg sleep recording to measure rem latency, sleep efficiency, and rem density, factors that have reliably discriminated between depressed and healthy subjects in previous research. subjects were then divided into two groups, one which met the profile for an abnormal sleep profile similar to depressed inpatients (n = 41) and the other with a normal sleep profile (n = 50). all subjects were treated with up to 16 weekly sessions of ipt. subjects with abnormal sleep profiles had significantly poorer response to ipt as measured by hrsd ratings, treatment attrition, and depression remission (defined as 4 consecutive weeks with hrsd <= 7). biologically disturbed patients appeared to respond poorly to ipt even though pretreatment depression severity did not impact outcome. the authors concluded that ipt may less effective for a subgroup of endogenously depressed patients (those with objective signs of neurobiological dysfunction), thus explaining the lack of agreement in earlier findings. social functioning ipt is based on the principle that depression can be treated by focusing on the interpersonal context (weissman, patient predictors of response to ipt 5 et al., 2000); thus, pretreatment social functioning might be expected to have an impact on ipt’s outcome. sotsky et al. (1991) found that less pretreatment social dysfunction, as measured by the 11-item social and leisure activities subscale of the clinician-administered social adjustment scale (sas), was associated with less depression severity and complete response across all four treatments at termination, but most markedly for ipt. subjects with more severe social deficits responded poorly to ipt. patients who had lower social dysfunction prior to treatment, higher interpersonal sensitivity, and higher satisfaction with interpersonal relationships tended to be more responsive to ipt. the authors theorized that patients might need a minimum baseline social functioning ability in order to respond well to ipt. in contrast, feske et al. (1998) found that subjects who did not respond to ipt had higher levels of social functioning, as measured by the social attainment scale, than those who did. though these two studies used different measures of social functioning and different definitions of response, the discrepancy in their findings requires further research. also of note, it has been found that subjects in the tdcrp who were divorced or separated responded better to ipt, whereas married patients responded better to cbt (barber & meunz, 1996). marital status was not significantly related to ipt outcome in either the feske et al. (1998) or brown and colleagues (2000) studies. the relationship of marital status to social functioning in the prediction of response to ipt remains to be explored in detail. further investigating the role of social functioning, cyranowski and colleagues (2002) reported data indicating that adults with insecure attachment styles may have poorer interpersonal functioning and higher vulnerability to depression. they described three patterns of adult insecure attachment—preoccupied, dismissing-avoidant, and fearfulavoidant—each with implications for interpersonal functioning. they examined data from 162 female participants with recurrent depression in frank’s study of maintenance ipt to explore the relationship of adult attachment status to treatment response. attachment styles were measured by the self-rated relationship questionnaire. the authors found that though the proportion of subjects who remitted (hrsd <= 7 for 3 consecutive weeks) did not differ by attachment profile, among subjects who did remit (n = 87), those with secure attachment had significantly less time to remission (mean 8.5 weeks) than those with fearfulavoidant attachment (mean 13 weeks). in this sample, women with fearful-avoidant attachment profiles tended to have a more negative view of self and others, more trouble socializing, and more interpersonal difficulties. although women with this profile responded to ipt in equal proportion to those who were securely attached, they responded more slowly. though limited by its use of a self-report measure of attachment style, this study provides evidence that a brief course of ipt may not be enough time for fearful-avoidant patients to develop a trusting relationship. perfectionism a series of studies examining tdcrp data has provided strong evidence for the damaging role of perfectionism on response to treatment. authors using tdcrp data have assessed perfectionism via the dysfunctional attitudes scale (das), a measure of cognitive dysfunction that assesses self-critical and socially dependent attitudes. overall, tdcrp subjects with lower cognitive dysfunction as measured by the das tended to respond better to cbt and imipramine-cm than to placebo (sotsky et al., 1991). cognitive dysfunction did not predict ipt response. using a principle-components analysis, blatt, quinlan, pilkonis, and shea (1995) identified two robust primary factors in the das: “need for approval” and “perfectionism.” pretreatment need for approval was not significantly related to outcome in any of the four tcdrp treatments, however, across treatments, high levels of pretreatment perfectionism predicted higher depression severity and more impaired functioning (gas and sas) at termination (blatt et al., 1995). a subsequent analysis found that the damaging effect of perfectionism on treatment outcome was consistent when response was measured at both termination and 18-month follow-up times and by clinical evaluators, patients, and therapists (blatt, zuroff, bondi, sanislow, & pilkonis, 1998). the authors also found a temporal effect for perfectionism; though patients at all levels of perfectionism showed improvement from intake to mid-treatment, during the second half of treatment patients with moderate to high levels of perfectionism ceased improving, whereas those with low perfectionism continued to improve. though the negative effects of perfectionism on outcome were seen across treatment types and not just in ipt, there is evidence that the adverse effects of perfectionism may be mediated by patients’ satisfaction with social relationships (shahar, blatt, zuroff, krupnick, & sotsky, 2004), and thus may be particularly relevant to ipt’s focus on relationships. it seems that perfectionism contributes to difficulty in establishing the interpersonal relationships necessary for brief therapies such as ipt. however, these findings, all of which are based on tdcrp data and operationalize perfectionism by the das, require further replication. personality disorder much research has indicated that patients with personality disorders have poorer and/or slower response to treatment for depression. using tdcrp data, shea and colleagues (1990) found that subjects with personality disorders, as diagnosed with the personality assessment form (paf) rated pretreatment by clinical evaluators, showed less improvement in social functioning at termination. though no significant differences were found in hrsd outcome across treatments, there was a trend for subjects treated with ipt or imipramine-cm to have a better outcome when no personality disorder was present. in an extension of the above analysis, shahar, blatt, zuroff, and keith 6 pilkonis (2003) found that when personality disorder as measured by the paf was treated as a continuous rather than a categorical variable, odd-eccentric cluster personality disorders (cluster a; paranoid, schizoid, and schizotypal) predicted worse outcome across treatments. bearden, lavelle, buysee, karp, and frank (1996) further explored the role of personality disorder on ipt response in their study of 76 subjects treated with 12 to 20 sessions of ipt. all subjects had a history of recurrent major depression, were currently experiencing a depressive episode of probable or definite endogenous subtype, and had baseline scores of 15 or above on the hrsd. the authors found that more total dsm-iii diagnoses of personality disorders and more anxious-fearful cluster personality disorders (cluster c; avoidant, dependent, and obsessivecompulsive), as measured with the scid personality disorders interview, predicted greater time to remission from depression (hrsd <= 7 for 3 consecutive weeks). a higher number of disordered personality traits and a rating of high personality disturbance versus low personality disturbance were related to longer time to respond to treatment. brown, schulberg, and prigerson (2000) similarly found that patients receiving ipt who had a current dsm-iii axis ii personality disorder were significantly less likely to recover. barber and muenz (1996) provided further insight into the role of anxious-fearful personality disorders on response to ipt, examining the ways in which avoidant personality disorder (avpd) and obsessive-compulsive personality disorder (ocpd), as measured by the paf, interacted with treatment to affect outcome in tdcrp subjects who received cbt or ipt. in accordance with their hypothesis, the authors found that ipt was more effective at reducing depression for subjects with ocpd whereas cbt was more effective with subjects with avpd. the authors theorized that ipt may be better suited to obsessive patients because it uses internal coping strategies to motivate change. avoidant patients who utilize more external coping strategies may not be well suited to ipt. a limitation in all studies described above, however, is that personality disorder was evaluated during the depressive episode, either at intake, or, in the case of bearden et al. (1996), at four weeks into treatment. it is thus difficult to discern the effects of depression on personality from true axis ii personality disturbance. anxiety because depression is often comorbid with anxiety disorders, the influence of anxiety on response to treatment for depression is important to consider. brown, schulberg, madonia, shear, and houck (1996) explored the role of lifetime anxiety disorders as measured by the diagnostic interview schedule (dis). patients with a lifetime anxiety disorder presented with greater severity of depression, were more likely to drop out of the study, and showed less improvement over eight months when treated with either ipt or nortriptyline. patients with depression alone, compared to patients with depression and anxiety, showed greater and more rapid reduction in symptoms, especially between intake and month four. patients with comorbid anxiety tended to take twice as long to show similar reductions in depression severity. looking at rates of full recovery (defined as hrsd <= 7), the researchers observed that ipt subjects with depression alone or with depression and lifetime generalized anxiety disorder were more likely to have recovered at four and eight months than subjects with depression and a lifetime panic disorder. these differences were not observed in the nortriptyline group. feske et al. (1998) provided further evidence for the deleterious effect of anxiety disorders, and panic disorder in particular, on response to ipt. in their study of women with recurrent unipolar depression, treatment non-remitters (defined as hrsd >= 7 for 3 consecutive weeks) had significantly higher levels of somatic anxiety (measured by the hrsd) and were more likely to meet lifetime criteria for panic disorder (measured by the sads or scid) compared to treatment remitters. total anxiety level as reported on the sads and psychic anxiety as reported on the hrsd did not differentiate between remitters and non-remitters. it appears that ipt may effectively treat depression with some comorbid anxiety unless this anxiety is of a more somatic nature, as in panic disorder, in which case ipt is not as effective and pharmacotherapy may be warranted. expectations of improvement a final patient characteristic that has been studied as a predictor of response to treatment for depression, including ipt, is expectation of improvement. across many types of psychotherapy, patients’ expectations of improvement from treatment have been shown to be powerful predictors of outcome (reviewed in meyer et al., 2002). indeed, one of the ways in which ipt therapists may help patients recover from depression is by helping to increase expectations of treatment success by explicitly indicating that the outlook for recovery is good (weissman et al., 2000). findings from the tdcrp support the role of patient expectations in outcome (meyer et al., 2002; sotsky et al., 1991). treatment expectancy in the tdcrp was assessed via a one-item measure administered at intake asking patients to rate their expectation of their outcome. patient global expectancies, defined as status in one year assuming no other treatment, were also assessed with one item at intake. researchers found that patient treatment expectations significantly predicted full recovery and reduction of depression symptoms across treatments with a medium effect size. patient global expectancies, however, were not correlated with outcome (meyer et al., 2002; sotsky et al., 1991). a separate study conducted during the training of ipt therapists for the tdcrp found that negative patient expectations of outcome were correlated with greater hostile, defensive, and help-rejecting attitudes among patients, which in turn impeded therapists’ ability to effectively administer ipt patient predictors of response to ipt 7 (foley, o’malley, rounsaville, prusoff, & weissman, 1987). this study provides support for the effects of patient expectations for outcome in ipt in particular. perhaps related to expectations of outcome, brown, schulberg, and prigerson (2002) found that patients who perceived more internal control over their health responded significantly better to ipt. the role of the therapeutic alliance the therapeutic alliance is widely acknowledged as a key ingredient in effective psychotherapy across treatment types. in the tdcrp, stronger therapeutic alliances in early sessions and across all sessions, as measured variously by the evaluator-rated vanderbilt therapeutic alliance scale (vtas) and the patient-report barrett-lennard relationship inventory (b-l rl), were strongly associated with less attrition and greater improvement in all treatment groups. in fact, more variance in outcome was attributable to the alliance than to the treatment method (krupnick et al., 1996; blatt, zuroff, quinlan, & pilkonis, 1996). given the crucial role of the alliance on therapeutic outcome, it is not surprising that the alliance has been found to mediate and moderate several key patient predictors of response to treatment. for example, meyer et al. (2002) found that the strength of the therapeutic alliance (as measured by the vtas) appeared to mediate the relationship between patients’ expectations and treatment outcome across treatments in the tdcrp. patients with higher expectations of treatment outcome tended to develop stronger relationships with their therapists, which in turn led to a better outcome. investigating the effect of perfectionism on the therapeutic relationship across treatments in the tdcrp, zuroff and colleagues (2001) observed that the negative relationship between perfectionism and treatment response was partially mediated by the failure of perfectionists to develop stronger therapeutic alliances (measured by the vtas) as therapy progressed. blatt, zuroff, et al. (1996) further noted that though quality of therapeutic relationship (measured by the b-l rl) was unrelated to outcome for patients with either very high or very low levels of perfectionism, it was associated with outcome for patients with moderate levels of perfectionism. in other words, for somewhat perfectionistic patients, a positive therapeutic relationship moderates the negative effects of perfectionism and helps to predict a better outcome. as seen in these preliminary studies of perfectionism and expectations of outcome, a patient’s contribution to the therapeutic alliance may be one of the pathways through which patient characteristics affect outcome of treatment. clinical applications and directions for future research this review has found evidence in the literature of several patient moderators of response to ipt for depression. examining the data presented here, a profile of patients who may respond better to ipt emerges. it appears that to respond optimally to ipt as a treatment for depression, a patient should have a duration of the current episode of less than 6 months; a normal sleep profile; some minimum level of social functioning; an adult attachment style other than fearful-avoidant; less characterological perfectionism; lack of a personality disorder; lack of somatic anxiety symptoms or a lifetime diagnosis of panic disorder; positive expectations for the outcome of treatment; and more perceived internal control over health. some of these characteristics, such as somatic anxiety and social functioning, appear to be specific factors affecting response to ipt in particular. others, such as perfectionism and treatment expectations, are non-specific predictors of response across several types of treatment that have been shown to apply to ipt. both specific and non-specific factors are important to consider in determining patients’ likelihood to respond to ipt. of additional importance in making treatment decisions are factors that have been found to differentiate ipt’s effectiveness from that of other treatment options, including more severe depression (ipt may be better than clinical management alone); atypical depression (ipt may be better than pharmacotherapy); divorced or separated marital status (ipt may be better than cbt); and presence of obsessive compulsive personality disorder (ipt may be better than cbt). of note, several variables seem consistently unrelated to ipt outcome, including age, gender, age of onset of first depressive episode, and number of previous depressive episodes (brown, schulberg, & prigerson, 2000; feske et al., 1998; sotsky et al., 1991). the clinical applicability of these findings in determining the “goodness of fit” for ipt and increasing particularly effective aspects of ipt (e.g., by further encouraging positive expectations of treatment outcome) is promising; however, more research in this area is needed. the research to date is limited by its dependence on one study, the tdcrp, for most results, with few findings replicated outside of this sample. the tdcrp was a well-designed study using highly trained, experienced therapists to deliver treatment. it is unknown whether predictors of response in the tdcrp would extend to ipt conducted by less experienced therapists in a less structured setting. it is noteworthy that the findings of other studies (e.g., brown, schulberg, & prigerson, 2000; feske et al., 1998) seem to conflict with the tdcrp findings in several respects. these contradictory findings may be due to differing populations studied, measures used, and/or definitions of response used; this requires further research. additionally, the findings regarding nonspecific predictors of response (e.g. perfectionism) require replication with studies addressing ipt treatment in particular. the role of therapist characteristics in predicting response to ipt, alone and in interaction with patient variables, is another avenue for future research, especially in light of findings regarding the key role of the therapeutic alliance in predicting response to treatment. as yet there is keith 8 little data in this regard. however, preliminary research across tdcrp groups indicates that more effective therapists are not ones with more experience but rather with more psychological as opposed to biological orientations to the clinical process (e.g., they tended to favor psychotherapy over biological interventions for the treatment of depression) (blatt, sanislow, zuroff, & pilkonis, 1996). the implications of this finding for ipt have not yet been addressed. in conclusion, though some knowledge has been accumulated about patient predictors of response to ipt for depression, more research is needed to replicate and extend current findings. additional research is also needed to focus on other potential predictors of response and on the interaction of established predictors with therapist and treatment variables. references barber, j. p., & muenz, l. r. 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(2000). relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression. journal of consulting and clinical psychology, 68, 114-124. overview of studies reviewed key patient predictors of ipt response features of depression social functioning personality disorder anxiety expectations of improvement 61 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university eǔǿȅȗρ�^ǔǹǟে�гljƺljρ�ƺǿǐ��ȅǿǿȣǿǩƞρ�xƺȗƞǩljǩȓƺƞǩȅǿ genna m. mashinchi and craig ravesloot, rural institute for disabilities, university of montana kljǵǔljƞǩκǔॸ�eǧǩș�șƞȣǐρ�ǔπƺǿǩǿǔș�ƞǧǔ�ȗǔǹƺƞǩȅǿșǧǩȓș�ljǔƞλǔǔǿ�λȅȗƿǩǿǡ�ǿǔǿȅȗρॹ�ǿǔǿȅȗρ�șǔǹǟেǔгljƺljρ�শe^�ষॹ�ƺǿǐ�ljȅǿǿȣnity participation among older adults. method: 203 united states older adults (age 55+) were recruited through mturk to complete surveys and a memory task. a multiple linear regression was used to regress mse and community participation. main findings: entering all variables into the model explained 45% of the variance in community participation (r2 = ঀࢶࢵॹ��ǐǵঀ�[ࢳ�઀�ঀࢲࢵॹ�'শࢸॹࢲࢵࢲ�ষ�e�઀ࢷࢲ�ঀࢷࢳॹ�ȓ�ઃ�ঀࢲࢱࢱষঀ�e^��λƺș�ȓȅșǩƞǩκǔǹρ�ȗǔǹƺƞǔǐ�ƞȅ�ljȅǿǿȣǿǩƞρ�ȓƺȗƞǩljǩȓƺƞǩȅǿ�শݾ�઀�ঀࢹࢴॹ�ȓ�ઃ� ঀࢲࢱࢱষॹ�ƺș�ȓȗǔǐǩljƞǔǐঀ�/ȅλǔκǔȗॹ�ljȅǿƞȗƺȗρ�ƞȅ�ǧρȓȅƞǧǔșǔșॹ�λȅȗșǔ�λȅȗƿǩǿǡ�ǿǔǿȅȗρ�শݾ�઀�েঀࢳࢳॹ�ȓ�઀�ঀࢲࢱࢱষ�ƺǿǐ�ǡȗǔƺƞǔȗ�ǐǩгljȣǹƞρ� ȗǔǿǔǿljǔȗǩǿǡইljȅǿljǔǿƞȗƺƞǩǿǡ�শݾ�઀�ঀࢷࢳॹ�ȓ�ઃ�ঀࢲࢱࢱষ�ȓȗǔǐǩljƞǔǐ�ǧǩǡǧǔȗ�ǹǔκǔǹș�ȅǟ�ljȅǿǿȣǿǩƞρ�ȓƺȗƞǩljǩȓƺƞǩȅǿঀ� conclusions: it is reasonable to conclude that one’s beliefs about their memory ability is an important consideration when one chooses to engage in community events. ?dzͧ͡ȥȵǯȸ࣒�ȝdzȝȥȵͧ�ȸdzșǿणdzϭǩǚǩ࣓ͧ�ǩȥȝȝɂȟȉȿͧ�ȱǚȵȿȉǩȉȱǚȿȉȥȟ࣓�ǚǿȉȟǿ࣓�ǯdzȝdzȟȿȉǚ࣓��șͬȅdzȉȝdzȵहȸ�ǯȉȸdzǚȸdzࣚ� as the world’s older adult population grows, older individuals are susceptible to a heightened risk of experiencing age-related cognitive challenges, such as dementia (aartsen et al., 2002, fritsch et al., 2005). to help combat this growing problem, researchers have worked to identify factors that can support or improve cognitive functioning. one such factor that has gathered extensive support in the literature is participation in community leisure activities, such as ones that include social engagement (e.g., attending events with friends, having dinner with friends, participating in a card game group; fratiglioni et al., 2004; scarmeas et al., 2001; sobral & paúl, 2013; verghese et al., 2003). however, participating in these ƺljƞǩκǩƞǩǔș�ljƺǿ�ljǔ�ǐǩгljȣǹƞ� ǩǟ�ȅǿǔ�ǧƺș�ǐǩгljȣǹƞρ�ȗǔǿǔǿbering or concentrating, which might impair their ability to track a conversation, answer questions, or carry out multi-step instructions to complete an activity (cowan, 2014). additionally, if one feels that their cognitive abilities are poor, they might be more likely to avoid these activities, instead choosing to isoǹƺƞǔ� ƞǧǔǿșǔǹκǔș� ƞȅ� ljρȓƺșș� ǔπȓǔȗǩǔǿljǩǿǡ� ǐǩгljȣǹƞǩǔș� ȅȗ� feelings (nieboer et al, 2020). to examine this idea further, the present study examined the relationships ljǔƞλǔǔǿ� ǿǔǿȅȗρ� șǔǹǟেǔгljƺljρॹ� λȅȗƿǩǿǡ� ǿǔǿȅȗρॹ� and community participation among older adults. eǔǿȅȗρ�^ǔǹǟে�гljƺljρ � eǔǿȅȗρ�șǔǹǟেǔгljƺljρ�শe^�ষ�ǩș�ǐǔйǿǔǐ�ƺș�ƞǧǔ�ljǔǹǩǔǟș� an individual holds about their memory ability (lalitha & aswartha reddy, 2021; pearman & trujillo, 2013; sawin, 2021). the concept of mse stems from banǐȣȗƺঢ়ș�șǔǹǟেǔгljƺljρ�ƞǧǔȅȗρॹ�λǧǩljǧ�ȗǔǟǔȗș�ƞȅ�ƺǿ�ǩǿǐǩκǩǐȣal’s self-perception of their ability to organize and execute tasks under given conditions (bandura, 1997). in line with past research that has supported the positive relationship between mse and memory performance, �ƺǿǐȣȗƺ�ǧρȓȅƞǧǔșǩφǔǐ�ƞǧƺƞ�ƞǧȅșǔ�λǩƞǧ�ǹȅλ�șǔǹǟেǔгljƺljρ� perform poorer on tasks, compared to those with highǔȗ� șǔǹǟেǔгljƺljρ�শ�ƺǿǐȣȗƺॹࢺࢹࢺࢲ�আ��ǔƺȣǐȅǩǿ�૭��ǔșȗǩljǧard, 2011). as bandura notes, this poorer performance occurs as those who doubt their ability to carry out a task are less invested in the tasks, which results in less ǔаȅȗƞॹ�ȓǔȗșǩșƞǔǿljǔॹ�ƺǿǐ�ǿȅƞǩκƺƞǩȅǿআ�șǔƞƞǩǿǡ�ǹȅλǔȗ�ǡȅƺǹș� for themselves; experiencing higher anxiety; and committing less to accomplish these goals (beaudoin & desrichard, 2011; lalitha & aswartha reddy, 2021). mse is an important construct within metamemory that has been used to explain the cognitive decline that occurs with aging (beaudoin & desrichard, 2011; /ǔȗƞφȅǡ�ǔƞ�ƺǹঀॹࢸࢹࢺࢲষঀ�xƺșƞ�ȗǔșǔƺȗljǧ�ǧƺș�ǩǐǔǿƞǩйǔǐ�ƺ�ljȅȗrelation between mse and memory task performance for older adults, with higher mse associated with better memory performance (lalitha & aswartha reddy, 2021; pearman & trujillo, 2013; sawin, 2021). other studies have found evidence that higher mse is predictive of memory performance in cases of both laboratory and simulated-everyday episodic memory tasks (turvey et al., 2000; west et al., 1996). in addition to being positively related to memory performance, such that low mse is related to poor memory performance (beaudoin & desrichard, 2011; lalitha & aswartha reddy, 2021; pearman & trujillo, 2013; sawin, 2021), mse has been found to be negatively related to beliefs about forgetting, such that stronger beliefs 62 about forgetting and aging being related was associated with lower mse (vallet et al., 2015). in addition to being related to one’s ability to remember, mse has been shown to be related to one’s ability to complete șǔǹǟেljƺȗǔ�ƞƺșƿșঀ�^ƺǹǩǿƺș�শࢲࢳࢱࢳষ�ǟȅȣǿǐ�ƞǧƺƞ�șǔǹǟেǔгljƺljρ�ǩș� related to self-management behaviors in older adults who live alone. similarly, vellone et al. (2016) found ƞǧƺƞ�ǩǿ�ƞǧȅșǔ�λǩƞǧ�ǩǿȓƺǩȗǔǐ�ljȅǡǿǩƞǩȅǿॹ�ȅǿǔঢ়ș�șǔǹǟেǔгljƺcy in being able to care for themselves was an importƺǿƞ� ǟƺljƞȅȗ� ƞǧƺƞ� ǩǿмȣǔǿljǔǐ� șǔǹǟেljƺȗǔ� ƺljǩǹǩƞǩǔșঀ� 2ǿ� ǟƺljƞॹ� ȅǿǔঢ়ș� șǔǹǟেǔгljƺljρ�ǿǔǐǩƺƞǔǐ� ƞǧǔ� ȗǔǹƺƞǩȅǿșǧǩȓ� ljǔƞλǔǔǿ� working memory ability and self-care ability, illustratǩǿǡ� ƞǧǔ� ǩǿмȣǔǿljǔ� ȅǟ� șǔǹǟেǔгljƺljρ� ǔκǔǿ�λǧǔǿ�λȅȗƿǩǿǡ� ǿǔǿȅȗρ� ǩș� ȓȅȅȗঀ�(ǩκǔǿ� ƞǧǔșǔ� йǿǐǩǿǡșॹ�tǔǹǹȅǿǔ� ǔƞ� ƺǹঀ� recommended interventions that could increase self-efйljƺljρ� ƺǿǐॹ� ǩǿ� ƞȣȗǿॹ� ǩǿȓȗȅκǔ� șǔǹǟেljƺȗǔঀ� �ǐǐǩƞǩȅǿƺǹǹρॹ� ȓƺșƞ�ȗǔșǔƺȗljǧ�ƺȓȓǔƺȗș�ƞȅ�șȣǡǡǔșƞ�ƺ�ǡǔǿǐǔȗ�ǐǩаǔȗǔǿljǔ�ǩǿ� mse, with fallan and opstad (2016), huang (2012), ƺǿǐ� vǔșƞ� ǔƞ� ƺǹঀ� শࢳࢱࢱࢳষ� йǿǐǩǿǡ� ƞǧƺƞ� ǿƺǹǔș� ȗǔȓȅȗƞǔǐ� ǧǩǡǧǔȗ� șǔǹǟেǔгljƺljρॹ� ƺǿǐ�λǔȗǔ�ǿȅȗǔ� ǹǩƿǔǹρ� ƞȅ� ȅκǔȗǔșƞǩmate their abilities, when completing cognitive tasks. working memory working memory is a memory/executive functioning ability that allows one to actively hold and manipulate information for a brief amount of time, such as reordering numbers or completing mathematical problems (aben et al., 2012; cowan, 2008; mccabe et al., 2010; miyake & shah, 1999). working memory has been measured in multiple ways, primarily with mental arithmetic or digit span tasks (wechsler, 2008). due to its role in planning, working memory ability is needed to complete vital self-care tasks, such as remembering to take medications or remembering that one took the medications. in fact, insel et al. (2006) found that working memory tasks ƺǿǐ� ǔπǔljȣƞǩκǔ� ǟȣǿljƞǩȅǿ� λǔȗǔ� ƞǧǔ� ȅǿǹρ� șǩǡǿǩйljƺǿƞ� predictors in a model used to predict medication ƺǐǧǔȗǔǿljǔঀ� xȅȅȗ� λȅȗƿǩǿǡ� ǿǔǿȅȗρ� ljƺǿ� ƺǹșȅ� ƺаǔljƞ� an individual’s participation in the community, as working memory is necessary for several aspects of social-cognitive information processing, including tracking a conversation, the information presented, relationships between others, names just learned, and others’ feelings towards topics (meyer et al., 2012). present study although past research has explored the relationship between mse and memory ability in general (lalitha & aswartha reddy, 2021; pearman & trujillo, 2013; sawin, 2021), to the best of the authors’ knowledge, only two studies have appeared to examine the relationship between mse and working memory. one study, ljȅǿǐȣljƞǔǐ�ljρ�/ȅаǿƺǿ�ƺǿǐ�^ljǧȗƺλ�শࢸࢱࢱࢳষॹ�ǩǿκǔșƞǩǡƺƞǔǐ�ƞǧǔ�ǩǿмȣǔǿljǔ�ȅǟ�șǔǹǟেǔгljƺljρ�ƺǿǐ�λȅȗƿǩǿǡ�ǿǔǿȅȗρ� ȅǿ�ǿƺƞǧǔǿƺƞǩljƺǹ�ȓȗȅljǹǔǿেșȅǹκǩǿǡ�ȓǔȗǟȅȗǿƺǿljǔঀ�/ȅаǿƺǿ�ƺǿǐ�^ljǧȗƺλ�ǟȅȣǿǐ�ƞǧƺƞ�șǔǹǟেǔгljƺljρ�λƺș�ljǔǿǔйljǩƺǹ� as demands on working memory increased, and these йǿǐǩǿǡș�ȓȗȅȓȅșǔǐ�ƞǧƺƞ�ȅǿǔঢ়ș�ƺljǩǹǩƞρ�ƞȅ�ǔгljǩǔǿƞǹρ�ƺǿǐ� șƞȗƺƞǔǡǩljƺǹǹρ�șȅǹκǔ�ȓȗȅljǹǔǿș�ǩǿljȗǔƺșǔǐ�λǩƞǧ�șǔǹǟেǔгljƺljρঀ� additionally, mashinchi et al. (2022) used a hierarchical regression analysis and found that mse explained a large, unique portion of variance in working memory ability after controlling for age, depression, and anxiety. further, the authors of the present study are unaware of any research that has investigated the relationship between mse and community participation. this șƞȣǐρ�șȅȣǡǧƞ�ƞȅ�йǹǹ�ƞǧǩș�ǡƺȓ�ǩǿ�ƞǧǔ�ǹǩƞǔȗƺƞȣȗǔ�ljρ�ǔπƺǿining the relationship between mse and community participation. hypotheses are as follows: 1) mse and working memory ability will be positively correlated λǩƞǧ�ljȅǿǿȣǿǩƞρ�ȓƺȗƞǩljǩȓƺƞǩȅǿ�λǧǩǹǔ�ǐǩгljȣǹƞρ�ǩǿ�ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿș�ƺǿǐ�ǐǩгljȣǹƞρ�ȗǔǿǔǿljǔȗǩǿǡ�ƺǿǐ� concentrating will be negatively correlated with community participation, with all variables having statistiljƺǹǹρ�șǩǡǿǩйljƺǿƞ�ǩǿǐǔȓǔǿǐǔǿƞ�ǔаǔljƞș�ȅǿ�ljȅǿǿȣǿǩƞρ�ȓƺȗƞǩljǩȓƺƞǩȅǿআ�ƺǿǐࢳ�ষ�ǿȅƞǩljǩǿǡ�ǿǔǿȅȗρ�ljǧƺǿǡǔșॹ�ǐǩгljȣǹƞρ� ǩǿ�ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿșॹ�ƺǿǐ�ǐǩгljȣǹƞρ�ȗǔǿǔǿljǔȗing and concentrating will all be negatively correlated with mse while working memory ability will be positively correlated with mse, with all variables having șƞƺƞǩșƞǩljƺǹǹρ� șǩǡǿǩйljƺǿƞ� ǩǿǐǔȓǔǿǐǔǿƞ� ǔаǔljƞș� ȅǿ� e^�ঀ method participants participants were all united states residents over the age of 55 and were recruited through mturk, an online community that completes surveys for moneƞƺȗρ� ȗǔλƺȗǐșঀ��ǿ�eeȣȗƿ�йǹƞǔȗ�λƺș�ƺȓȓǹǩǔǐ� ƞȅ�ǔǿșȣȗǔ� that all participants were united states residents. an eeȣȗƿ�ƺǡǔ�йǹƞǔȗ�λƺș�ƺȓȓǹǩǔǐॹ� șȣljǧ� ƞǧƺƞ�ȅǿǹρ�ȓƺȗƞǩljǩȓƺǿƞș�ƞǧƺƞ�йƞ�λǩƞǧǩǿ�ƞǧǔ�ƺǡǔ�ȓƺȗƺǿǔƞǔȗ�ȅǟࢶࢶ��ƺǿǐ�ȅǹǐǔȗ� were able to participate in the study. in order to participate in the study, potential participants had to achieve mashinchi, ravesloot 63 memory self-efficacy, community participation an approved task completion rate (hit rate) of 95%, meaning that they had to demonstrate worker quality by being approved by 95% of the researchers that they had completed studies for in the past. participants were excluded if they reported an age that was not over 55, if more than 5% of their data were missing, or if their data did not appear to be of high quality. two hundred and three eligible participants consented to participate in the study. one participant did not complete the demographic questionnaire but was inljǹȣǐǔǐ�ǩǿ�ƞǧǔ�йǿƺǹ�ƺǿƺǹρșǩșঀ���੢ࢱঀࢱࢶ�ǿȅǿǔƞƺȗρ� ǩǿljǔǿtive was awarded to participants in exchange for their time. an a priori power analysis for a linear multiple ȗǔǡȗǔșșǩȅǿॹ� йπǔǐ� ǿȅǐǔǹॹ� șǩǿǡǹǔ� ȗǔǡȗǔșșǩȅǿ� ljȅǔгljǩǔǿƞ� was conducted on g*power 3.1. this power analysis was two-tailed, the alpha error probability was set to .05, and the desired power was set to .95. results of this analysis yielded a sample size of at least 89 participants would be needed to achieve these parameters. assessments and measures demographics self-reported demographic information regarding age, gender, ethnicity, and educational attainment was collected from each participant. in the analyses, gender was binary coded, with 1 = male and 2 = female. additionally, participants were asked to indicate (yes/no) if they had noticed their ability to remember things had changed over the years. further, participants completed the washington group short set of questions on disability (centers for disease control and prevention [cdc], 2015), which queries any difйljȣǹƞρ� λǩƞǧ� șǔǔǩǿǡॹ� ǧǔƺȗǩǿǡॹ� λƺǹƿǩǿǡॹ� ȗǔǿǔǿljǔȗǩǿǡই concentrating, communicating, and/or completing self-care tasks using a 4-point likert scale with 1 = no ǐǩгljȣǹƞρ�ƺǿǐࢵ��઀�ljƺǿǿȅƞ�ǐȅ�ƺƞ�ƺǹǹঀ�eǧǔ�ȓȗǔșǔǿƞ�șƞȣǐρ� analyzed the data for items pertaining to remembering/concentrating and completing self-care tasks. edzȝȥȵͧ�^dzșǿण�ϭǩǚǩͧ� to assess participants’ mse, the present study ȣșǔǐ� ƺǿ� ƺǐƺȓƞƺƞǩȅǿ� ȅǟ� ƞǧǔ� eǔǿȅȗρ� ^ǔǹǟে�гljƺljρ� questionnaire (mseq; berry et al., 1989), which is designed to assess participants’ prediction of their memory ability. the authors of the present study adapted the mseq by including only the mseq’s ǐǩǡǩƞ� ȗǔljƺǹǹ� ǩƞǔǿșঀ� 'ȣȗƞǧǔȗॹ� ƞǧǔ� ǩƞǔǿș� λǔȗǔ� ǿȅǐǩйǔǐ� ƞȅ�șȓǔljǩйljƺǹǹρ�ƺșƿ�ȓƺȗƞǩljǩȓƺǿƞș�ƞȅ�ȓȗǔǐǩljƞ�ƞǧǔǩȗ�ǿǔǿȅry ability on the forward, backward, and sequencing conditions of the digit span memory task (adapted from wechsler, 2008). the present study’s measure of e^��λƺș� ǟȅȣǿǐ� ƞȅ�ljǔ�ǧǩǡǧǹρ� ȗǔǹǩƺljǹǔ� শݽ�઀� ঀࢴࢺষॹ�λǩƞǧ� alpha levels for each of the conditions as follows: ǟȅȗλƺȗǐ� শݽ�઀� ঀࢹࢸষॹ�ljƺljƿλƺȗǐ� শݽ�઀� ঀࢸࢹষॹ� ƺǿǐ� șǔȕȣǔǿljǩǿǡ� শݽ� ઀� ঀࢺࢸষঀ� ^ǔǔ�eƺljǹǔ� �ࢲ ǟȅȗ� ǩƞǔǿș� ƺǿǐ� ǩƞǔǿ�ǿǔƺǿș community participation to assess community participation, participants were administered the ten-item “undertaking activities” section of the maastricht social participation proйǹǔ�শe^xxআ�eƺȗș�ǔƞ�ƺǹঀॹࢺࢱࢱࢳ�ষঀ�eǧǩș�șǔljƞǩȅǿ�ǔπƺǿǩǿǔș� ljȅƞǧ� ljȅǿșȣǿȓƞǩκǔ� ȓƺȗƞǩljǩȓƺƞǩȅǿ�ৄ�λǧǩljǧ� ǩș� ǐǔйǿǔǐ� ƺș� ƺljƞǩκǩƞǩǔș� ƞǧƺƞ� ƺǹǹȅλ� ƺǿ� ǩǿǐǩκǩǐȣƺǹ� ƞȅ� ljǔǿǔйƞ� ǟȗȅǿ� ƞǧǔ�ȅаǔȗǩǿǡș�ȅǟ�șȅljǩǔƞρ�শǔঀǡঀॹ�ȓƺȗƞǩljǩȓƺƞǩǿǡ�ǩǿ�ƺ�ljȅȣȗșǔ� or eating at a restaurant) — and formal social particǩȓƺƞǩȅǿ�ৄ�λǧǩljǧ�ǩș�ǐǔйǿǔǐ�ƺș�ƺljƞǩκǩƞǩǔș�ƞǧƺƞ�ƺǹǹȅλ�ƺǿ� ǩǿǐǩκǩǐȣƺǹ�ƞȅ�ȅаǔȗ�ƺ�ljȅǿƞȗǩljȣƞǩȅǿ�ƞȅ�șȅljǩǔƞρ�শǔঀǡঀॹ�ȓƺȗticipating in organized volunteer work or organized clubs; mars et al., 2009). the ten items asked participants to indicate the frequency with which they parƞǩljǩȓƺƞǔǐ� ǩǿ� șȓǔljǩйlj� ljȅǿǿȣǿǩƞρ� ƺljƞǩκǩƞǩǔș� ǩǿ� ƞǧǔ�ȓƺșƞ� four weeks. the present study used a 4-point likert scale as follows: 1 = not at all, 2 = less than once a week, 3 = once or twice a week, and 4 = more than twice a week. the mspp has been found to have strong convergent validity and discriminant validity with the frenchay activities index, which is a measure of participation, similar to the mspp (mars et al., 2009).. working memory ability given the novelty of this project, the authors sought to use a reliable working memory task that has strong psychometric properties (wechsler, 2008). thus, a digit span task was used. this digit span task was similar to the wechsler adult intelligence scale fourth edition working memory index (wais-iv; wechsler, 2008). in the present study, the digit strings ȓȗǔșǔǿƞǔǐ� ƞȅ� ȓƺȗƞǩljǩȓƺǿƞș� ǐǩаǔȗǔǐ� ǟȗȅǿ� ƞǧǔ� șƞȗǩǿǡș� presented in the wais-iv, but the procedure was similar. the digits for this study’s task were presented on screen, making this a visual working memory task, whereas the wais-iv’s digit span task is a verbal memory task. this change in format of the digit șȓƺǿ� ƞƺșƿ� λƺș� ǿƺǐǔ� ƞȅ� ƺκȅǩǐ� ȓȗǔǐǩljƞǔǐ� ǐǩгljȣǹƞǩǔș� participants might encounter when completing an auditory digit span task, such as the need for working 64 mashinchi, ravesloot speakers, headphones, or assistive audio technology. participants were asked to remember a set of numbers under three varied conditions: forward, backward, ƺǿǐ�șǔȕȣǔǿljǩǿǡঀ�2ǿ�ƞǧǔ�йȗșƞ�ljȅǿǐǩƞǩȅǿॹ�ǐǩǡǩƞ�șȓƺǿ�ǟȅȗward, participants were instructed to recall the numbers in the same order in which they were presented. in the second condition, digit span backward, participants were instructed to recall the numbers in the reverse order with which they were presented (e.g., if presented 2-3, asked to recall it as 3-2). in the third condition, digit span sequencing, participants were asked to recall the digits presented in order from least to greatest in value (e.g., if presented 4-1-8, asked to recall it as 1-4-8). the string of numbers was presented one by one in the middle of the screen for one second. the numbers and timing were programmed to auto advance on the screen by a timer feature. an extra number was added to the digit string with each additional trial. once all digits of a string were presented, the screen changed to include a text box in which participants were instructed to type in each number string with one space between each number. the text box was programmed to recognize the correct answer. if correct, participants auto advanced to a digit string with an additional digit included. if not, participants were auto advanced to the second trial string, in which they were given another chance to answer a string with the same digit amount, identical to the wais-iv’s digit span. if participants answered this string incorrectly, participants auto advanced to the next condition (e.g., backward). scores were summed automatically by the software. the total digit span score ranges from 0-48, with each condition’s score ranging from 0-16. the present study’s digit span task had an internal reliability score of .92. additionally, the internal consistency reliability for the three conditions are as follows: digit span forward = .75, digit span backward = .81, digit span sequencing = .78. procedure the institutional review board at the university of montana approved this study prior to data collection. data were collected online using a qualtrics-based survey that was posted on mturk. first, participants reviewed the consent form and consented to participate in the study. once written consent was obtained, all participants completed the mse items, and then completed the digit span task. next, participants completed the washington group short set, the mspp, and the demographics questionnaire. finally, all participants ȗǔκǩǔλǔǐ�ƺ�ǐǔljȗǩǔйǿǡ�ǟȅȗǿॹ�ȅȣƞǹǩǿǩǿǡ�ƞǧǔ�ȓȣȗȓȅșǔ�ȅǟ� the study, and received a code to input into mturk to receive the monetary incentive for their participation. results participants the age of participants ranged from 55 to 80 years (m = 65.25, sd = 4.90) and were predominantly female (67%) and caucasian (66%). ninety-two percent of participants had an education greater than a high school degree. thirty-three participants reported that they noticed that their ability to remember things had changed over the years. seventy-eight participants reported that ƞǧǔρ�ǐǩǐ�ǿȅƞ�ǧƺκǔ�ǐǩгljȣǹƞρ�ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿșॹ� while 64% of participants reported that they did not ǧƺκǔ�ǐǩгljȣǹƞρ�ȗǔǿǔǿljǔȗǩǿǡ�ȅȗ�ljȅǿljǔǿƞȗƺƞǩǿǡঀ�^ǔǔ�eƺble 2 for the full demographic statistics of the sample. hypothesis tests the assumptions of linearity, normally distributed errors, and uncorrelated errors were assessed for all variables. the shapiro-wilks tests for each variable λƺș� șǩǡǿǩйljƺǿƞ� শȓș�ઃঀࢶࢱষॹ� ƺǿǐ�ƺ�κǩșȣƺǹ� ƺǿƺǹρșǩș�ȅǟ� ƞǧǔ� data revealed a slight positive skew in the distribution, as well as positively skewed clustering. thus, the data for these analyses deviate somewhat from a normal distribution warranting caution for interȓȗǔƞǩǿǡ� ƞǧǔ� șǩǡǿǩйljƺǿljǔ� ȅǟ� ǩǿǟǔȗǔǿƞǩƺǹ� ƞǔșƞ� șƞƺƞǩșƞǩljșঀ� a collinearity analysis was conducted to examine any problematic correlations between predictor variables. in accordance with denis (2016), which stated that a vif score of 10 suggests that a study’s parameƞǔȗݾ��λƺș�ǿȅƞ�ljǔǩǿǡ�ȓȗǔljǩșǔǹρ�ǔșƞǩǿƺƞǔǐ�ǐȣǔ�ƞȅ�ƺ�ǹƺȗǡǔ� șƞƺǿǐƺȗǐ� ǔȗȗȅȗॹ� ƞǧǔ� ȓȗǔșǔǿƞ� șƞȣǐρ� ȣșǔǐ� ƺ� t2'� ljȣƞȅа� score of 10. vif scores for all variables passed this ljȣƞȅа� ǟȅȗ�ljȅƞǧ� ȗǔǡȗǔșșǩȅǿ� ƺǿƺǹρșǔș� শƺǹǹ�t2'ș�ઃࢲ�ঀࢴࢺষঀ� prior to computing the regression analyses, binary pearson r correlations were computed to examine the relationships between each variable (see table 3). conƞȗƺȗρ�ƞȅ�ƞǧǔ�йȗșƞ�ǧρȓȅƞǧǔșǩșॹ�ȗǔșȣǹƞș�ȗǔκǔƺǹǔǐ�ƞǧƺƞ�ƞǧǔ�ȗǔlationships between community participation and the ǟȅǹǹȅλǩǿǡ� κƺȗǩƺljǹǔș� λǔȗǔ� ljȅƞǧ� șƞƺƞǩșƞǩljƺǹǹρ� șǩǡǿǩйljƺǿƞ� শȓș�ઃ� ঀࢲࢱࢱষ�ƺǿǐ�ȓȅșǩƞǩκǔ� ǩǿ�ǐǩȗǔljƞǩȅǿॸ�e^�ॹ�ǐǩгljȣǹƞρ� ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿșॹ�ƺǿǐ�ǐǩгljȣǹƞρ�ȗǔǿǔǿljǔȗǩǿǡই concentrating. working memory ability was negatively correlated with community participation (p < .001). 65 memory self-efficacy, community participation community participation a multiple linear regression analysis was conǐȣljƞǔǐ� ƞȅ� ǔπƺǿǩǿǔ� ǧȅλ�e^�ॹ� ǐǩгljȣǹƞρ� ljȅǿȓǹǔƞǩǿǡ� șǔǹǟেljƺȗǔ� ƞƺșƿșॹ� ǐǩгljȣǹƞρ� λǩƞǧ� ȗǔǿǔǿljǔȗǩǿǡইljȅǿljǔǿtrating, and working memory ability are associated with community participation. entering all variables into the equation explained 45% of the variance in community participation (r2 = .45, adj. r2 = .42, f(7, 141) = 16.26, p < .001; see table 4). greater mse was positively related to more community participaƞǩȅǿ�শݾ�઀� ঀࢹࢴॹ�ȓ�ઃ� ঀࢲࢱࢱষॹ�ƺș�ȓȗǔǐǩljƞǔǐঀ�/ȅλǔκǔȗॹ�ljȅǿƞȗƺȗρ� ƞȅ� ƞǧǔ� йȗșƞ� ǧρȓȅƞǧǔșǩșॹ�λȅȗșǔ�λȅȗƿǩǿǡ�ǿǔǿȅȗρ� ƺljǩǹǩƞρ� শݾ� ઀� েঀࢳࢳॹ� ȓ� ઀� ঀࢲࢱࢱষ� ƺǿǐ� ǧƺκǩǿǡ� ǡȗǔƺƞǔȗ� ǐǩгljȣǹƞρ�ȗǔǿǔǿljǔȗǩǿǡইljȅǿljǔǿƞȗƺƞǩǿǡ�শݾ�઀�ঀࢷࢳॹ�ȓ�ઃ�ঀࢲࢱࢱষ� predicted higher levels of community participation. eǔǿȅȗρ�^ǔǹǟে�гljƺljρ a multiple linear regression analysis was conductǔǐ�ƞȅ�ǔπƺǿǩǿǔ�ǧȅλ�ǐǩгljȣǹƞρ�ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿșॹ� ǐǩгljȣǹƞρ�λǩƞǧ�ȗǔǿǔǿljǔȗǩǿǡইljȅǿljǔǿƞȗƺƞǩǿǡॹ�ƺǿǐ�ǿȅƞǩljing memory changes are associated with mse. entering all variables explained 13% of the variance in mse, r2 = .13, adj. r2 = .09, f(7, 140) = 2.95, p = .007; see table �ষঀ��ȅǿƞȗƺȗρ�ƞȅ�ƞǧǔ�șǔljȅǿǐ�ǧρȓȅƞǧǔșǩșॹ�ǡȗǔƺƞǔȗ�ǐǩгljȣǹƞρࢶ ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿș�শݾ�઀ࢱ�ঀࢵࢳॹ�ȓ�઀�ঀࢳࢱষॹ�ƺǿǐ�ǡǔǿǐǔȗ�শݾ�઀�েࢱঀࢳࢳॹ�ȓ�઀�ঀࢲࢱষ�ȓȗǔǐǩljƞǔǐ�ǧǩǡǧǔȗ�ǹǔκǔǹș�ȅǟ�e^�ঀ discussion findings �ȅǿșǩșƞǔǿƞ�λǩƞǧ�ƞǧǔ�йȗșƞ�ǧρȓȅƞǧǔșǩșॹ�ǡȗǔƺƞǔȗ�e^�� was positively associated with community participaƞǩȅǿঀ�eǧǩș�йǿǐǩǿǡ�ǿǩǡǧƞ�șȣǡǡǔșƞ�ƞǧƺƞ�ȅǿǔঢ়ș�ljǔǹǩǔǟș�ƺljȅȣƞ� ƞǧǔǩȗ�ǿǔǿȅȗρ�ljƺǿ�ǩǿмȣǔǿljǔ�λǧǔƞǧǔȗ�ƞǧǔρ�ljǧȅȅșǔ�ƞȅ�ȓƺȗticipate in community activities or not. for example, if an individual does not think that their memory ability is strong, especially compared to their friends or to others they might interact with, they might choose to stay home to avoid embarrassment or the stress of attendǩǿǡ�ƞǧǔ�ǔκǔǿƞঀ�/ȅλǔκǔȗॹ�ljȅǿƞȗƺȗρ�ƞȅ�ƞǧǔ�йȗșƞ�ǧρȓȅƞǧǔșǩșॹ�λȅȗșǔ�λȅȗƿǩǿǡ�ǿǔǿȅȗρ�ƺljǩǹǩƞρ�ƺǿǐ�ǡȗǔƺƞǔȗ�ǐǩгljȣǹty remembering/concentrating also predicted higher levels of community participation. this is surprising, as the literature has proposed that those experiencing ljȅǡǿǩƞǩκǔ�ǐǩгljȣǹƞρ�ƺȗǔ�ǿȅȗǔ�ǹǩƿǔǹρ�ƞȅ�ǔπȓǔȗǩǔǿljǔ�șȅljǩƺǹ� isolation (dinapoli et al., 2014; shankar et al., 2013). � eǧǔ�йǿǐǩǿǡș�ȅǟ� ƞǧǔ�ȓȗǔșǔǿƞ� șƞȣǐρ�ǿǩǡǧƞ� șȣǡǡǔșƞ� that individuals who experience greater cognitive ǐǩгljȣǹƞρ�ǿǩǡǧƞ� ƞǔǿǐ� ƞȅ� șǔǔƿ� ȅȣƞ� ƺǹƞǔȗǿƺƞǩκǔॹ� ȓǹǔƺșȣȗ able activities or activities that might enhance their social support, which is contrary to the idea that this ǩǿljȗǔƺșǔǐ� ǐǩгljȣǹƞρ�λȅȣǹǐ� ǹǔƺǐ� ǩǿǐǩκǩǐȣƺǹș� ƞȅ� șƞƺρ� ƺƞ� ǧȅǿǔ�ǐȣǔ�ƞȅ�ƞǧǔ�ǔπƞȗƺ�ǔаȅȗƞ�ǩƞ�ƞƺƿǔș�ƞȅ�ǹǔƺκǔ�ƞǧǔǩȗ�ǧȅǿǔঀ� further, an explanation might be found in greenglass et al. (2006), which examined how proactive coping — a form of coping in which an individual views stressors as challenges rather than threats — was related to greater functional independence and lower depression in older adults. it is possible that older adults λǩƞǧ�ǐǩгljȣǹƞρ�κǩǔλ�ljȅǿǿȣǿǩƞρ�ƺljƞǩκǩƞǩǔș�ƺș�ljǧƺǹǹǔǿǡes, motivating them to participate in order to achieve and maintain independence (greenglass et al., 2006) � vǩƞǧ� ȗǔǡƺȗǐ� ƞȅ� e^�ॹ� ƺ� șȣȗȓȗǩșǩǿǡ� йǿǐǩǿǡ� ƞǧƺƞ� contradicted the second hypothesis was that greater ǐǩгljȣǹƞρ�ljȅǿȓǹǔƞǩǿǡ�șǔǹǟেljƺȗǔ�ƞƺșƿș�λƺș�ǟȅȣǿǐ�ƞȅ�ȓȗǔdict higher levels of mse. it is possible that this study’s results were an example of the role that social desirability can play in mse and memory performance, as explored by sawin (2021). social desirability refers to one’s desire to minimize negative and enhance positive attributes of themselves, which can result in underreporting negative behaviors while overreporting positive behaviors (latkin et al., 2017; sawin, 2021). in these cases, as potentially suggested by the present study’s data, one might overreport their memory abilǩƞρ�ǩǿ�ƺǿ�ǔаȅȗƞ�ƞȅ�ljȅǿljǔƺǹ�ƞǧǔǩȗ�ǔπȓǔȗǩǔǿljǔ�ȅǟ�ǐǩгljȣǹƞρ� completing self-care tasks. this would also provide an explanation as to why working memory ability was negatively related to community participation, ƺș� ǩƞ� ǩș�ȓȅșșǩljǹǔ�ƞǧƺƞ�ǿǔǿȅȗρ�ƺljǩǹǩƞρ� ǩș�ǿȅƞ�ƺș� ǩǿмȣǔǿtial as social desirability is. if correct, this idea would contrast with the literature that examines the threat of stereotypes associated with aging (e.g., older adults are not as cognitively able strictly due to their age), on an individual’s abilities on memory tasks, such that ability is reduced due to buy-in of these stereotypes (chasteen et al., 2005; stein et al., 2002). if older adults instead choose to overreport their memory ƺljǩǹǩƞρॹ�ƺƞƞǔǿȓƞǩǿǡ�ƞȅ�ƺȓȓǔƺȗ�ljǔƞƞǔȗ�ȅа�ƞǧƺǿ�ƞǧǔρ�ƺȗǔॹ� then this social desirability factor might have a greatǔȗ�ǔаǔljƞ�ƞǧƺǿ�șƞǔȗǔȅƞρȓǔș�ƺșșȅljǩƺƞǔǐ�λǩƞǧ�ƺǡǔ�ȅȗ�ǐǩгculty completing self-care tasks could have on ability.. 'ȣȗƞǧǔȗॹ�ȅȣȗ�йǿǐǩǿǡș�ǩǹǹȣșƞȗƺƞǔǐ�ƞǧƺƞ�ǿǔǿ�ǧƺǐ�ǧǩǡǧer mse compared to women. this was similar to the йǿǐǩǿǡș�ȅǟ�'ƺǹǹƺǿ�ƺǿǐ�kȓșƞƺǐ�শࢷࢲࢱࢳষ�ƺǿǐ�/ȣƺǿǡ�শࢳࢲࢱࢳষॹ� λǧǩljǧ�ȅljșǔȗκǔǐ�ƞǧƺƞ�ǿƺǹǔș�ȗǔȓȅȗƞǔǐ�ǧǩǡǧǔȗ�șǔǹǟেǔгljƺljρ� on math tasks. it is possible that the working memory 66 mashinchi, ravesloot task was considered by participants to be a math task because it involved numbers, which could help explain ƞǧǔ� ǡǔǿǐǔȗ� ǐǩаǔȗǔǿljǔș� ȗǔκǔƺǹǔǐ� ǩǿ� ƞǧǔ� ȓȗǔșǔǿƞ� șƞȣǐρঀ � 'ǩǿƺǹǹρॹ�ǡǩκǔǿ�ȓƺșƞ�ȗǔșǔƺȗljǧ�йǿǐǩǿǡș�ƞǧƺƞ�e^��λƺș� positively related to working memory, it was surprising that mse was not positively related to working memory. it is possible that the executive functioning component of working memory caused the relationship between mse and memory that was observed in past research to not be true of working memory. it is also possible that the present study’s limitations, which are discussed in detail below, led to a positive relationship between mse and working memory remaining undetected. limitations and suggestions for future research the present study was subject to three primary limitations: 1) a lack of diversity in the sample, 2) recruiting participants via mturk, 3) participants were asked to self-report their levels of community participation. � ^ȓǔƺƿǩǿǡ�ƞȅ�ƞǧǔ�йȗșƞ�ǹǩǿǩƞƺƞǩȅǿॹ�ǿȅșƞ�ȓƺȗƞǩljǩȓƺǿƞș� ǩǐǔǿƞǩйǔǐ� ƺș� ǟǔǿƺǹǔ� শࢷࢷঀࢹઔষॹ��ƺȣljƺșǩƺǿ� শࢶࢷঀࢷઔষॹ� ƺǿǐ� achieved higher than a high school education (91.5%). this lack of variation could decrease the external vaǹǩǐǩƞρ�ȅǟ�ƞǧǩș�șƞȣǐρঢ়ș�йǿǐǩǿǡșঀ�'ȣƞȣȗǔ�ȗǔșǔƺȗljǧ�șǧȅȣǹǐ� retest these hypotheses with a larger and more diverse sample to increase the ability to generalize results. second, all participants were recruited using mturk, which is an online survey platform created by amazon. this could have limited the external validity ȅǟ� ƞǧǔ� йǿǐǩǿǡșॹ� ƺș� ȓƺȗƞǩljǩȓƺƞǩǿǡ� ǩǿ� ƞǧǔ� ȓȗǔșǔǿƞ� șƞȣǐρ� would have required technical skills to get on mturk, as well as awareness about mturk’s monetary incentives in exchange for participation in research studies. eǧǩș�ljȅȣǹǐ�ȓƺȗƞǩljȣǹƺȗǹρ�ƺаǔljƞ�ƞǧǔ�ȓȅȓȣǹƺƞǩȅǿ�ƞǧƺƞ�ǩș�ljǔing examined in this study, as older adults are less likely to possess technological skills and be aware of mturk, compared to younger populations. it is possible that the older adults who participated in this study possess characteristics that might serve as a latent, confoundǩǿǡ�κƺȗǩƺljǹǔ�ƞǧƺƞ�ǿǩǡǧƞ�ǧƺκǔ�ƺаǔljƞǔǐ�ƞǧǔ�ȓȗǔșǔǿƞ�șƞȣǐρঢ়ș� йǿǐǩǿǡșॹ� ƺǹƞǧȅȣǡǧ� ƞǧǔȗǔ� ǩș� ǔκǩǐǔǿljǔॹ� ȣșǩǿǡ� ƞǧǔ� șƺǿǔ� method and population sample as the present study, to suggest that the memory performance of an mturk șƺǿȓǹǔ�ȅǟ�ȅǹǐǔȗ�ƺǐȣǹƞș�ǐȅǔș�ǿȅƞ�ǐǩаǔȗ�ǟȗȅǿ�ƺ�ǿȅȗǿƺtive, traditional sample of older adults (mashinchi et al., 2021). future research should use one sample to conduct data collection through two methods: 1) via mturk data collection, and 2) via in-person data colǹǔljƞǩȅǿॹ� ƺǿǐ� ƞǧǔǿ�ljȅǿȓƺȗǔ� ƞǧǔ�йǿǐǩǿǡș� ƞȅ�ǐǔƞǔȗǿǩǿǔ� ǩǟ� ƞǧǔȗǔ� ƺȗǔ� ǐǩаǔȗǔǿljǔș� ǩǿ� ƞǧǔ� ǔπȓǔȗǩǔǿljǔș� ȅǟ� ȓƺȗƞǩljǩȓƺǿƞș�ǐȣǔ�ƞȅ�ƞǧǔ�ǐǩаǔȗǔǿljǔ�ǩǿ�ǐƺƞƺ�ljȅǹǹǔljƞǩȅǿ�ǿǔƞǧȅǐঀ � 'ȣȗƞǧǔȗॹ� ƞǧǔ� ƺǡǔ� йǹƞǔȗș� ƞǧƺƞ� eeȣȗƿ� ƺǹǹȅλș� ƺȗǔ� ȓȗǔșǔƞ� ƺǿǐ� ȣǿǿȅǐǩйƺljǹǔঀ� 'ǩǟƞρেйκǔ� ƺǿǐ� ȅǹǐǔȗ� ǩș� ƞǧǔ� oldest age grouping that can be selected. this means that those 55-64 years old were included in the study. there is evidence that this age range is when subjective memory complaints begin (jenkins et al., 2019), which would result in a low reported mse, and thus would be an important age sample to include in this study. despite this evidence, the 55-64 age grouping is not often subject to concerns about cognitive decline (aartsen et al., 2002). it is possible that this minimum age could have negatively skewed the results from the present study and might serve as an explanation as to why a positive relationship between mse and working memory was not found. similarly, the median age of participants was 65 years old, which is on the younger end of the age range, and might have led to an inability to detect a relationship between mse and working memory. future research should seek to recruit older ȓƺȗƞǩljǩȓƺǿƞș�ƺǿǐ�ljȅǿȓƺȗǔ�йǿǐǩǿǡș�ƞȅ�ƞǧǔ�ȓȗǔșǔǿƞ�șƞȣǐρ� in order to determine if there is a point at which mse, working memory ability, or community participation changes (e.g., comparing 65-year-old scores to 85-yearold scores). given that the human population is getting older (crimmins, 2015; semenova & stadtlander, 2016), this distinction will be important to determine. additionally, it is important to note that 23 (6.5%) participants were excluded because their reported age was younger than 55. although the mturk йǹƞǔȗ�λƺș�ȣșǔǐ�ƞȅ�ȗǔljȗȣǩƞ�ȅǿǹρ�ƞǧȅșǔࢶࢶ��ƺǿǐ�ȅǹǐǔȗॹ�ǩƞ�ǩș� possible that some participants have found ways to ljρȓƺșș� ƞǧǔ�йǹƞǔȗ� ǩǿ�ȅȗǐǔȗ� ƞȅ� ljȅǿȓǹǔƞǔ� ƞƺșƿș� ǟȅȗ�ǿȅǿetary incentives. given these issues, the authors of the present study echo the recommendation made by chmielewski and kucker (2019) to screen data for completion, validity, and reliability prior to conducting analyses. researchers using mturk might need to plan to recruit more participants that an a priori power analysis suggests are needed for the study. third, the community participation data for this study was collected using a self-report measure. this option could allow for participants to erroneously recall how often they have engaged in community activities, either by over or underestimating. future research should include measures beyond self-re 67 memory self-efficacy, community participation port, such as asking participants to receive a stamp or initial on a card every time they participate in a community event. it is also possible that variables not accounted for in the present study, such as the geographic location and the socioeconomic status of both individuals and the community, might be related to community participation. future research should seek to include these variables in their explorations. in addition to future research suggestions to address limitations, future research should also further examine how proactive coping might have explained the present study’s results and determine λǧǔƞǧǔȗ� ȅǹǐǔȗ� ƺǐȣǹƞș� λǩƞǧ� ǐǩгljȣǹƞǩǔș� κǩǔλ� ljȅǿǿȣnity activities as motivated challenges to secure independence, as suggested by greenglass et al. 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(ǔǿǐǔȗ� ƺǿǐ� ƺǡǩǿǡॸ� ^ȓƺƞǩƺǹ� șǔǹǟেǔгljƺljρ� ƺǿǐ� ǹȅcation recall. basic and applied social psychology, 24(1), 71–80. https://doi.org/10.1207/ s15324834basp2401_7 70 mashinchi, ravesloot 71 memory self-efficacy, community participation 72 mashinchi, ravesloot 73 memory self-efficacy, community participation 74 mashinchi, ravesloot tcjournalv2.3 issn 1088-4661 2009 volume 11 graduate student journal of psychology brian sherman anitha venkataramani-kothari editors published annually by the department of counseling and clinical psychology teachers college, columbia university graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2006 by the department of counseling & clinical psychology 2006, vol. 8 teachers college, columbia university issn 1088-4661 needs assessment of spanish language training for psychologists and other professionals in a university community jamie e. brass indiana university of pennsylvania populations of native spanish-speakers and latinos in the united states are growing and moving into parts of the country that are not prepared to provide services to them. little information is available for psychologists who are interested in increasing competence in working with linguistic minorities. faculty members and graduate students at indiana university of pennsylvania were surveyed to determine if training in the areas of spanish language and working with latino populations would benefit the university community. responses indicated that many people were interested in obtaining training and that psychologists in particular seemed to see the importance and utility of such training. those developing training programs must consider that respondents were not willing to spend much time or money to obtain training. the latino population in the united states is growing rapidly and is projected to constitute 20% of the overall population of this country by the year 2010 (dingfelder, 2005). in the united states, spanish is spoken by about 12% of the population, is the second most common language in 43 states, and some areas of the united states are populated by a majority of spanish speakers (wikipedia, downloaded 2005). given this information, it appears that there may be an increasing need for individuals in service industries, such as the field of psychology, to have cultural competency in working with latino populations. in addition, proficiency in spanish may be necessary to work effectively with the growing population of native spanish speakers. a literature search on therapy or other mental health work with bilingual (spanish and english) individuals in their native language yielded few results. the available literature suggests that therapists and mental health professionals should consider factors such as the ability of a client to speak in english if it is not his or her native language, keeping in mind that the emotional content of speech may be lost or confused in translation from spanish to english (santiago-rivera, 2001). the current literature does not give much attention to how language might be used by therapists during therapeutic interventions, even though it is clear that language can be important when considering obstacles to successful therapy. other researchers have noted that therapy may be more meaningful for bilingual indiv ms. brass is a graduate student in the department of psychology, indiana university of pennsylvania. the author would like to thank dr. husenits of the department of psychology for her support and encouragement on this needs assessment and other studies of this nature. correspondence concerning this article should be addressed to jamie e. brass at 201 uhler hall, indiana university of pennsylvania, indiana, pa 15705. iduals if it is conducted in their primary language, or if the individual is permitted to switch between dominant and non-dominant languages to clarify his or her expressions (guttfreund, 1990). several researchers interviewed for recent articles on therapy with latino clients indicated that latinos drop out of therapy more often than european americans and that the rate of drop-out may be due to clients not feeling understood, either from a cultural or linguistic perspective (dingfelder, 2005; dittman, 2004). given the shortage of research in this area, it would not be surprising to find that many therapists are unsure of how to proceed with latino clients. as latinos continue to move into areas that are not currently populated by linguistic and cultural minorities, there is an increased need for spanish language and cultural competence training for professionals in a variety of fields (bender & harlan, 2005). part of this training includes learning how to take into account appropriately the importance of language and cultural meaning with those for whom spanish is their first language (zuniga, 1992). this is particularly necessary when dealing with the emotional content of speech and the affect observed when individuals speak their native language (guttfreund, 1990). another aspect involves preparing professionals to speak spanish fluently within their professional realms (bender & harlan, 2005). because the literature on working with bilingual individuals is so scarce, and because there are many different factors involved in such work, a needs assessment was conducted to determine what type of training is desired by professionals and graduate students in a variety of fields, and in psychology in particular. this pilot study was conducted at indiana university of pennsylvania (iup), in indiana, pennsylvania. method participants 10 brass 11 this survey was sent to all iup faculty and graduate students with valid email addresses. requests for participation were sent to 2,895 individuals and 13.1% of those individuals responded. measure participants were asked to complete a web-based survey that requested information on demographics, work habits, and interest in trainings/workshops on both working with latino populations and learning spanish. respondents were asked to complete a demographic questionnaire to provide a more complete picture of those individuals participating in the study. information gathered included ethnicity, native language, experience with other languages, and the departmental affiliation of the respondent. additional information was sought to establish whether respondents worked with minorities on a regular basis, had encountered individuals who spoke little or no english, and had worked directly with latinos. information was also obtained to assess interest and willingness to participate in a workshop designed to teach spanish and skills for working with latino populations. design participants were contacted via email and asked to follow a link to a web-based survey. one week after initial contact a reminder email, which included a second request for participation, was sent to individuals who had not responded. all emails and data collection were handled by a third party, studentvoice, so that anonymity could be assured. data gathered from respondents were analyzed globally to assess the composition of the university community and its need for training. information from respondents in psychology departments on campus was analyzed in greater depth because a training program specific to psychologists was the ultimate goal of this needs assessment. results university-wide analysis data collected from the needs assessment survey were analyzed in terms of percentages of people endorsing a certain item. three hundred eighty people from 65 departments on campus responded to the survey. they represent 13.1% of the population of faculty and graduate students at iup. the majority of respondents identified themselves as european-american (80.5%). asian-americans (9.2%), african-americans (2.9%), and latino/hispanic individuals (1.8%) were the largest minority groups represented. several individuals (3.2%) surveyed declined to answer the question regarding ethnicity. respondents identified 20 native languages, with english listed as the majority language (86.3%). chinese (3.2%) and arabic (2.1%) were identified as the second and third most frequently spoken native languages. over 79% of participants indicated some level of experience, ranging from beginner status to fluent, with one of 18 second languages spoken by respondents. of those who spoke a second language, 40.2% spoke spanish, 17.5% spoke french, 9.9% spoke german, and 2.6% spoke italian. only 10.7% of the respondents who indicated that they spoke spanish were fluent. two hundred fifteen respondents (56.6%) indicated that they worked with minority individuals on a regular basis. a group of respondents (46.8%) indicated that they had interactions with people who spoke little or no english. spanish was the primary language of 34% of the non-english speakers encountered. a majority of people (59.7%) indicated that it would be beneficial for them to speak spanish, and 66.1% of respondents indicated that they would like to begin or continue learning to speak spanish. additionally, 57.6% of respondents indicated that they would benefit from training on working effectively with latino populations. respondents were surveyed as to their interest in a hypothetical conference that would include training in both spanish-language and working with latino populations. almost half (47.9%) of the respondents were willing to pay for a conference, and over a third were interested in a training that lasted one day or less. approximately 18 % of respondents said they would be interested in attending a weekend-long training, and a longer, one week training interested 10.5% of respondents. analysis of psychology departments respondents from psychology departments or programs comprised 22.4% of the total sample, or 85 individuals. of that group, 78.8% of individuals were female and 22.4% of individuals were male. the majority of respondents in this group indicated that they were european-american (90.6%) and were native english speakers (97.6%). a majority (71.8%) of respondents indicated that they had some experience with one of seven other languages. the language most represented was spanish and 40% of respondents endorsed some level of experience with the language. most psychology department respondents who indicated that they spoke spanish considered themselves beginners (44.1%). no one indicated fluency in spanish. less than half of the respondents in the psychology group indicated that they worked with minorities (30.6%), had encountered non-english speakers (28.2%), or interacted with latinos (23.5%) on a regular basis. of those who worked with minorities, only 7.7% indicated that they worked with latinos. however, of those who had encountered non-english speakers, 62.5% indicated that they encountered people who spoke spanish. needs assessment of spanish language training 12 despite the low numbers of psychology department respondents who worked regularly with minorities, most people indicated that they would like to have training in working with latino populations (78.8%) and/or in spanish language (77.6%). roughly 46% of respondents indicated that they were willing to spend up to $100 on training and 29.4% of were willing to devote one day to such training. an additional 27.1% of respondents were willing to spend one weekend on training. ability to earn continuing education units would make 61.2% of people more willing to participate in training in spanish or in working with spanish-speaking/latino populations. discussion indiana university of pennsylvania is comprised of people from a variety of ethnic groups and who speak a number of different primary languages. although iup is a small, rural school, the faculty and graduate students seemed motivated to gain the knowledge necessary to work with minority groups, and with spanish-speaking and other latino populations in particular. many individuals indicated that they had some experience speaking spanish, had worked with latinos in some professional capacity, and were interested in additional training in spanish and in working with spanish-speaking and latino minority groups. over 50% of individuals surveyed said that they thought it was beneficial to speak spanish and that they would like to learn to do so. when the responses of individuals who identified themselves as members of a psychology department were analyzed, similar findings were encountered. the subsample of psychology department respondents indicated that they were more homogeneously european-american and englishspeaking than the total sample. a greater proportion of respondents in this category indicated some experience speaking spanish, although no respondent was fluent. as was found with those from other departments, psychology department respondents indicated some amount of regular work with latinos and some encounters with individuals who speak only spanish. however, a much larger percentage of psychology department respondents indicated an interest in training in spanish, an interest in working with minority cultures, a greater belief that speaking spanish could be beneficial to their careers, and a greater desire to learn to speak spanish. given the support for trainings in spanish language and in interacting with latinos in a professional capacity, it was interesting to note that less than 30% of respondents were willing to spend more than $100 and less than 35% of respondents were willing to devote more than one weekend to such training. the ability to earn continuing education credits seemed to be an influential factor contributing to whether an individual would be willing to participate in a training session. when compared to information gathered at the university level, psychology department members were not willing to spend as much money to receive training as other respondents. however, respondents from the psychology department showed a greater interest in trainings in spanish language and in working with latinos than did respondents from the university as a whole. based on the information gathered, particularly from the psychology subset of respondents, it appears that there is an interest in training in spanish language and in working with latino populations. unfortunately, many of the individuals surveyed did not feel that they could devote much time or money to training in this area. future research might explore what would make people more willing to attend language training and how an effective spanish language and cultural skills training program could be developed at a minimum cost. additionally, it may be worth exploring intensive immersion workshops for spanish language training as so few individuals seemed to have the time for or the willingness to devote the time to longer, more traditional training programs. limitations this study had a number of limitations that should be addressed in future research. first, potential participants were contacted by email, which would preclude participation by those individuals who do not regularly access their university-issued email accounts. also, it is possible that those individuals who chose to participate did so because they already had an interest in this area and so were more willing to take the time to respond. thus, response bias was a concern with this study and limited its generalizability. there was also no way to differentiate between respondents who were graduate students and respondents who were faculty. it is likely that individuals in training programs might have a different pattern of responses than those individuals working in the field and teaching at the university. additionally, iup is located in a small-town area surrounded by rural communities. a different pattern of results might have been found at a larger university or at a university in a more urban or coastal location. it might be interesting to compare results from this study with results from another university. finally, members of many other departments on a university campus might be unlikely to encounter individuals on a regular basis whose primary language is spanish. last, limiting the survey to individuals in service, medical, or mental health areas might also yield both different overall results and results more relevant to the needs of mental health service providers and their clients. conclusion and future directions this study highlighted the interest in increasing cultural competency that exists even among members of a rural university community. it may provide a starting point for brass 13 future research into the training needs of mental health professionals and how best to meet those needs. the fact that a number of individuals at a small university expressed interest in this study indicates that there might be more support for training in spanish language and cultural competency among professionals and students in urban areas and at large schools. information gathered from this study will be used to develop a pilot workshop designed to teach mental health professionals basic spanish language skills and cultural competency for use in working with latino populations. with that in mind, the response bias encountered in this study may not be as problematic as it could have been because those individuals with an interest in this type of workshop are probably the individuals most likely to participate in the survey. despite the limitations of this study, valuable information was obtained and can be used in the development of future studies and programs. as the population of spanish-speaking individuals throughout united states grows, there will be a greater need for training people who provide services to the community. this is especially true in rural areas where fewer professionals may have had exposure to foreign languages or contact with diverse cultures. development of bilingual or multilingual training programs for mental health practitioners and other service providers in the community should be a priority. references bender, d. e. & harlan, c. (2005). increasing latino access to quality health care: spanish language training for health professionals. journal of public health management practice, 11(1), 46-49. dingfelder, s. f. (2005). closing the gap for latino patients. monitor on psychology, 36(1), 58-61. dittman, m. (2005). homing in on mexican americans’ mental health success. monitor on psychology 36(1),70-71. dittman, m. (2004). more minority providers means fewer service gaps. monitor on psychology, 35(10), 46-47. guttfreund, d. g. (1990). effects of language usage on the emotional experience of spanish-english and englishspanish bilinguals. journal of consulting and clinical psychology, 58(5), 604-607. santiago-rivera, a. l. (2001). developing a culturally sensitive treatment modality for bilingual spanishspeaking clients: incorporating language and culture in counseling. journal of counseling & development, 74, 12-17. spanish in the united states. retrieved october 25, 2005 from wikipedia.com. zuniga, m. e. (1992). using metaphors in therapy: dichos and latino clients. social work, 37(1), 55-60. microsoft word letter from the editors.docx individually, we are one drop. together, we are an ocean. –ryunosuke sator letter from the editors: now in its 11th year, the graduate student journal of psychology (gsjp) has made great progress in its efforts to bring student research to the forefront. as with past editors of the gsjp, we began this academic year with several ideas on how to improve upon the previous issue. and much to our delight, the journal’s increased exposure (across the u.s. and canada) and growing number of article submissions called for organizational restructuring. we were quick to identify areas within our editorial process that could be streamlined. while maintaining the intrinsic excitement and charm of a student group, we adopted a structured management style putting into place our first editorial board. our editors began work on their respective divisions at the very beginning of the academic year fulfilling their responsibilities assiduously as the year progressed. it is our belief that the benefits of implementing a formal structure to our process are evident in this final product – volume 11. submissions were reviewed, re-reviewed, copy-edited, and formatted in a seamless sequence yielding one of the journal’s most diverse volumes ranging from the physiology of psychotherapy to neuroscience and the law. the breadth and depth of the articles in this issue reflects the focused effort of every member of our dedicated editorial board. of course, we also greatly value the work of our contributing authors, not only for their important and interesting research, but also for their commitment and cooperation throughout this journey. finally, we would like to acknowledge our faculty advisor and director of clinical training, dr. barry farber, who has been the cornerstone of our journalistic endeavors providing sage advice and support while encouraging independent decisionmaking. going forward, we plan to keep enhancing the journal and expanding our readership, and in so doing, adding to gsjp’s brilliant legacy. we hope you enjoy the final product of our combined efforts as much as we did producing it. brian j. sherman anitha venkataramani-kothari editor-in-chief editor-in-chief 2 5 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university merging multiple and/or divergent datasets using spss: a method review and tutorial lillian m. audette, katherine a. johnson, marie s. hammond, jenna s. lehmann, and michael oyeteju, department of psychological sciences & counseling, tennessee state university many researchers face problems merging multiple datasets with divergent or mismatched cases and/or variables to form a more complete dataset. this is particularly true when conducting research with humans in which data is obtained from multiple sources, such as self-report questionnaires, institutional databases, and/or collateral contacts. challenges that occur in ȣƞǩǹǩφǩǿǡ�ǐƺƞƺ�ǟȗȅǿ�ǐǩκǔȗǡǔǿƞ�șȅȣȗljǔș�ǩǿljǹȣǐǔ�ǐǩаǔȗǔǿƞ� șƞȗȣljƞȣȗǔșॹ�ǐǩаǔȗǔǿƞ�ǟȅȗǿƺƞșॹ�ȅȗ�ƞǧƺƞ�ǐƺƞƺ�ǩș�ǩǿljȅǿȓǹǔƞǔ� when compared to the original dataset. the present article focuses on merging multiple datasets either generated longitudinally or containing ǐǩаǔȗǔǿƞ�κƺȗǩƺljǹǔșঀ��πƺǿȓǹǔș�ȅǟ�ƞǧǔ�ǐƺƞƺșǔƞș�ƞȅ�λǧǩljǧ� we refer include pre-/post-testing for intervention research, longitudinal research utilizing two or more waves of data, or instances in which data from multiple sources related to the same case. these datasets are likely to be mismatched in that they may not contain the same variables (in the instance of adding cases) or may not include the same cases (in the instance of adding variables). other relevant datasets might be considǔȗǔǐ� ৚ljȅǿȓǹǔπ৛� ǩǿ� ƞǧƺƞ� ƞǧǔ�ǐƺƞƺșǔƞș� ljȅǿƞƺǩǿ�ǐǩаǔȗǔǿƞ� κƺȗǩƺljǹǔș�ƺǿǐ�ǧƺκǔ�ǐǩаǔȗǔǿljǔș�ǩǿ�ljƺșǔșঀ�'ȅȗ�ǔπƺǿȓǹǔॹ�ǩƞ� may be that graduate students working as a part of a larger research team are tasked with managing the data and will need to understand the process and steps to ǔгljǩǔǿƞǹρ�ljȅǿljǩǿǔ�ƞǧǔșǔ�ǐƺƞƺșǔƞșঀ� it should be noted that in order to align with current terminology, rather than describing these datasets ƺș� ৚ljȅǿȓǹǔπॹ৛� λǧǩljǧ� ǧƺș� ƺ� șȓǔljǩйlj� ǿǔƺǿǩǿǡ� λǩƞǧǩǿ� the social sciences (guha et al., 2009), we will use the term “divergent” to refer to datasets that do not match variable for variable, time frame by time frame, and/or case for case. further, the term “merge” will be used in this article rather than “combining” in that combining implies a common data structure that facilitates bringing the datasets together, while the term “mergǩǿǡ৛�ƞρȓǩljƺǹǹρ�ȗǔǹǩǔș�ȅǿ�ƺ�৚ƿǔρ৛�ȅȗ�৚ǩǐǔǿƞǩйǔȗ৛�κƺȗǩƺljǹǔ� that provides the common link between the datasets. this is distinct from data fusion, which occurs when multiple data sources are integrated without full preservation of all data (haghighat et al., 2016). the goal of the process to be described is that the datasets are merged in such a way that all data is retained from its ȅȗǩǡǩǿƺǹ�ǐƺƞƺșǔƞ�ǩǿ�ƞǧǔ�йǿƺǹ�ȓȗȅǐȣljƞঀ� when it comes to merging two or more datasets that contain mismatching and/or missing cases, several complications could occur – resulting in compromised analyses. for instance, mismatched data may indicate that data were added to the dataset incorrectly. additionally, missing data can result in decreased analysis power or, depending on the analysis required, may prevent an analysis from being completed entirely. accurate dataset merging is vital to prevent potential errors from being introduced, prevent data loss, and allow researchers to have more reliable and valid datasets with which to conduct analyses. thus, the accurate merging of discrete datasets allows researchers to conduct analyses on a more accurate dataset, therefore producing results that have greater reliability, are more generalizable, and are more replicable. for the purposes of this article, the focus will stay on mismatched or divergent dataset merging using spss software. literature review to assess the need for an informative guide regarding how to merge mismatched datasets, the authors chose two separate approaches to conducting the lit 'ȅȗ�ǿƺǿρ�ȗǔƺșȅǿșॹ�ȗǔșǔƺȗljǧǔȗș�ȓǹƺljǔ�ƞǧǔǩȗ�ǐƺƞƺ�ǩǿ�ǿȣǹƞǩȓǹǔ�ǔǹǔljƞȗȅǿǩlj�ǐƺƞƺșǔƞș�ƺǿǐ�ǹƺƞǔȗ�йǿǐ�ƞǧƺƞ�ƞǧǔρ�λǩșǧ�ƞȅ�ljȅǿljǩǿǔ�ƞǧȅșǔ�ǐƺƞƺșǔƞș� for a particular analysis. this article reports on an analysis of the extant literature on combining multiple and/or divergent datasets ƺǿǐ�ȓȗȅκǩǐǔș�ljȅƞǧ�ƺ�ƞȣƞȅȗǩƺǹ�ƺǿǐ�ȗǔǹƺƞǔǐ�șρǿƞƺπ�ƞǧƺƞ�ljȅǿljǩǿǔș�ǿȅǿেǿƺƞljǧǩǿǡ�ǐƺƞƺșǔƞș�শǩঀǔঀॹ�ǟȗȅǿ�ǐǩаǔȗǔǿƞ�șȅȣȗljǔșষ�ǩǿ�șȣljǧ�ƺ�λƺρ� ƞǧƺƞ�ƺǹǹ�ǐƺƞƺ�ǩș�ljȅǿƞƺǩǿǔǐ�ǩǿ�ƞǧǔ�йǿƺǹ�ljȅǿljǩǿǔǐ�ǐƺƞƺșǔƞ�λǩƞǧ�ǩǐǔǿƞǩйljƺƞǩȅǿ�ȅǟ�ǐƺƞƺ�șȅȣȗljǔঀ�eǧǩș�șρǿƞƺπ�ȗǔȓȗǔșǔǿƞș�ƺǿ�ǩǿȓȗȅκǔǿǔǿƞ� over the existing spss (v23-v27) combining dataset routines in terms of 1) expanding the types of datasets that can be combined, 2) ljȅǿȓǹǔƞǔǿǔșș�ȅǟ�ƞǧǔ�ȗǔșȣǹƞǩǿǡ�ǐƺƞƺșǔƞॹ�ƺǿǐࢴ�ষ�ǟƺljǩǹǩƞƺƞǩǿǡ�ǿƺǿƺǡǔǿǔǿƞ�ȅǟ�ǿȣǹƞǩȓǹǔ�ƺǿǐইȅȗ�ǐǩκǔȗǡǔǿƞ�ǐƺƞƺ�șǔƞșঀ��ǿ�ƺǐǐǩƞǩȅǿƺǹ�ljǔǿǔйƞ� of using this process is the incorporation of a method to test the accuracy of the merged data and thus verify the data quality. the spss syntax along with instructions and examples are reviewed in the article. keywords: spss, syntax, datasets, merging, longitudinal data 6 audette et al. erature searches. first, a literature search using the research databases ebscohost (which is an umbrella dataset encompassing approximately 70 individual publisher databases), web of science, sage premier, science direct, and google scholar was conducted. the boolean search phrase utilized for this search was as follows: spss and dataset and (merg* or combin* or concatenat* or mung* or wrangl*). for databases that do not use the boolean system exactly (e.g., google scholar), these search terms were added manually to the advanced search settings of each database. the terms mung and wrangle were incorporated once we discovered that these terms are used outside of psychology to describe the data-cleaning process, which includes dataset merging (braun et al., 2018; endel & piringer, 2015; rattenbury et al., 2017). the above search phrase and its individual search terms were used to identify articles containing these terms in their abstracts. the resulting list from ebscohost provided 27 peer-reviewed articles, while the web of science search produced 24. none of these results acknowledged the problem of merging mismatched or divergent datasets. a second literature search was conducted using google and google scholar. since google scholar uses a limited form of boolean, the search phrase was changed to the following: spss and dataset and (merge or merged or merging or combine or combination or combining or combined or mung or munging or munged or concatenate or concatenated or concatenating or wrangle or wrangled or wrangling). other combinations of these search terms were also used (e.g., data wrangling, data munging, merging datasets). the results of this search found examples of both peer-reviewed articles and books that address dataset merging, but neither focused on mismatched dataset merging nor used spss for this purpose. previous research literature on merging datasets for analyses of psychological data primarily used the statistical analysis system (sas) software (foley, 1998; foley, 2005) for this process, rather than spss. parenthetically, research literature reviewed the steps ƞȅ�ȅljƞƺǩǿ�ƺ�ǿǔȗǡǔǐ�ǐƺƞƺșǔƞ�λǩƞǧ�ƞǧǔ�șȓǔljǩйlj�κƺȗǩƺljǹǔș� and cases of interest. again, however, no mention was made of merging mismatched or divergent datasets. scholarly works and textbooks were reviewed to identify potentially helpful instruction in this area. both works that did focus on the use of spss and works that did not specify which program they recommended using covered only basic dataset merging practices. these sources either did not provide information on ƞǧǔ� ǐǩгljȣǹƞǩǔș� ǹǩƿǔǹρ� ƞȅ� ljǔ� ǔǿljȅȣǿƞǔȗǔǐ� ǩǿ� ǿǔȗǡǩǿǡ� mismatched or divergent datasets (stehlik-barry & babinex, 2017) or they only emphasized the importance of considering these challenges without providing guidance or details on its technicalities (braun et al., 2018; endel & pringer, 2015; rattenbury et al., 2017). guides on merging datasets for non-psychological research purposes have also not focused on spss, but rather on software programs such as r and python (ojeda et al., 2014). there does, however, appear to be plenty of gray literature (articles not formally published by commercial academic publishers) surrounding this topic in spss (haddaway et al., 2015, p. 1). examples of this gray literature include 1) websites that host questions, discussions, and video tutorials related to the common practices for merging datasets (coyer, 2013; truong, 2016), 2) academic websites with instructions (coleman, n.d.; glynn, 2002), 3) basic commands given by international business machine (ibm; ibm, n.d.); and 4) other spss tutorial websites (spss-tutorials.com, n.d.). however, most of the gray literature provides limited basic commands such as merge datasets or compare datasets, which do not adequately ƺǐǐȗǔșș�șȓǔljǩйlj�ǐǩκǔȗǡǔǿƞ�ȅȗ�ǿǩșǿƺƞljǧǔǐ�ǐƺƞƺșǔƞ�ǿǔȗǡing issues encountered by researchers. dataset merging methods requirements to address the above-mentioned issues, the extant litǔȗƺƞȣȗǔ� ȓȗǔκǩȅȣșǹρ� ǩǐǔǿƞǩйǔǐ�λƺș� ȗǔκǩǔλǔǐ� ƞȅ� șȣȗǟƺljǔ� existing guidelines and/or requirements. this type of information was found primarily in the gray literature (e.g., coleman, n.d.; coyer, 2013; decator, 2015; 2�eॹ� ǿঀǐঀআ� eȗȣȅǿǡॹ� ǿঀǐঀষঀ� ^ǩπ� ȗǔȕȣǩȗǔǿǔǿƞș� ȅǟ� ǔаǔljtive dataset merging methods to ensure the accuracy ȅǟ�ǐƺƞƺ�λǔȗǔ� ǩǐǔǿƞǩйǔǐ� ǟȗȅǿ� ƞǧǩș� ǹǩƞǔȗƺƞȣȗǔঀ�eǧǔ�йȗșƞ� three requirements are basic expectations of any dataset merging method (coleman, n.d.; coyer, 2013). the next three requirements are more complex and are șȓǔljǩйlj� ƞȅ�ǿǔȗǡǩǿǡ�ǐƺƞƺșǔƞș� ƞǧƺƞ�ljȅǿƞƺǩǿ�ȅκǔȗǹƺȓȓǩǿǡ� variables as well as overlapping cases, and whose cases sometimes contain mismatched data (decator, 2015; ibm, n.d.; truong, n.d.). these six requirements have implications for the structure and variables contained ǩǿ�ƞǧǔ�йǿƺǹ�ljȗǔƺƞǔǐ�ǐƺƞƺljƺșǔॹ�ƺș�λǩǹǹ�ljǔ�ǐǩșljȣșșǔǐ�ljǔǹȅλঀ 7 merging multiple and/or divergent datasets in spss requirement 1: include all cases eǧǔ�ǿǔȗǡǔǐ�ǐƺƞƺljƺșǔ� শйǿǩșǧǔǐ�ȓȗȅǐȣljƞষ� șǧȅȣǹǐ�ljȅǿtain all the cases from dataset 1 and all the cases from dataset 2 (and any additional datasets). the case data from each respective dataset should be faithfully replicated in the merged database. requirement 2: include all variables the merged database should hold all the variables present in all datasets, as well as all variables present in only one of the datasets. the width, number of decǩǿƺǹ�ȓǹƺljǔșॹ� ǹƺljǔǹșॹ�κƺǹȣǔ� ǹƺljǔǹșॹ�ǿǩșșǩǿǡ� șȓǔljǩйljƺƞǩȅǿॹ� ljȅǹȣǿǿ�λǩǐƞǧॹ�ƺǹǩǡǿǿǔǿƞॹ�ǿǔƺșȣȗǔ�șȓǔljǩйljƺƞǩȅǿॹ�ƺǿǐ� role of each variable should be faithfully replicated in the merged database. requirement 3: variable settings fidelity the merging method integrates variables without changing the variable regardless of the type (numeric, string) and regardless of measure (scale, nominal, ordinal). in addition to the three basic requirements listed above (coleman, n.d.; coyer, 2013), the merged database should provide researchers with three additional pieces of information. the following requirements are more complex, intending to assist researchers when the datasets to be merged are suspected of containing unique, overlapping, or mismatched cases, all of which șǧȅȣǹǐ�ljǔ�ǩǿljǹȣǐǔǐ�ǩǿ�ƞǧǔ�йǿƺǹ�ǐƺƞƺljƺșǔঀ� requirement 4: indication of unique cases by dataset a merged database should provide information as to when a case is unique to dataset 1 or dataset 2 (rather than being present in both original datasets), and which dataset it originates from. for example, a merged dataset should tell us if a case with id 13 exists uniquely in dataset 1 or dataset 2. requirement 5: indication of overlapping cases a merged database should indicate when a case in dataset 1 is also a case in dataset 2. for example, a merged database should tell us if a case with id 16 originated in dataset 1 and whether it also exists in dataset 2. requirement 6: indication of mismatched data by case a merged database should tell us when a case in dataset 1 and a case in dataset 2 have a matching id but contain mismatching data while retaining both instances of data in the merged database. detecting mismatching data is a crucial requirement when merging datasets whose data, cases, or variables do not perfectly match using spss. for example, a merged database should tell us if a case with id 16 in dataset 1 has “brief cognitive behavioral therapy” entered for the “treatment” variable, but a case with id 16 in dataset 2 has “brief object relations therapy” entered for the “treatment” variable. in addition, both instances of data should be preserved within the merged database. for example, we should see both forms of cases with id 16 in the merged database, one with “brief cognitive behavioral therapy” and one with “brief object relations therapy” entered for “treatment.” thus, an indicator of match/mismatch and the retention of both instances of the data should appear in the merged database. to clarify several of the six requirements (discussed above) should be represented by one or more variables within the merged dataset. new variables within the dataset should be generated to represent at least one, if not more, of the six requirements. each of the six requirements should be encoded into a variable λǩƞǧǩǿ� ƞǧǔ� ǐƺƞƺșǔƞঀ� eǧǔ� йǿƺǹ�ǿǔȗǡǔǐ� ǐƺƞƺșǔƞ� șǧȅȣǹǐ� ǩǿljǹȣǐǔॹ� ǩǿ�ƺ� șȓǔljǩйlj�κƺȗǩƺljǹǔॹ� ƞǧǔ�ǐƺƞƺșǔƞ�ǿƺǿǔ�ǟȗȅǿ� which each case was taken. this must be a unique variable, separate from the other variables. for example, for one of the authors’ research projects, data was ǡƺƞǧǔȗǔǐ� ǟȗȅǿ�ƞǧȗǔǔ�ǐǩаǔȗǔǿƞ� ǩǿșƞǩƞȣƞǩȅǿșঀ� 2ǿ� ƞǧǩș� ǩǿstance, in merging the data a new variable was created λǧǩljǧ�ǩǐǔǿƞǩйǔǐ�ƞǧǔ�ǐƺƞƺșǔƞইǩǿșƞǩƞȣƞǩȅǿ�ȅǟ�ȅȗǩǡǩǿঀ�eǧǩș� variable, included in the merged dataset, provides information about the origin of the data and thus met this requirement. thus, the dataset of origin variable should not rely on non-encoded methods (such as case origin based upon the cases’ ordering i.e., spss row number) within the dataset. if case origin is denoted ljρ�ljƺșǔ�ȅȗǐǔȗॹ�ƺǿǐ�ƞǧǔ�йǿƺǹ�ǿǔȗǡǔǐ�ǐƺƞƺșǔƞ�ǩș�ǔκǔȗ�ȗǔেȅȗdered, the information regarding case origin could be lost. to summarize, each of the six dataset merging reȕȣǩȗǔǿǔǿƞș�ǿȣșƞ�ljǔ�ǟȣǹйǹǹǔǐ�ljρ�ljǔǩǿǡ�ǔǿljȅǐǔǐ�ƺș�șǔȓarate variables within the dataset or in such a way that the information cannot be easily lost. conducting the dataset merge currently, spss does not include a built-in function that would perform a dataset merge that ensures all six requirements (above) are met. for example, the add files command does not identify cases that are unique to one of a researcher’s original datasets, 8 nor is it able to identify duplicate cases that have mismatched data, thus, not meeting requirements 4 and 6. the merge datasets command does not meet requirements 4, 5, or 6. in order to meet requirement 1 using merge datasets, additional syntax is needed. similarly, the match files command does not meet requirements 1, 4, 5, or 6. finally, the compare datasets command does not meet requirements 1, 2, 3, or 4. in determining which syntax best meets all six requirements, a literature review was conǐȣljƞǔǐ�λǧǩljǧ�ρǩǔǹǐǔǐ�йκǔ�শࢶষ�ƿǿȅλǿ�ȓȅșșǩljǹǔ�ǿǔƞǧȅǐș� for combining datasets in spss. a total of 12 experǩǿǔǿƞș�λǔȗǔ� ljȅǿǐȣljƞǔǐ�ȣșǩǿǡ� ƞǧǔ�йκǔ�ǿǔƞǧȅǐșॹ�λǩƞǧ� ǔƺljǧ�ǿǔƞǧȅǐ�йȗșƞ�ljǔǩǿǡ�ƞǔșƞǔǐ�ǩǿ�ǩƞș�șǩǿȓǹǔșƞ�ǟȅȗǿ�ƺǿǐ� then tested again in more complex forms. a summary of the experiments conducted, and their outcomes can be found in table 1. � eǧǔ�йǿƺǹ�ȓȗȅǐȣljƞ� শljƺșǔǐ�ȅǿ� ƞǧǔ�ȅȣƞljȅǿǔ�ȅǟ� ǔπperiment 12) was a set of spss syntax to successfully overcome the challenges associated with merging mismatched datasets using the least number of steps. it should be noted that the following steps were developed using spss v23 (ibm corp., 2015) and tested using spss v25 and v27 (ibm corp., 2017, 2020). it should be noted that conducting the merge using this syntax works across all versions including spss v28 (ibm corp., 2021); however, changes made to v28 in the point-and-click options may create a mismatch between the instructions provided herein. spss syntax the following instructions on how to use the syntax are applicable when researchers have two datasets that they wish to merge. it can also be used repeatedly if more than two datasets must be merged. please refer to appendix a for the syntax related to each step. 2ƞ� ǩș�ƺǹșȅ� ǩǿȓȅȗƞƺǿƞ�ƞȅ�ǿȅƞǔ�ƞǧƺƞ� ƞǧǔ�йǡȣȗǔș�ȓȗȅκǩǐǔǐ� ƞǧȗȅȣǡǧȅȣƞ�ƞǧǩș�șǔljƞǩȅǿ�ƺȗǔ�șǩǿȓǹǩйǔǐ�ǡȗƺȓǧǩljș�ȅǟ�ƞǧǔ� analysis for demonstration only and were not conǐȣljƞǔǐ�ȣșǩǿǡ�ƞǧǔ�șȣȓȓǹǔǿǔǿƞƺǹ�йǹǔșঀ��eǧǔ�șȣȓȓǹǔǿǔǿƞƺǹ�йǹǔș�ƺȗǔ�ȓȗȅκǩǐǔǐ�ǟȅȗ�ƞǧǔ�ȓȣȗȓȅșǔ�ȅǟ�ȓȗƺljƞǩljǩǿǡ�ƞǧǔ� procedure with a more realistic dataset. original datasets for variables shared by the two original datasets, the variable information should match perfectly (type, width, label, values, etc.). the following steps will erroneously identify matching variables as separate variables when they do not have identical characteristics (type, width, etc.). before beginning the next steps, identify which dataset will be your “dataset 1” and open both original datasets. see figure 1 for an example of two original datasets to be merged. it is also necessary to clean the data from each of the datasets to be merged to the best of one’s ability before beginning the dataset merging process. syntax step 1: comparing cases between datasets the purpose of step 1 is to create a new variable that encodes the number of unique cases present in dataset 1, the number of cases present in both original datasets that are perfectly matched, and the number of cases present in both original datasets that contain mismatching data. the output will identify the location of the mismatched data in the dataset. please note that the datasets will remain separate. step 1 uses pointand-click to run the compare datasets command (which can be found under the data menu). before running the command, make the following point-and-click changes. in the “compare” tab, put the id variable in case ids, and put all “matched fields” into “fields to compare.” in the “attributes” tab, select “do not compare the data dictionaries.” 2ǿ�ƞǧǔ�৚kȣƞȓȣƞ৛�ƞƺlj�șǔǹǔljƞ�৚мƺǡ�ǿǩșǿƺƞljǧǔș�ǩǿ�ƺ�ǿǔλ� йǔǹǐ৛�ƺǿǐ�ǿƺǿǔ�ƞǧǔ�ǿǔλ�κƺȗǩƺljǹǔ�λǧƺƞ�ρȅȣ�λǩșǧ�শλǔ� used “mismatches”). also, in the “output” tab, unselect “limit the case-by-case table.” click “paste” and run the resulting syntax on dataset 1. see figures 2a and 2b for example datasets 1 and 2 after step 1 as well as an example output after step 1. audette et al. figure 1: simple datasets pre-combination. this is a simple example of two separate, mismatched datasets. 9 step 2: merging variables and cases into one dataset and identifying cases by dataset step 2 merges all variables and cases into dataset 1. from dataset 1, select merge files then add cases command. this is also found in the data menu. before running the command, make the following point-and-click changes. put all “unpaired variables” in “variables in new active dataset.” as needed, manually pair variables from the two original datasets. select “indicate case source as variable” and name the new variable that you wish to use (we used “sourcedataset2”). click “paste” and run the resulting syntax on dataset 1. this step will add all variables and all cases to dataset 1. it will also identify which cases come from dataset 1 or dataset 2 in the newly created variable. see figure 3 for the example dataset 1 after step 2. after completing this step, it may be helpful to label the values of this new variable, the syntax for which can be found in appendix a. a value of 1 indicates that a case originates from dataset2 while a value of 0 indicates that a case originates from dataset 1. step 3: identifying mismatches, matches, and unique cases within dataset 1 step 3 duplicates the variable created in step 1, which ǩǐǔǿƞǩйǔș� ǿǩșǿƺƞljǧǩǿǡॹ� ǿƺƞljǧǩǿǡॹ� ƺǿǐ� ȣǿǩȕȣǔ� ljƺșǔș� present in dataset 1. the duplicated variable is the one that will be manipulated in steps 4 and 5. step 3 can be done with the syntax (provided in appendix a) using your preferred variable names inserted (we used “casescompared”). the resulting duplicate variable only encodes information about matches, mismatches, and unique dataset 1 cases for those cases from dataset 1. the duplicated variable contains no information for cases added from dataset 2, a problem that will be addressed in step 4 and step 5. see figure 4 for the example dataset 1 after step 3. once again, we suggest labeling the values of this new variable. a value of 1 in merging multiple and/or divergent datasets in spss figure 2a: simple mismatched datasets in spss after step 1. this is an example of what the new variable created via step 1 would look like once added. figure 2b: example step 1 output. this is an example of the output that would be generated after completing step 1 which provides a summary of case comparisons between the two datasets. figure 3: spss data view after step 2. this is an example of the variables added after step 2 which includes all variables existing in dataset 2 that do not exist in dataset 1 and a new variable that ǩǐǔǿƞǩйǔș�ƞǧǔ�șȅȣȗljǔ�ȅǟ�ǔƺljǧ�ljƺșǔঀ 10 dicates a mismatch between both datasets, 0 represents a match in both datasets, and -1 indicates that a case is unique to dataset1. the syntax for creating these labels can be found in appendix a. step 4: labeling matches and mismatches from dataset 2 step 4 uses the syntax we developed (utilizing the lag function), and the variables created in steps 2 and 3. utilizing the lag function and the “sourcedataset2” variable, step 4 encodes for all cases within the newly created “casescompared” variable (from step 3). step 4 encodes information as to whether the case is a match between datasets, a mismatch between datasets, or unique to dataset 1. this step is important because without it only cases from dataset 2 would have information encoded in the “casescompared” variable. again, the syntax is found in appendix a. when running the syntax, be careful to change the variable names to your chosen variable names, and to run the șȅȗƞǩǿǡ�șρǿƞƺπ�йȗșƞ�শλǔ�ǩǿljǹȣǐǔǐ�ǔπƺǿȓǹǔș�ƞȅ�ǟƺljǩǹǩƞƺƞǔ� understanding). your id variable must be in numerical descending order (e.g. 1, 1, 2, 3, 4, 4), with cases from dataset 1 listed or appearing before cases from dataset 2. this syntax solves the problem from step 3, however, the variable “casescompared” still does not encode when a case is unique to dataset 2. see figure 5 for the example dataset 1 after step 4. step 5: identifying cases unique to dataset 2 step 5 encodes in the “casescompared” variable when cases are unique to dataset 2. the syntax can be found in appendix a. since the only cases with no data in “casescompared” are those which are unique to �ƺƞƺșǔƞࢳ�ॹ�ƞǧǩș�șρǿƞƺπ�ǩǐǔǿƞǩйǔș�ǔǿȓƞρ�ǐƺƞƺ�ǩǿ�৚�ƺșǔșcompared” and encodes them as unique to dataset 2. the syntax also includes a method of labeling this new value. see figure 6 for the example dataset 1 after step 5. discussion � eǧǔȗǔ� ǩș� șǩǡǿǩйljƺǿƞ� ǹǩƞǔȗƺƞȣȗǔ� ƞǧƺƞ� ȓȗȅκǩǐǔș� ƞȣƞȅȗǩƺǹș� ƺǿǐ� ǩǿșƞȗȣljƞǩȅǿș�ȅǿ� ƞǧǔ�ljƺșǩlj�ǿǔȗǡǩǿǡ�ȅǟ�йǹǔș� λǩƞǧ�ǩǐǔǿƞǩljƺǹ�κƺȗǩƺljǹǔș�ƺǿǐইȅȗ�ljƺșǔșঀ�^ǩǡǿǩйljƺǿƞ� ǹǩƞǔȗature discussing these basic merging techniques can be found for programs such as r, spss, and stata. what has not been discussed in the literature but may be of use to students and researchers using smallto medium-sized datasets, is a procedure that reliably merges datasets with missing or mismatched cases and/or variables within spss. while numerous software programs are used to conduct research, one of the more frequently used software programs to teach statistical analysis, particularly within the social sciences, is spss. oftentimes students are introduced to data analysis using the drop-down menus within spss rather than syntax. this article has provided information on both the use of drop-down menus and syntax to conduct data merging. depending on the individual’s comfort level and the version of spss being used, ǔǩƞǧǔȗ� ȅǟ� ƞǧǔșǔ� ȓȗȅljǔǐȣȗǔș�ǿƺρ� ljǔ�ǿȅȗǔ� ǔаǔljƞǩκǔঀ� 2ǿ� the case of an individual using version 27 or earlier, the drop-down menus provide point-and-click ease of conducting the analysis. while for those with greater comfort and/or facility using syntax, merging using the syntax is likely to be more comfortable regardless of the version used. there are several advantages to using this proceǐȣȗǔ�ƞȅ�ǿǔȗǡǔ�ǐǩκǔȗǡǔǿƞ�ǐƺƞƺșǔƞșঀ�eǧǔ�йȗșƞ�ƺǐκƺǿƞƺǡǔ� is that it allows the researcher to store all data within a single dataset. this facilitates data analysis for most procedures. the second advantage is that by having all data in one dataset, analyses accounting for missing audette et al. figure 4: spss data view after the creation of a variable that 2ǐǔǿƞǩйǔș�eǩșǿƺƞljǧǔșॹ�eƺƞljǧǔșॹ�ƺǿǐ�hǿǩȕȣǔ��ƺșǔș�[ǔǡƺȗǐǩǿǡ� cases originating from dataset 1 (step 3). figure 5: ^x^^��ƺƞƺ�tǩǔλ��ǟƞǔȗ�^ƞǔȓࢵ��λǧǩljǧ�2ǐǔǿƞǩйǔș�eǩșmatches and matches in cases originating from dataset 2. figure 6: ^x^^��ƺƞƺ�tǩǔλ��ǟƞǔȗ�^ƞǔȓࢶ��λǧǩljǧ�2ǐǔǿƞǩйǔș��ƺșǔș� unique to dataset 2. 11 data are more easily conducted from within one dataset rather than across multiple datasets. the third advantage is that this procedure allows one to conduct analyses that can only be performed within a single dataset. the fourth advantage is that embedded within the syntax is a data quality check which increases the likelihood that the merged data is accurate and represents the population of interest. an additional consideration is related to the speed ȅȗ�ǔгljǩǔǿljρ�ȅǟ�ƞǧǔ�ȓȗȅljǔǐȣȗǔঀ�2ƞ�șǧȅȣǹǐ�ljǔ�ǿȅƞǔǐ�ƞǧƺƞ� ƞǧǔ�șȓǔǔǐॹ�ǔгljǩǔǿljρॹ�ƺǿǐ�ƺǿȅȣǿƞ�ȅǟ�șƞȅȗƺǡǔ�ȗǔȕȣǩȗǔǐ� ƞȅ�ljȅǿƞƺǩǿ�ƞǧǔ�ǐƺƞƺșǔƞ�λǩǹǹ�ljǔ�ƺаǔljƞǔǐ�ljρ�ƞǧǔ�șǩφǔș�ȅǟ�ƞǧǔ� datasets involved. large datasets (such as those found in the national center for education statistics, etc.), will require greater computing power and storage capacity than smaller datasets. conclusion merging datasets accurately is vital to ensuring that no data is altered or lost and that researchers can easily understand the sources of all their data. presently, there is no consensus on best practices for merging spss datasets with overlapping and potentially mismatched cases. the present article introduces one method to handle such a situation. the recommended method results in a merged dataset that includes all cases and variables, in their original form, stemming from ƞλȅ�ȅȗ�ǿȅȗǔ�ȅȗǩǡǩǿƺǹ�ǐƺƞƺșǔƞșঀ�2ƞ�ljȗǔƺƞǔș�ƺǿ�ȅȣƞȓȣƞ�йǹǔ� ƞǧƺƞ�ǩǐǔǿƞǩйǔș�ǔƺljǧ�ǩǿșƞƺǿljǔ�ȅǟ�ljƺșǔ�ǿǩșǿƺƞljǧ�ƺǿǐ�ƞǧǔ� location of each mismatch within the dataset. it also results in a single variable that encoded whether a case was 1) a perfect match between datasets 2) a mismatch between datasets with non-matching data 3) unique to one dataset and which original dataset contains that unique case. alternative strategies are recommended when the datasets to be merged contain overlapping cases but no or few shared variables. references braun, m. t., kuljanin, g., & deshon, r. p. (2018). special considerations for the acquisition and wrangling of big data. organizational research methods, 21(3), 633-659. https://doi. org/10.1177/1094428117690235 coleman, m. (n.d.). merging datasets in spss. retrieved december 12, 2017, from http://www.d.umn.edu/~mcoleman/tutorials/spss/merge. html coyer, l. (2013, april 20). /ȥ͡�ǩǚȟ�ͧȥɂ�ȝdzȵǿdz�ȿ͡ȥ�ϫșdzȸ� in spss when the cases are not perfectly the same? [online forum post]. researchgate. retrieved december 12, 2017, from https://www.researchǡƺƞǔঀǿǔƞইȓȅșƞই/ȅλউljƺǿউρȅȣউǿǔȗǡǔউƞλȅউйǹǔșউ in_spss_when_the_cases_are_not_perfectly_ the_same. decator, d. d. (2015, february 8). spss syntax part 4: double entry comparison. retrieved october 12, 2017, from https://www.ddecator. com/blog/2015/2/spss-syntax-part-4-double-entry-comparison endel, f., & piringer, h. (2015). data wrangling: making data useful again. ifac-papersonline, 48(1), 111-112. https://doi.org/10.1016/j.ifacol.2015.05.197 foley, m. j. 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(2009). visualization databases for the analysis of large complex datasets. proceedings of the 12th 2ǿƞǔȗǿƺƞǩȅǿƺǹ� �ȅǿǟǔȗǔǿljǔ� ȅǿ� �ȗƞǩйljǩƺǹ� 2ǿƞǔǹǹǩgence and statistics (aistats), usa, 193-200. retrieved october 20, 2022 from https://proceedings.mlr.press/v5/guillory09a.html. haddaway, n. r., collins, a. m., coughlin, d., & kirk, s. (2015). the role of google scholar in evidence reviews and its applicability to grey literature searching. plos one, 10(9). https://doi. org/10.1371/journal.pone.0138237 haghighat, m., abdel-mottaleb, m., & alhalabi, w. (2016). discriminant correlation analysis: real-time feature level fusion for multimodal biometric recognition. ieee transactions on merging multiple and/or divergent datasets in spss 12 audette et al. information forensics and security, 11(9), 1984–1996. https://doi.org/10.1109/tifs.2016.2569061 ibm corp. (2015). ibm spss statistics for windows (version 23.0) [computer software]. ibm corp. ibm corp. 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[dothang truong]. (2016, july 21). spss missing values. [video]. youtube. https://www. youtube.com/watch?v=dnthjjqlz9q 13 merging multiple and/or divergent datasets in spss 14 audette et al. step 1: ***step 1*** *compare datasets dataset activate dataset1. sort cases by id. compare datasets /compdataset = dataset2 /variables all /caseid id /save flagmismatches=yes varname=mismatches matchdataset=no mismatchdataset=no /output varproperties=none casetable=yes tablelimit=600. step 2: ***step 2*** *merging all variables and cases into dataset1 add files /file=* /file=’dataset2’ /in=sourcedataset2. variable labels sourcedataset2 ‘case source is dataset2’. execute. add value labels sourcedataset2 1 ‘from dataset2’ 0 ‘from dataset1’. execute. step 3: ***step 3*** *creating new mismatches variable called casescompared compute casescompared = mismatches. execute. add value labels casescompared 1 ‘mismatch between both datasets’ 0 ‘match in both datasets’ -1 ‘unique to dataset1’. execute. step 4: ***step 4*** *duplicating casescompared encoded information for cases from dataset2 sort cases by id(a) sourcedataset2(a) mismatches(a). execute. if ((id = lag(id)) and (sysmis(casescompared))) casescompared=lag(casescompared). execute. step 5: ***step 5*** *encoding in casescompared those cases which are unique to dataset2 if (sysmis(casescompared)) casescompared=-2. execute. add value labels casescompared -2 ‘unique to dataset2’. execute. appendix a syntax for steps one through five graduate students journal of psychology copyr graduate students journal of psychology copyright 2004 by the department of counseling and clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 attachment relationships between children with physical disabilities and their caregivers anna nedelisky the new school university past research has empirically linked the experience of raising a disabled child to high levels of parental stress, depression, social isolation, psychological maladjustment, and child maltreatment. findings from this research indicate that the cumulative influence of these factors may significantly affect the child-caregiver attachment relationship. likewise, exposure to medical intervention, repeated hospitalizations, onerous care-giving responsibilities, and extensive financial outlays has also been found to constitute a source of stress for the caregivers of a child with a physical disability. a consequence of this stress is that attachment relations may, in some instances, be adversely affected. the effects of childhood physical disability on the child-caregiver attachment relationship will be further explored in this review of the literature. designed to explore child-caregiver attachment relations in families in which there is a child with a physical disability. a series of behaviors used to achieve and maintain proximity to a caregiver in infancy signifies the formation of an attachment relationship (bowlby, 1969). yet, the implications of this early relationship experience appear to extend far beyond these first years of life, in that the attachment relationship may also serve to teach the child how to interpret and interact with the world in general (bowlby, 1969). the effects of childhood physical disability on the family & the disabled child roughly 41 million people in the u.s. have been estimated to have a disability (kaye, 1998). ten point seven percent of these disabled individuals are 18 years of age or younger and are considered “limited in their activity” (i.e. functional limitations in adults and limitations in play in children; kaye, 1998). children below the age of five account for two to three percent of this number (wenger et al., 1996). a chronic physical disorder is defined as any disorder which interferes with the daily functioning of the individual for more than three months in a year, causes hospitalization lasting for more than one month in a year, or is predicted to do either at the time of diagnosis (pless & pinkerton, 1975). factors, such as the severity of the physical impairment, the potential for developmental delay, and the financial and social support of the family, play a crucial role in determining how the child and his/her family adjust to the physical disability (hendricks et al., 2000; wiegner & donders, 2000). the attachment relationship established between a child with a physical disability and his or her caregiver may be impacted by the presence of a disability in a number of meaningful ways. childhood physical disability has been associated with an increased vulnerability to psychological as well as social maladjustment in both the caregiver(s) and the disabled child (lavigne et al., 1992; miller et al., 1992; patterson et al., 1992, wallander et al., 1988). this phenomenon appears to have an interactive effect in that the burden of caring for a child with a physical disability seems to be correlated with the increased risk of psychological and/or social maladjustment in the caregiver (breslau, staruch & mortimer, 1982; wallander & varni, 1998; weigner & donders, 2000), and the experience of being provided for by a caregiver who has a psychological or social maladjustment seems to increase the pre-existing risk that the physically disabled child may develop such a maladjustment as well (emery & o’leary, 1984; orvaschel & walsh-allis, 1988; turner, beidel, & costello, 1987). as a result, it appears evident that the presence of a child with a physical disability may have a significant effect on the well being of the individual caregiver and the child, as well as the child-caregiver attachment relationship. this paper is providing the care needed by a child with a physical disability can be a burden on the family (leonard et al., 1993; patterson et al., 1992). for some families, providing for a disabled child may consist of care that is needed up to 24 hours a day, seven days a week, for years on end. the chronic burden of caring for a child with a physical disability can lead to a depletion of caregiver time and energy, disruptions to family life due to multiple visits to medical facilities, constant anxiety in relation to financial problems and the future of the disabled child, as well as feelings of guilt and isolation (breslau, staruch, & mortimer, 1982). studies investigating the relationship between family ad correspondence concerning this article should be addressed to anna nedelisky. e-mail: anedelis@aol.com. 5 nedelisky justment and the presence of a child with a physical disability have also reported elevated levels of depression in parents of disabled children (breslau, staruch, & mortimer, 1982; canning, harris, & kelleher, 1996; jessop, riessman, & stein, 1988). likewise, parents of a child with a physical disability experience higher levels of stress than parents of a non-disabled child (hendricks et al., 2000; patterson et al., 1992; leonard et al., 1993). the impact of this stress may be mediated by the methods the family develops for allocating responsibility for care within the home, the parent’s pre-morbid psychological adjustment, or current degree of social support (wiegner & donders, 2000). reviews investigating the adverse effects of childhood physical disability have confirmed that children who have a chronic physical disability are twice as likely to develop a secondary emotional disorder than physically healthy children (eiser, 1990; pless & nolan, 1991). a predictive association between parental depression, anxiety, and marital discord on child maladjustment has been demonstrated in research on physically healthy children (emery & o’leary, 1984; orvaschel & walsh-allis, 1988; turner & beidel, & costello, 1987; varni & setoguchi, 1993). when the established risk of psychological maladjustment in parents of physically disabled children is taken into account (breslau, staruch & mortimer, 1982; wallander & varni, 1998; weigner & donders, 2000), it is reasonable to suggest that children with a physical disability may have an even greater risk of becoming maladjusted. varni and setoguchi (1993) found that social support appears to mediate the relationship between psychological maladjustment and healthy adjustment in physically disabled children. family support and perceived social support (as in the cognitive appraisal that one is cared for and valued and that significant others are available to them if they are needed [heller, swindle, dusenburg, 1986]) from parents, classmates, teachers, and friends were all found to be significant factors in the positive adaptation of children with physical disabilities (varni & setoguchi, 1993). furthermore, varni and colleagues (1991) recommend that teaching social skills (such as conversation and friendshipmaking skills, as well as teaching how to handle teasing and name-calling) may serve as an intervention against the development of maladjustment in children who are disabled. attachment theory attachment behavior, according to bowlby (1969, p. 371), “refers to any of the various forms of behavior that a child commonly engages in to attain and/or maintain a desired proximity.” these behaviors can include smiling, looking, vocalizing, following, or clinging. ainsworth (1967) suggested that greeting behaviors, gazing, and exploration are also attachment behaviors. bowlby (1969) viewed the attachment between the child and the caregiver as a reciprocal phenomenon in which both parties must emit and accurately respond to the other’s signals and cues. the way in which parents respond to their infant’s signals determines to a large degree the quality of the child-caregiver attachment relationship (isabella & belsky, 1991). the influence of the attachment relationship is thought to extend beyond infancy and, in essence, acts as a foundation upon which the individual learns to relate to others as well as to the world in general (bowlby, 1969). implications of a physical disability in childhood on the child-caregiver attachment relationship attachment and the communication/interpretation of cues disabled children, in many instances, are unable to send unambiguous cues or to respond to the caregiver in a clear manner (osofsky, 1976). a sense of constant fear or distress, depression and emotional numbing are common reactions to persistent illness and disability (cox & lambrenos, 1992). the communication of fear and distress are infant attachment behaviors that precede the emergence of the attachment relationship (cox & lambrenos, 1992). in a review of the literature on childhood physical disability and child-caregiver attachment, cox and lambrenos (1992) found that social and emotional communication may develop in such a way that the caregiver has a great deal of difficulty in understanding the child’s meaning and, therefore, in alleviating the child’s distress. as a result of the physical disability, the child’s emotions may be expressed in such a way that the caregiver has difficulty registering or interpreting them. “it may be presumed,” suggest cox and lambrenos (1992, p. 1040), “that the quality of an attachment relationship may be impaired if physical disabilities interfere with child attachment behaviors or with relevant parent-child interactions that precede their appearance.” just as the caregiver may have difficulty interpreting a disabled child’s cues and signals, a child with a physical disability may also have difficulty interpreting the caregiver’s actions (cox & lambrenos, 1992). the child may subsequently fail or be delayed in learning to associate feelings with certain expressions and may, therefore, be less capable of either regulating or expressing his/her own affective state. the disabled child may also be less physically able to orient him/herself in close proximity to the caregiver, which traditionally facilitates a greater sense of security in the child (cox & lambrenos, 1992). a child who feels distant from the caregiver may in turn come to feel abandoned by the caregiver, which could further serve to complicate the attachment process. attachment and hospitalization young children, regardless of physical disability, require continuous and sensitive care-taking experiences in order to develop a sense of trust in the people around them (minde, 2000). in a hospital, however, a young child’s 6 child-caregiver attachment relationships need to be assured of continual and sensitive care is repeatedly violated. a study by minde and colleagues (1980) reported that infants who were hospitalized for an average of 49 days were cared for by an average of 72 different nurses. the over-stimulation and consistent change evident in the lives of these young, hospitalized children clearly illustrates the difficulty they face in securing any sense of solidarity or trust in their surroundings. the experience of prolonged hospitalization in childhood may subsequently be found to affect a child’s capacity to form healthy attachments. similar to bowlby (1959), douglas (1975) and quinton and rutter (1976) found that repeated hospitalizations may be associated with an indefinite separation from the child’s caregivers and may be very traumatic and stressful experiences. unfortunately, some children seem to be given reason to fear that the separation represented by their stay in the hospital may be more extensive than it first appears. thompson (1985) found that mothers of young infants appeared much more committed to their infants if their infants were allowed to go home for two or more weeks during the first three months of life. these findings support earlier research by lampe, trause and kennell (1977) who matched 30 hospitalized infants by social class and illness and then compared the degrees to which they were visited by their parents. lampe and colleagues (1977) found that only 16% of infants who had never been home were visited daily by their parents or caretakers, whereas 70% of those who had been home received daily visits. these findings appear to indicate that the attachment relationship is attained, to some degree, through the experience of providing complete care for the infant in the home and that this level of attachment must be achieved before the parents or caregivers can truly commit themselves to the infant (lampe, trause, & kennell, 1977). attachment & stress parents of disabled children experience a number of stressors (breslau, staruch, & mortimer, 1982; hendricks et al., 2000; miller et al., 1992; patterson et al., 1992; leonard et al., 1993; wiegner & donders, 2000). the infant-mother attachment relationship and the experience of stress were assessed in a sample of 100 economically disadvantaged infants and mothers (vaughn et al., 1979). higher stressfulevent scores were found to be associated with a change from secure to anxious attachment at 12 and 18-month assessments (vaughn et al., 1979). in a study of attachment and life circumstances, thompson, lamb, and estes (1982) found that attachment classifications are prone to modification as conditions change in the family. the studies by thompson and colleagues (1982) and vaughn and colleagues (1979) were completed with non-disabled middle and lower class populations. however, given the well established association between stress and the experience of caring for a physically disabled child (breslau et al., 1982; henricks et al., 2000; leonard et al., 1993; miller et al., 1992; patterson et al., 1992), it seems reasonable to generalize from these findings that stress in the context of caring for a physically disabled child may result in a diminished child-caregiver attachment relationship. this generalization seems to be supported by crisis theory, which posits that people who experience a great deal of stress tend to become inner focused and become less capable of attending to cues in their environment (capuzzi, 1989). when applied to a discussion of the formation of child-caregiver attachment in the context of a childhood disability, it seems likely that the stress involved in having a disabled child may result in a decrease of caregiver sensitivity to the child’s cues, which would in turn affect the caregiver’s responsiveness to the child. the disabled child-caregiver attachment relationship for children with physical disabilities and non-disabled children alike, ratings of maternal sensitivity, accessibility, emotional expressivity, and acceptance during the fourth quarter of the infant’s first year of life are all factors that appear to predict whether an infant will subsequently be classified as forming a secure or insecure attachment (ainsworth et al., 1978). though a moderate level of attentiveness and stimulation during the last few months of a child’s infancy sounds like a reasonable feat to accomplish, research has shown that mothers of disabled children have a great deal more with which to contend. rogers (1988) found that mothers of children with disabilities tend to be more active and express less positive affect than mothers of non-disabled children. other researchers have consistently reported that, in comparison with controls, mothers of physically disabled children are more active, controlling and stimulating, and less responsive in their interactions (tyler & kogan, 1972; wasserman et al., 1985). in light of the fact that maternal sensitivity and emotional responsivity have been found to be positively correlated with the formation of secure attachment in normal samples (ainsworth et al., 1978) and that mothers of disabled children have been found to be less likely to interact with their children in this manner (rogers, 1988; tyler & kogan, 1972; wasserman et al., 1985), the apparent lack of a difference in attachment security reported by some researchers among disabled infant groups versus non-disabled infants is interesting (cox & lambrenos, 1992). in a study by wasserman, lennon, allen, and shilansky (1987), the apparent lack of attachment differences between a disabled and non-disabled child population was further explored. attachment was assessed in 46 nondisabled infants and 36 disabled infants (who were diagnosed with mostly congenital facial or orthopedic malformations). this study reported no difference in attachment security between the non-disabled and the physically disabled samples. consistent with ainsworth’s findings 7 nedelisky other research investigating the attachment phenomenon in disabled populations has indicated that childhood disability does not defeat attachment between young disabled children and their caregiver(s), although the extent to which the disability may impair the attachment relationship is still unclear (blacher & meyer, 1983; cox & lambrenos, 1992; capuzzi, 1989). having previously found an apparent association between the physical manifestation of the disability, the performance of the child on intelligence measures, and maternal detachment, wasserman, allen and solomon (1985) next sought to understand if there is a relationship between patterns of mothering and the maladjustments or deficits in children with physical disabilities. fourteen disabled infants (facial and orthopedic disabilities) and their mothers, 14 premature infants (who share the deviant early experience of extended hospitalization with physically disabled infants, but have no current disabilities) and their mothers, and 14 healthy infants and their mothers were videotaped in free-play, separation, and reunion scenarios at nine, 12, 18, and 24 months. infants with physical disabilities were found to have consistently less focused elaborated play and scored 24 months behind healthy infants in standardized measures of cognitive-linguistic functioning (wasserman et al., 1985). infants with physical disabilities were also found to be less likely to employ social initiatives (such as requesting interaction with his/her mother or the experimenter) and were more passive in respect to separation and exploration at the age of two years. whereas healthy infants tended to develop increasingly positive affective expression with age (i.e. smiles, laughter, affectionate contact, and positive physical expression), infants with physical disabilities tended to decrease in positive affective expression (wasserman et al., 1985). (1978), early maternal responsivity (i.e. matching or responding to the infant’s bids or cues) and availability (i.e. attention directed towards the infant) were found to be associated with infant attachment security for both groups. specifically, in both disabled and non-disabled groups, higher levels of maternal responsivity, availability, and agerelated increments of positive maternal affect (i.e. exhibiting warmth or happiness) at nine months were associated with secure infant attachment. mothers of disabled infants were found to be lower in responsivity at nine months, higher in positive affect at 12 months, and were not found to differ in nine-month availability from the control mothers. in sum, the results of this study’s comparison of attachment in disabled versus non-disabled infants found that mothers of disabled infants are no more or less likely to foster secure attachment in their infants than control mothers; they simply seem to use a different strategy for its promotion (wasserman et al., 1987). building on this finding, the results of a study by capuzzi (1989) showed that there was a significant increase in attachment in a disabled population and their mothers between one and six months and also between one and 12 months. this finding led capuzzi (1989) to propose that the attachment relationship between the disabled infant and his/her mother is dynamic in that it adapts and develops over time. “like any other affectional relationship,” notes vaughn and colleagues (1979, p. 975), “infant-mother attachments arise from interaction; they continue to develop even after an affective bond has formed, and they are responsive to changes in the behavior of either partner.” this study by capuzzi (1989) indicated that social support appears to buffer the negative effects of having a disabled infant on the infant-mother attachment relationship. in particular, capuzzi (1989) found that affirmative support appeared to be most important in predicting maternal attachment, though she stressed that more research into this topic is needed. wasserman and her colleagues (1985) found that mothers of children with physical disabilities generally exerted a greater attempt to respond to the differences in their child’s competence by stimulating, focusing, and using other compensatory methods than mothers of either premature or healthy children. a developmental increase in the use of encouragement, one component of which is positive reinforcement, was particularly noted in mothers of children with physical disabilities. the findings of wasserman and colleagues (1985) suggested, however, that the sustained effort of such compensatory labors might lead to maternal burn out or even the maternal distancing effects observed in the study by wasserman & allen (1985). in a review of the attachment literature pertaining to children with a series of physical as well as mental and developmental disabilities, blacher & meyer (1983) reported that the attachment relationship between disabled children and their caregivers may be delayed or even absent. the presence of a disability in childhood, therefore, may have an adverse or detrimental effect on the quality or formation of the child-caregiver attachment relationship. past research by holt (1968) appears to stand in support of these findings. in collecting follow up data on a study of 30 eight to 12 year old children who had been hospitalized between two to five years of age for a variety of different illnesses, holt (1968) found that some children failed to include their mothers in drawings of their families. the exclusion of the mother suggested to holt (1968) that the children might have felt abandoned by their mothers during their respective hospitalizations. the fact that these drawings were made in later youth appears to indicate that the perceived maternal abandonment in early childhood may have a lasting effect on the child’s attachment to his/her mother. another factor, which may act as a potential challenge to the disabled infant-caregiver attachment relationship, is the developmental milestone marked by the age of two. as wasserman and her colleagues have discussed in the previously reviewed studies (wasserman & allen, 1985; wasserman et al., 1985), the age of two marks a pivotal time in a young child’s life when increases in cognitive skill, independence, and exploration occur. just as this age can be exciting, it can also be an extraordinarily difficult time for caregivers who have yet to recognize the full extent of their child’s disability. wasserman and allen (1985) 8 child-caregiver attachment relationships noted that children born with physical disabilities might be different behaviorally from developmentally normal children as early as their second year. these differences may not be due to their general risk status so much as mediated by the experience of early child-caregiver separation, repeated hospitalizations, or thwarted caregiver hopes (wasserman & allen, 1985). whereas children with physical disabilities may not appear to differ from healthy children in attachment, play, and affective expression at one year, divergences in behavior may become evident by the age of two (wasserman et al., 1985). likewise, an increase in maternal ignoring may become apparent as the physically disabled child reaches the age of two (wasserman et al., 1985). noting that physically disabled infants, who were not especially delayed or ignored at one year, appear to experience maternal ignoring by the age of two, researchers suggested that mothers of physically disabled children may get their first sense that the child is not as lively or as active as was expected and may subsequently withdraw from the child at this age (wasserman et al., 1985). the emergence of the physically disabled child’s second year, therefore, may have profound implications for the quality of the physically disabled child-caregiver attachment relationship, as well as mark a crucial time for meaningful intervention. rejection versus attachment in contrast to the act of forming an attachment, researchers have found that parental rejection and/or a reluctance to attach to the disabled infant may be common (cox & lambrenos, 1992). attachment appears to not only play a significant role in the nurturing and growth of a child, but it may also play a role in the stability of the home and the safety of the disabled child (blacher & meyers, 1983). believing that the existence as well as the quality of the attachment relationship is particularly pertinent to how parents of disabled children mediate the varied crises and agonies they experience, blacher and meyers (1983) suggested that attachment plays a significant role in the care of this vulnerable population: … the quality of attachment could well relate to the early burnout of parents as care-providers, to the early inclination to place children out of the natural home, to abuse or neglect, to family accord or discord, and even to the quality of parent collaboration with service providers and school personnel. (p. 359) brooks-gunn and lewis (1982) also studied the effects of childhood physical disability on the child-caregiver attachment relationship. they found that the age-related decrease in maternal responsivity to infants’ fretting and crying was much more rapid for disabled infants and their mothers than in the comparison group. based on these findings, brooks-gunn and lewis (1982) suggested that there is a correlation between decreased maternal responsivity and the description of the disabled child as “difficult.” these researchers stressed that disabled infants dubbed “difficult” were not necessarily found to be any less responsive in their behavior than a comparison group, despite the fact that they were perceived as such by their mothers. brooks-gunn and lewis (1982) found that by the end of the first year, mothers of disabled infants vocalized less in response to interaction sequences initiated by their infants’ behavior than mothers of non-disabled children. this difference in maternal responsivity to interactions initiated by the behavior of the “difficult” disabled infant was found to persist to the end of the infants’ second year (brooks-gunn & lewis, 1982). in a study of ten children with cerebral palsy, kogan and colleagues (1974) also noted a marked decline in maternal responsivity to their disabled children. data collected at three one-year intervals (between the ages of one to four) showed a gradual decrease in maternal warmth and acceptance as the disabled child aged in comparison with an age-matched non-disabled group. kogan and colleagues (1974) noted that a decline in maternal warmth and acceptance in the mothers of disabled children appeared to be related to the child’s increasing deficit in gross motor development. likewise, preliminary research by cox and lambrenos (1992) suggests that many parents seem to “turn off” their responses to their disabled children as they discover that their children are not making the developmental progress that might be reasonably expected of them as they enter their second year of life. major developmental markers such as a failure or a delay in the child’s ability to stand, walk, or talk at certain expected ages are events which parents, who may have previously operated in denial, are now perhaps forced to read and interpret as an indicator of the child’s disability (cox & lambrenos, 1992). cox and lambrenos (1992) warn that parents, who choose to “turn off” their responses to their disabled children and subsequently withdraw from them during their second year of life, could experience a serious impact on the existing childcaregiver attachment relationship (cox & lambrenos, 1992). the disabled child-caregiver attachment relationship: a risk factor for maltreatment research by past theorists, such as helfer (1975), has been in accord with recent reports suggesting that a disruption in the attachment relationship does indeed appear to be a risk factor for maltreatment in a disabled child population (brooks-gunn & lewis, 1982; cox & lambrenos, 1992). the child abuse prevention and maltreatment act (capta) defines “maltreatment” as: at minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an 9 nedelisky act or failure to act which presents an imminent risk of serious harm. (42 u.s.c.a. §510g(2), 1998) blacher, j., & meyers, c.e. (1983). a review of attachment formation and disorder of disabled children. american journal of mental deficiency, 87, 359-371. helfer (1975) proposed that parental maltreatment of disabled children might be due to a disability-related interference affecting the bonding process between the child and the caregiver(s). schwartz and schwartz (1977) concurred, suggesting that poor maternal attachment may be a factor in the maltreatment of disabled children. ainsworth (1980) proposed that influential disruptions in the formation of the infant-caregiver attachment relationship frequently occur when the infant is separated from the caregiver at or immediately after birth. despite the fact that recent attempts to demonstrate these findings have been contradictory (rode et al., 1981), it remains plausible that disabled children appear to run a greater risk of such separations and, as a result, attachment relationship disruptions may be more likely in this population (holt, 1968; lampe, trause, & kennell, 1977; minde, 2000; thompson, 1985). recommendations bowlby, j. (1969). attachment and loss: attachment (vol. 1). london: hogarth. breslau, n., staruch, k., & mortimer, e. (1982). psychological distress in mothers of disabled children. american journal of the disabled child, 136, 682-686. brooks-gunn, j., & lewis, m. (1982). affective exchanges between normal and handicapped infants and their mothers. in t. field, & a. fogel (eds.), emotion and interaction: normal and high risk infants. hillsdale, nj: erlbaum. canning, r.d., harris e.s., & kelleher, k.j. (1996). factors predicting distress among caregivers to children with chronic medical conditions. journal of pediatric psychology, 21, 735-749. capuzzi, c. (1989). maternal attachment to disabled infants and the relationship to social support. research in nursing & health, 12, 161-167.child abuse prevention and maltreatment act of 1998, 42 u.s.c.a. § 510g(2) (west suppl.1998). through an extensive review of the literature, this author concludes that a unidirectional causal relationship between childhood physical disability and the quality of the child-caregiver attachment relationship is not possible to establish at this time, though it is apparent that the presence of a physical disability may constitute a risk factor to the well-being of the child-caregiver attachment relationship (capuzzi, 1989; cox & lambrenos, 1992). like any other relationship, however, the child-caregiver attachment relationship is a dynamic entity that develops over time (capuzzi, 1989; vaughn et al., 1979). initiating appropriate interventions to promote the healthy development of this attachment relationship, as well as greater emphasis in the research community on the longitudinal study of the effect of physical disability on the child-caregiver attachment relationship, represent the next steps in further clarifying our understanding of the attachment phenomenon in a physically disabled child population (cox & lambrenos, 1992). by educating caregivers regarding issues, such as the significance of the attachment relationship to the development of the child or the beneficial attributes of social support and improved communication skills, intervention programs could make a significant contribution to the care and well being of the disabled child (minde, 2000). cox, a.d. & lambrenos, k. 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(2000). predictors of parental distress after congenital disabilities. developmental and behavioral pediatrics, 21, 271-277. references 88 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university the effects of face masks on emotion interpretation in socially anxious individuals lexie m. mathis towson university, department of psychology the covid-19 pandemic (henceforth referred to as the pandemic), prompted widespread use of face masks in public settings. with this necessary protective measure, there were unintended social and mental health consequences. masks impair emotion recognition (carbon, 2020; gori et al., 2021; grundmann et al., 2021), and negatively impact perceptions of others, including perceived closeness (grundmann et al., 2021), empathy (wong et al., 2013), and friendliness (wiesmann et al., 2021). importantly, social anxiety (sa) affects the interpretation of emotions, including hypervigilance for threat faces (klumpp & amir, 2009; mogg et al., 2004) and biases in emotion interpretation (button et al., 2013; gutiérrez-garcía & calvo, 2017; schofield et al., 2007; yoon & zinbarg, 2008). considering these impacts, socially anxious individuals (sa individuals) may demonstrate unique patterns of emotion inference when viewing masked faces. social anxiety and emotion interpretation more specifically, regarding emotion interpretation biases, gutiérrez-garcía and calvo (2017) studied interpretations of ambiguous emotional faces and found that when compared to non-anxious controls, sa individuals were more likely to correctly detect low intensity displays of disgust and anger, more likely to incorrectly identify neutral faces as angry, and less likely to interpret neutral faces as happy or sad. these findings may reflect a greater ability or motivation of sa individuals to identify social threat emotions, possibly due to their hypervigilance for threat faces. further, using an incidental learning task, yoon and zinbarg (2008) found that sa individuals demonstrate a default bias toward interpreting neutral faces as threatening. this bias may impact the mental health of sa individuals, as they also attribute excessive social cost to interacting with others displaying negative emotions of various intensities (i.e., they report that it would be excessively bad for them to interact with individuals displaying negative emotions, as compared to control participants’ reports; button et al., 2013; schofield et al., 2007). impacts of face masks moreover, researchers have found evidence that emotion identification accuracy is impaired when masks are worn. several experimental studies have examined this topic by having participants view photos of individuals and identify the facial expressions displayed, with and without the presence of masks in the photos (carbon, 2020; gori et al., 2021; grundmann et al., 2021). all three of these recent studies found evidence that masks presented a challenge to emotion identification, as accuracy was lower for masked faces. this effect exists regardless of participant age, as it has been shown in children as young as age three (gori et al., 2021) and in young, middle-aged, and older adults (carbon, 2020; gori et al., 2021; grundmann et al., 2021). aside from impacting emotion identification, masks also have effects on social judgments and percep previous research has found emotion interpretation biases in individuals with social anxiety (sa) when emotions are ambiguous. additionally, research has shown that face masks impair emotion recognition. the present within-subjects, quasi-experimental study examined the impact of face masks on emotion identification in individuals with sa. after pre-screening using a brief sa scale (the sias-6, a shortened version of the social interaction anxiety scale), 92 undergraduate students with qualifying sa scores completed an emotion identification task. the task included images of masked and unmasked individuals expressing four emotions. results indicated impaired accuracy for all types of masked trials. when examining incorrect choice selections, it was found that neutral masked faces were misinterpreted as sad or fearful significantly more than their unmasked counterparts, suggesting a mask-specific interpretation bias. in relation to previous research on sa and hypervigilance for threat faces, when considering all masked trials, accuracy was highest for masked angry trials. while this study was limited in that it did not include a non-anxious group, the results have interesting implications. importantly, the present findings suggest that some previously identified sa-related emotion interpretation characteristics persist when viewing masked faces (e.g., hypervigilance for threats), while others do not (e.g., default bias for interpreting neutral as hostile). future research should focus on elucidating the causes of the present results, which are important to this population and clinicians, as socially anxious individuals attribute greater social cost to negative emotions; thus, misinterpretation of emotions as negative may be detrimental to their mental health. keywords: social anxiety, face masks, emotion recognition, face perception, emotions 89 tions of others. in their experiment examining masks and emotion identification, grundmann et al. (2021) also examined participants’ social judgments of the image models. they found that participants’ ratings of perceived closeness to the individual pictured were lower when the individual was wearing a mask. further, wiesmann et al. (2021) investigated an intervention to mitigate the negative effects of masks on the doctor-patient relationship. their intervention, which consisted of smiling portrait photos placed on the chests of hospital staff members, was associated with significantly higher ratings of staff friendliness compared to when the staff wore masks alone. this suggests that patients perceive staff members as less friendly when masks are worn. similar effects were found prior to the pandemic; in a randomized-controlled trial, wong et al. (2013) examined the effect of medical face masks worn by physicians on the doctor-patient relationship. they found that patients perceived their doctors as significantly less empathetic when the doctors were masked versus not. taken together, the results of these three studies indicate that masks negatively impact perceptions of others, including perceived closeness (grundmann et al., 2021), empathy (wong et al., 2013), and friendliness (wiesmann et al., 2021). considering the effects of sa on emotion interpretation, these impacts on perceptions of others may be exacerbated by the interpretation biases already present in sa. implications for the present study while it is known that masks impair emotion recognition (carbon, 2020; gori et al., 2021; grundmann et al., 2021) and induce more negative perceptions of others (grundmann et al., 2021; wiesmann et al., 2021; wong et al., 2013), researchers have not yet identified specific populations which may be affected to a higher degree. as such, sa individuals may be at a higher risk of misinterpreting facial expressions when masks must be worn. specifically, sa individuals interpret ambiguous faces as hostile (gutiérrez-garcía & calvo, 2017; yoon & zinbarg, 2008) this may also be true when masks are worn, as they make expressions more uncertain. those with sa attribute excessive social cost to interacting with individuals displaying negative emotions (button et al., 2013; schofield et al., 2007), and thus, misinterpretation of emotions may be detrimental to their mental health. this would be important for mental health professionals to be aware of when treating individuals with sa during the pandemic. based on evidence from prior research, the purpose of the present study was to examine emotion interpretation in individuals with sa when viewing masked and unmasked faces. a 2 (masking) x 4 (expression) within-subjects, quasi-experimental design was used to assess the following hypotheses: h1: sa individuals will demonstrate lower accuracy for masked faces, with the lowest accuracy for neutral masked faces. h2: neutral faces will be most commonly confused with anger, with this being more likely to occur when faces are masked. h3: sa scores will be negatively correlated with overall accuracy, and with accuracy for masked trials, while being positively correlated with the percentage of neutral faces confused as angry. method participants participants were 92 undergraduate psychology students at a large mid-atlantic university with qualifying self-reported sa scores. all received course credit for participating. sa is especially prevalent in young adults and has increased during the pandemic (hawes et al., 2021), making this a relevant population. five participants were excluded, three for being outliers and two for other reasons (incomplete data and prior knowledge of the study), leaving 87 participants in analyses. a priori power analysis was used initially to inform the number of participants needed for a 2 x 4 within-subjects anova, and post hoc power analysis indicated an achieved power of 88.08% with 87 participants for an effect size of η2p = 0.05 (morepower version 6.0.4; campbell & thompson, 2012). a brief sa scale (sias-6; peters et al., 2012) was used to pre-screen participants for social anxiety. inclusion criteria consisted of a sias-6 score of at least 7 and a minimum age of 18 years old. the sample was diverse in race (42.5% white, 29.9% black, 10.3% hispanic/ latinx, 8.0% multiracial, 6.9% asian, 2.3% other) and similar in age (m = 19.49, sd = 1.79). the majority of the sample identified as female (72.4%). this reflects the higher prevalence of sad in females compared to males in the united states (national institute of mental health, 2017), although other factors, such as major, likely contributed to this gender ratio as well. 4.5% identified as nonbinary or another gender identity. effects of face masks in socially anxious individuals 9090 measures & materials social interaction anxiety scale mattick and clarke’s (1998) social interaction anxiety scale (sias) is a 19-item self-report measure of an individual’s social interaction fear. a 6-item version (sias-6) was developed by peters et al. (2012). the items are statements intended to measure anxiety levels when initiating and maintaining social interactions; for example, “i have difficulty making eye contact with others.” participants rate the degree to which each statement is characteristic of themselves on a 5-point likert scale ranging from 0 (not at all) to 4 (extremely). the sias includes two reverse scored items. total scores are calculated, with optimum cutoff scores being 39.5 for identifying sad using the sias (carleton et al., 2009) and 7 when using the sias-6 (peters et al., 2012). the sias is both reliable and valid (mattick & clarke, 1998), and the sias-6 is comparable to the original scale (peters et al., 2012). emotion identification task for the emotion identification task, all participants viewed the same set of 96 images, which systematically differed in expressed emotion (happy, angry, fearful, neutral), mask-wearing (mask, no mask), and sex (male, female). stimuli appeared individually in a qualtrics survey (qualtrics, provo, ut), with the masked image block first (gori et al., 2021) to avoid participant demand characteristics. stimuli order was randomized within blocks. because race can impact emotion identification (kang & lau, 2013; tuminello & davidson, 2011) through stereotyping and social categorization, only caucasian faces were shown, as in previous work (e.g., schofield et al., 2017). to mitigate these potential confounding effects, race was kept consistent throughout. the images were randomly selected from the chicago face database (cfd; version 3.0; ma et al., 2015), with each model appearing only once to avoid habituation. the cfd provides two types of happy images, however, only open-mouth happy images were used. cfd images are standardized in many ways, including characteristics of the models, environment, and photography (ma et al., 2015). models had multiple photos taken for each expression and independent raters identified the best photo of each. neutral images were highly reliable based on norming data collected from a large and racially diverse sample; however, such data was not obtained for emotional images. for the present study, adobe photoshop was used to digitally edit a randomly selected subset of images, adding a mask (906 x 644 pixels) that was tailored to the face of each individual, and adding faint shadows for realism. masks were centered horizontally and placed vertically to cover the nasolabial-alar crease. an example of a cfd image before and after editing can be seen in figure 1, and the cfd codes for all images used are available online at the link provided in the data availability statement. in the task, six multiple-choice options (happy, content, neutral, angry, fearful, and sad) were provided in a consistent order. content and sad served as positive and negative distractor options to avoid ceiling effects and were intended to be somewhat distinguishable from the emotions shown. two measures were obtained: accuracy and neutral trial incorrect choice selections (the percentage of responses for each incorrect option when the correct answer was neutral; this was used to determine if any interpretation biases were present). demographic information within the qualtrics survey were several demographic questions regarding age, gender, and race. all were open-ended questions, allowing participants to respond freely. responses to the gender and race questions were later categorized. categories were created based on the most common responses given. gender categories were female, male, non-binary, and other, while race categories were white, black, hispanic/latinx, multiracial, asian, and other. procedure after receiving irb approval, sias-6 pre-screening occurred online. the researcher was blind to pre-screening scores during data collection. each participant came to a university laboratory, provided written informed consent, and completed the qualtrics survey on a university desktop computer. this included several open-ended demographic questions, the emotion identification task, and the sias. the researcher debriefed them, answered any questions, and provided mental health resources. pre-screening and study data were combined, downloaded to microsoft excel, and analyzed using ibm spss statistics 27. university covid-19 precautions were complied with in the laboratory. results in the present study, masking and expression of mathis 91 effects of face masks in socially anxious individuals the image models were manipulated, and subsequently, sias total scores, emotion identification accuracy, and neutral trial incorrect choice selections were measured. accuracy outcomes were checked for skewness and outliers before analysis. three outliers were identified, having unusually low scores attributed to lack of attention. unusually high scores were considered true data. while participants answered correctly in about three-quarters of all trials, accuracy for masked (m = 64.39%, sd = 8.30%) and unmasked (m = 86.71%, sd = 6.00%) trials notably differed. as for sa scores, the average sias score (m = 38.94, sd = 12.83) approached the cut-off score of 39.5, while the average sias-6 score (m = 11.31, sd = 3.95) exceeded the cut-off score of 7. prior to conducting the planned repeated measures anovas, test assumptions were checked. approximate normality was violated, as the dependent variables for each test were extremely skewed in some conditions. transformations were attempted; however, some conditions became overcorrected. thus, the aligned rank transform procedure (salter & fawcett, 1993), a nonparametric option which aligns and ranks data for each effect before conducting factorial anovas, was utilized through the program artool (elkin et al., 2021; wobbrock et al., 2011). for each main effect and interaction effect, a separate anova was conducted using the data aligned and ranked for that effect; only the effect for which the data was aligned was considered from each (wobbrock et al., 2011). for instance, to examine the main effect of masking, the data was aligned and ranked for said effect using artool. then, the appropriate anova was conducted using this data, however, only the main effect of masking could be considered from these results. this process was repeated for each main effect and interaction. mauchly’s test was used to check the assumption of sphericity and greenhouse-geisser corrected values were reported if violated. for each simple effects analysis, an additional anova was conducted using the data aligned and ranked for contrasts (elkin et al., 2021). accuracy to test h1, a 2 (masking: mask, no mask) x 4 (expression: happy, neutral, angry, fearful) repeated measures anova was performed on accuracy (figure 2). significant main effects of masking, f(1, 86) = 644.70, p < .001, η2p = .88, and expression, f(2.52, 216.57) = 35.59, p < .001, η2p = .29, ε = .84, were found. these effects were qualified by a significant interaction, f(3, 258) = 90.56, p < .001, η2p = .51. a simple effects analysis revealed that masks significantly impaired accuracy for happy, f(1, 86) = 741.70, p < .001, angry, f(1, 86) = 138.74, p < .001, and fearful trials, f(1, 86) = 495.51, p < .001, but not neutral trials. frequent confusion with one distractor option may have caused the lack of an effect on accuracy for neutral trials. here, the first part of h1, which stated that accuracy would be lower for masked faces, was supported, however, the second part of h1, which predicted that accuracy would be lowest for neutral masked trials, was not supported. interestingly, when comparing accuracy among all masked trials, accuracy was highest for masked angry trials (m = 79.50, sd = 13.13), suggesting that hypervigilance was present for ambiguous threat faces. neutral trial incorrect choice selections to test h2, a 2 (masking: mask, no mask) x 5 (expression choice: happy, content, angry, fearful, sad) repeated measures anova was performed on the percentages of incorrect responses for each option (figure 3). notably, seven participants were accurate for all neutral masked trials, unmasked trials, or both, meaning that n = 80, as participants with missing data were excluded here. significant main effects of masking, f(1, 79) = 69.75, p < .001, η2p = .47, and expression choice, f(2.43, 192.24) = 145.94, p < .001, η2p = .65, ε = .61 were found. these effects were qualified by a significant interaction effect, f(1.91, 151.07) = 27.06, p < .001, η2p = .26, ε = .48. a simple effects analysis revealed a significant effect of masking on selecting content, f(1, 79) = 15.96, p < .001, fearful, f(1, 79) = 17.42, p < .001, or sad, f(1, 79) = 18.86, p < .001, rather than neutral. specifically, when incorrect, participants tended to choose content instead of neutral for unmasked trials, while they tended to choose fearful and/or sad instead of neutral for masked trials. there was no effect of masking on selecting happy or angry rather than neutral. contrary to h2, there was a nonsignificant trend toward selecting angry for neutral unmasked faces. relationships among variables lastly, to test h3, spearman’s correlations among sa scores, accuracy outcomes, and neutral trial incorrect choice selections were calculated. “sa scores” refers to both sias and sias-6 scores. “accuracy outcomes” refers to accuracy for each masking condition. no correlations were significant among sa scores and accuracy outcomes or among sa scores and neutral trial incorrect choice selections. as such, 92 h3 was not supported. sias and sias-6 scores had a moderate positive correlation, r = .47, p < .001. discussion this study aimed to determine whether sa individuals demonstrate emotion interpretation biases when viewing masked faces, as previous research had not examined the effects of masks in populations that may be differentially affected by the associated emotion recognition challenges. the present study’s sa participants demonstrated impaired accuracy for identifying the emotions of masked individuals, while having high accuracy for masked angry trials and misinterpreting neutral faces as sad and/or fearful significantly more when masked than not. response tendencies were identified by examining confusions of neutral faces, but it is unknown if tendencies when viewing masked faces are specific to sa or if they are more generally applicable. accuracy consistent with previous research regarding the impact of masks on emotion recognition (carbon, 2020; gori et al., 2021; grundmann et al., 2021), accuracy was impaired for masked trials. accuracy was not significantly different for neutral trials based on masking, however, accuracy for neutral unmasked trials was lower than accuracy for other unmasked trials. this may have been due to one of the distractor emotions used, namely “content,” being similar to “neutral.” as seen in figure 3, more than half of incorrect responses for neutral unmasked trials were content (m = 54.78%). in addition, among all types of masked trials, the present study’s sa participants displayed the highest accuracy for masked angry trials. this is consistent with previous research which found that sa participants correctly identified low intensity displays of disgust and anger more often than non-anxious controls (gutiérrez-garcía & calvo, 2017), as participants in both studies identified ambiguous expressions of anger correctly. if this is specific to sa individuals, it may imply greater motivation or ability to identify ambiguous expressions of anger. further, this relates to prior findings of hypervigilance for threat faces by sa individuals (klumpp & amir, 2009; mogg et al., 2004), as anger is a social threat emotion. incorrect response tendencies for neutral trials as aforementioned, neutral faces were confused as fearful and/or sad more frequently when faces were masked than not. these response tendencies are particularly interesting and may reflect participants’ personal feelings during the pandemic. notably, the mean percentage of neutral masked faces confused as sad (m = 57.32%) was larger than the percentage confused as fearful (m = 5.62%). perhaps the tendency to misinterpret neutral masked faces as sad could be explained by the projection of depressive symptoms. there is reason to speculate such, as depression increased in prevalence since the pandemic began. early in the pandemic, the prevalence of moderate to severe depression in u.s. college students was approximately 36.2% (lee et al., 2021), while prior to the pandemic, 25.67% of u.s. college students had scores indicative of possible major depression (acharya et al., 2018). moreover, depression is the most common comorbid condition for individuals suffering from sad, with 35-70% having this comorbidity based on several clinical studies (koyuncu et al., 2019). given these statistics, the prevalence of depression in this sample was potentially high. if so, the sad response tendency may reflect participants projecting their own negative emotions onto the neutral faces viewed, particularly when ambiguous due to masking. importantly, projection of one’s own affective state when interpreting the emotions of others is supported by research. for example, trilla et al. (2021) observed the phenomenon of emotional egocentricity when participants’ affective states were manipulated before an emotion perception task. participants were more likely to judge faces as sad when they were experiencing sadness as opposed to happiness, indicating that projection affects the perception of facial expressions. furthermore, in a study comparing the responses of depressed, remitted, and healthy control individuals, leppänen et al. (2004) found an impairment in the recognition of neutral faces. specifically, depressed and remitted patients tended to mistake neutral faces for emotional faces (e.g., sad or happy), although false happy responses occurred more in the group of remitted patients. given this strong evidence for perception of neutral faces as sad in those with depressive symptoms, along with the phenomenon of emotional egocentricity shown by trilla et al. (2021) and the prevalence rates of depression mentioned previously, projection of depressive emotions may have impacted interpretations of neutral masked faces in the present study. in contrast, several prior studies have shown a bias for interpreting neutral faces as threatening in sa in mathis 93 effects of face masks in socially anxious individuals dividuals (gutiérrez-garcía & calvo, 2017; yoon & zinbarg, 2008), which was not replicated here. the present results illustrate that sa participants most frequently confused neutral faces as sad when masked, while gutiérrez-garcía and calvo (2017) found that sa individuals were less likely than non-anxious controls to interpret neutral faces as sad. this inconsistency suggests a mask-specific effect, however, it is unknown whether this is generalized or sa-based. although the neutral threat bias, such as that shown by yoon and zinbarg (2008), was not present for neutral unmasked trials either, the presence of prior masked trials may have impacted this, and thus, the previous findings are not refuted. further, the methodology may not have allowed for enough sa variation to produce similar results. the present study recruited participants with a minimum score, whereas previous studies selected extreme scores from a participant pool (gutiérrez-garcía & calvo, 2017), used median split grouping (klumpp & amir, 2009), or clinician diagnosis grouping (mogg et al., 2004). limitations the present study had several important limitations. first, it did not include a lowor non-anxious group due to the limited scope of this study, being that it served as a first-year project leading up to a master’s thesis. inclusion of a control group would aid in elucidating whether the identified mask-related response tendencies are specific to sa. second, the researcher lacked access to a clinical sample, relying on a brief sa scale for pre-screening, which was not as highly correlated with the full scale as expected (peters et al., 2012), suggesting measurement problems. third, ecological validity should be considered, as static images are unlike real life, where movement and contextual information facilitate emotion interpretation. implications and future research despite the limitations, the present findings contribute information to the research gap on populations that may be uniquely affected by the challenges associated with mask-wearing. as predicted, emotion identification accuracy was impaired for masked trials, however, neutral masked trials were misinterpreted differently than expected (as sad rather than angry). these findings can inform clinicians about how those with sa interpret the emotions of masked individuals, contributing to an improved understanding of pandemic-related effects when providing treatment. the mental health effects of the incorrect response tendencies identified here should be considered, as individuals with sa attribute excessive social cost to negative emotions, including fear and sadness (button et al., 2013). importantly, neutral masked faces were most often confused as sad, with this occurring significantly more than when unmasked. if sa individuals often misinterpret neutral masked faces as sad, this may cause greater anxiety for these individuals when in social situations due to their attribution of excessive social cost to interacting with individuals displaying sadness. furthermore, these findings may bring increased awareness to possible differential effects of masks on other neurodivergent populations. future research could examine the effects of masks on emotion interpretation in other populations typically affected by interpretation biases to determine whether the known effects are altered by the presence of masks. in addition, the higher accuracy shown for masked angry trials may reflect greater motivation or ability of sa individuals to identify these social threat emotions, which can be explained by their hypervigilance for threat faces (klumpp & amir, 2009; mogg et al., 2004). these results reinforce prior findings of hypervigilance for ambiguous threat faces, demonstrating that this effect is also applicable to situations when sa individuals view masked angry faces. however, the previously identified neutral threat bias, which is characteristic of sa, was not reproduced here, suggesting that this effect may not be present when viewing faces during the pandemic. instead, a different emotion interpretation bias in which neutral masked faces were most often misinterpreted as sad, may have taken precedence. this bias may result from the projection of depressive emotions, as depression is the most common comorbidity of sa and its prevalence increased during the pandemic. future research should examine the role of both sa and depression in interpreting the emotions of masked faces and should prioritize the inclusion of a lowor non-anxious control group. acknowledgements the author wishes to thank dr. kim shifren for her continued mentorship and valuable insight, dr. justin buckingham for consultation on study design, dr. jeff kukucka for statistical suggestions, and ryan rosenthal for his critical reviewal of the manuscript and support throughout. 94 declaration of interest statement the author reports no conflict of interest. data availability statement the data that support the present findings are openly available in open science framework at http://doi. org/10.17605/osf.io/vm4dc. references acharya, l., jin, l., & collins, w. 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(2013). effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. bmc family practice, 14(200), 1–7. http://www.biomedcentral.com/1471-2296/14/200 yoon, k. l., & zinbarg, r. e. (2008). interpreting neutral faces as threatening is a default mode for socially anxious individuals. journal of abnormal psychology, 117(3), 680–685. https://doi.org/10.1037/0021843x.117.3.680 96 figure 1 emotion identification task image examples note. although the same individual is shown here, this is for illustrative purposes only, as no individuals were included more than once in the task. for this individual, the expression shown is neutral and the mask-edited image was used in the task. cfd stimulus code: cfd-wf-211-001-n. (left) original cfd image. (right) mask-edited cfd image. mathis 97 effects of face masks in socially anxious individuals figure 2 emotion identification accuracy among masking and expression conditions note. n = 87. ***p < .001. 98 mathis figure 3 neutral trial incorrect choice selections note. n = 80. ***p < .001. 49 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university bouncing back: resilience, aggression, and depression in older gay men and lesbians tosha griggs & mark vosvick university of north texas, counseling psychology department older gay men and lesbians are at greater risk for depression due to a lifetime of sexual minority stress (fredriksen-goldsen et al., 2013). for gay men and lesbians, depression is associated with aggression and relationship problems (bernards & graham, 2013). however, aggression may foster resilience if aggression is expressed in a healthy, nonviolent manner that motivates a person to take positive action towards a greater purpose (russell & richards, 2003). what are the relationships between aggression and resilience with depression in a sample of older gay men and lesbians; and do group differences exist? data was collected from (n=50; older gay men) and (n=50; older lesbian women). spss 20 was used to run a multivariate analysis to test our overall model. through a minority stress lens (meyer, 1998), this study hypothesizes resilience moderates the relationship between aggression and depression. significant differences between older gay men and older lesbians’ aggression, resilience, and depression scores exist. for the older gay men and lesbian combined group, a moderation analysis indicated that in addition to aggression and resilience being single significantly predicted depression accounting for approximately 57% of the variance in depression. furthermore, resilience significantly moderated the relationship between aggression and depression in the model in the sample (n = 100) of older gay men and lesbians. keywords: older adult, minority stress, resilience our study will examine how aggression, being single, and resilience are associated with depression in older gay men and lesbians, using resilience as a moderator. this study uses three groups to investigate group differences between older gay men and lesbians. background in general, older adulthood is associated with stability, better problem-solving skills, psychological maturity, and wisdom (mirowsky & ross, 2001). however, older adulthood is also associated with financial strain, health-related issues, caregiving burdens, isolation, residential relocations, and bereavements of loved ones that negatively affect mental health in older adults (moos, schutte, brennan & moos, 2005; pearlin & skaff, 1996; wight, harig, aneshensel & detels, 2016). older adults overwhelmed with age-related stressors may be at greater risk for mental distress and depression (moos, schutte, brennan & moos, 2005; wight, leblanc, meyer & harig, 2015). depression and sexual minorities while previous results report the prevalence of depression decreases with older age in the sexual majority population, older gay men and lesbians continue to face risks that may increase their vulnerability to mental health issues (grossman et al., 2001). fredriksen-goldsen (2011) assessed the health risk factors of approximately 2,560 older gay men and older lesbians, between the ages of 50 to 95, and found an elevated risk of mental distress with approximately 31% of older gay men and lesbians reporting depression, 53% reported loneliness and 27% experienced the death of a partner (fredriksen-goldsen, 2011). similar to older sexual majority adults, older gay men and lesbians experience challenges associated with declines in health, loss of friends, and family and adjustments to retirement (van wagenen et al., 2013); however older gay men and lesbians also experience victimization related to their sexual minority status that older sexual majority adults do not (fredriksen-goldsen, 2012; grossman, d’augelli & o’connell, 2001). according to meyer (1995), sexual minority stress is the chronic stress associated with sexual minority status and is different from normal day-to-today stress because it attacks an individual’s identity. when an individual deals with multiple stressors at the same time the various stressors may strain coping resources (meyer, 2015; rook, 1998). older gay men and lesbians matured in a time when hate, discrimination, victimization, and being labeled mentally ill were the norm, and overcoming adversity is a common theme in their development (kuyper & fokkema, 2010; keuzenkamp & bos, 2007). overtime the abuse, discrimination, and sexual minority stress associated with sexual minority status may have long-lasting effects on the physical and mental health of older gay men and lesbians (fredriksen-goldsen et al., 2013; hatzenbuehler, 2016). additionally, evidence links minority stress to structural and health inequalities which can negatively impact mental and physical health outcomes in older gay men and lesbians (zeeman et al., 2019). structural inequalities are evident in the legal, educational, business, government, and healthcare systems (bentley, 2020). structural inequalities are when a majority 50 group sets rules and laws that serve the majority, while minority groups have limited access to resources (bentley, 2020). the interconnection of different identities and systems of oppression may impact older gay men and lesbians differently based on the beliefs of the majority groups (herek, 2002). for example, one study found that participants were more likely to regard gay men as mentally ill and supported adoption rights for lesbians more than for gay men (herek, 2002). even though previous researchers argue that men and women may have more similarities than differences, the intersectionality of gender, age, and sexual minority status may alter this theory (hyde, 2014). because structural social inequalities exist, gender and sexual minority status differences may be important determinants of health to consider (denton & walters, 1999). therefore, models that investigate the intersectionality of gender and sexual minority status, rather than just controlling for sex, may be more effective in predicting health outcomes for older gay men and lesbians (denton & walters, 1999). just controlling for sex may conceal the effects that sexual minority stress may have on health and hinder a more complete understanding of the effects different life experiences may have on health (denton & walters, 1999). furthermore, past studies focused more on collecting and interpreting data, rather than developing a model that will better explain the data (coburn & eakin, 1993). combining older gay men and lesbians into one minority group will give us data to interpret; but without consideration of the intersectionality, our generalizations may not adequately apply to the population (hyde, 2014). when the best model is considered for the data, better therapeutic interventions develop that are beneficial and are more likely to be effective for multiple determinants of health (denton & walters, 1999; hyde, 2014). previous studies collapse older gay men and lesbians into a single sexual minority group, and gender differences within sexual minorities may exist and should be investigated (fredriksen-goldsen et al., 2010; vosvick et al., 2010). for example, older gay men lived through and may have experienced personal trauma associated with the aids epidemic (rosenfeld et al., 2012). the aids epidemic is a defining moment because many older gay men experienced trauma associated with the death of friends and partners, while others had to learn how to cope with living with hiv/aids (rosenfeld et al., 2012). on the other hand, findings suggest depression is equally a concern for lesbians (bradford et al., 1994; tait, 1997). in general, 25% of women experience depression in their lifetime (salk et al., 2017) because of several economic, social, biological, and emotional factors (reiss, 2013), with lesbians carrying an extra burden because of sexual minority status (bostwick et al., 2019). concealment of sexual identity, lack of employment, living in a rural area, and being single are all factors associated with depression for older lesbians (oetjen & rothblum, 2000). relationship status and depression for older gay men and lesbians, as well as the sexual majority of older adults, having a supportive partner is associated with a greater sense of well-being, positive physical health outcomes, and reported lower scores on loneliness and depressive symptoms (grossman et al., 2001; herek, 2006). for example, a longitudinal study reported older gay men and lesbians that reported being divorced/separated had poorer health and more depressive symptoms than those who were married (luo et al., 2012). aggression and sexual minorities aggression is defined as overtly hurtful behavior towards a target in the form of verbal aggression (insults, sarcasm, and rudeness) or physical harm (ramirez & andreu, 2006). previous results suggest verbal aggression is more common (björkqvist, 2018). researchers hypothesized that aggression may stem from exposure to different stressors and negative life experiences (finch & graziano, 2001). therefore, older gay men and lesbians who have experienced discrimination, victimization, and sexual minority stress may be at an increased risk for aggression (silove, 2009). while aggression might be an understandable reaction to mistreatment, it may be potentially destructive (offredi, 2016; painuly et al., 2005) if the emotional expression is internalized or externalized (bridewell & chang, 1997). conversely, russell & richards (2003) reported aggression associated with anti-gay politics, may foster resilience if the aggression is expressed in a healthy manner that motivates a person to take positive action towards a greater purpose. negative emotions associated with discrimination may exist concurrently with taking positive initiative because aggression may motivate collective action that promotes feelings of empowerment (foster, 2000). griggs & vosvick 51 resilience moderates aggression and depression however, group differences in older gay mens’ and lesbians’ aggression may exist. for example, depressed women report more verbal aggression than depressed men (zuckerman, 1989). averill (1983) and frank, carpenter, and kupfer (1988) reported women to become verbally aggressive as often, as intensely, and for similar reasons as men. a different study reported women may have greater difficulty expressing their anger; and may suppress their emotions (kopper & epperson, 1996). while some studies found no gender differences in aggression (im et al., 2018). furthermore, aggression is positively associated with relationship problems and separation (bernards & graham, 2013) especially if the aggression is uncontrollable (baron et al., 2007; offredi, 2016). goldman & hagga (1995) reported depressed individuals express more aggression towards their partner when compared to non-depressed individuals (painuly et al., 2005). resilience and sexual minorities even though current research reports being a sexual minority is associated with negative mental health outcomes, most older gay men and lesbians successfully cope with sexual minority stress (fredriksen-goldsen et al., 2017; kaufman & compton, 2021). resilience in current literature has several different definitions, however, this study will define resilience as the ability to ‘bounce back’ from adversity (colpitts & gahagan, 2016; herrick et al., 2014). resilience is not a born trait, nor a skill that enables individuals to be resilient to all situations (bonanno & burton, 2013). instead, resilience is a dynamic process that involves internal processes, external and environmental factors, and the specific strategies executed by an individual (richardson & waite, 2002). although, these strategies may change over a lifespan based on the challenge and resources available (bonanno & burton, 2013; fletcher & sarkar, 2013). additionally, resilience is associated with positive health outcomes, well-being, life satisfaction, adaptive coping skills, and a decreased risk of depression (hash & rogers, 2013; wagnild, 2003). previous research collapsed older gay men and lesbians into a single sexual minority group; however, differences in resilience by gender should not be overlooked. for example, many older gay men learned self-reliance, survival skills, stress management, and how to care for themselves earlier in life and may adjust to older adulthood more successfully than sexual majority men (hash & rogers, 2013; wight et al., 2012). unfortunately, there is limited literature on older lesbians and resilience, however, older lesbians generally have increased social support and are less likely to live alone when compared to older gay men (fredriksen-goldsen et al., 2013). older gay men and lesbians may experience internalized aggression due to a lifetime of sexual minority stress and level of resilience may predict older gay men and lesbians’ ability to ‘bounce back’ from adversity (snyder et al., 1991). additionally, unique experiences of structural social inequalities may impact older gay men and lesbians differently (denton & walters, 1999). therefore a model that investigates these two groups separately will better explain our data (coburn & eakin, 1993). purpose of present study through a minority stress lens, this study will examine what the relationships are between aggression, being single, resilience, and depression in older gay men and lesbians, and the group differences (meyer, 2003). this study hypothesizes aggression and being single are positively associated with depression. resilience will be negatively associated with depression. aggression, resilience and being single will account for a significant proportion of variance in depression. resilience will moderate the relationship between aggression and depression. a significant difference between older gay men’s and older lesbians’ aggression, resilience, and depression scores will exist. method procedures after appropriate institutional review board approval was obtained, signed informed consent forms were obtained from all participants. the computerized self-report surveys were provided by the cphr research team. participant identity was completely anonymous, and the participants received an incentive of $25. participants our nih-certified research assistants administered a self-report survey to 50 gay cis-men and 50 cis-gender lesbians, 50 years of age and older (n = 100), living in the dallas/ft worth (dfw) metroplex and fluent in english. the cphr team recruited participants from a variety of places in dfw, including local bars, lgbt-friendly churches, the gay pride parade, community-based social groups, online social media, and professional organizations. 52 this study will investigate three groups: an older gay men and lesbian combined group, an older gay men only group, and an older lesbian only group. please see tables 1, 2 &3 near here for demographics. measures participants completed a demographic questionnaire that assessed age, sex, ethnicity, sexual minority status, relationship status, etc. as well as a battery of other psychosocial measures. the center for epidemiologic studies depression scale (cesd), the aggression questionnaire (aq), and the connor-davidson resilience scale (cd-risc) were used for this study. the center for epidemiologic studies depression scale (cesd; radloff, 1977) is a 20-item measure that assesses the frequency of depressive symptoms. this measure consists of a four-point likert-type scale ranging from ‘0-rarely or none of the time’ to ‘3-most or almost all of the time’. the overall scale has strong internal consistency with reported cronbach’s alpha of .90 and adequate concurrent and construct validity. the aggression questionnaire (aq; buss & perry, 1992) is a 29-item measure of aggression and includes 4 subscales that measure aspects such as physical aggression, verbal aggression, anger, and hostility. the aq consists of a five-point likert-type scale that ranges from ‘1-extremely uncharacteristic of me’ to ‘5-extremely characteristic of me’. the aq has good reliability with a reported cronbach’s alpha of .80 and adequate convergent and concurrent validity. the connor-davidson resilience scale (cdrisc; connor & davidson, 2003) is a self-report measure of resilience. this measure consists of 25 items on a 5-point likert-type scale ranging from ‘0-not at all true’ to ‘4-true nearly all of the time’ high scores reflect greater resilience. this instrument has a reported cronbach’s alpha of .89 and demonstrates high convergent validity. results g*power software was used to run a power analysis. data was collected by the center for psychosocial health research and spss 20 to analyze the data. prior to the data analyses, a missing data analysis was conducted using little’s mcar test and no missing data was found. a frequency table to screen for outliers and found that all values were within normal range, except for an education value of 55 years. the median was used instead of the mean for education because of an outlier value in table 1. normality plots were used to check that assumptions for a normal distribution were met. because our data did not meet the assumption of normality, log was used to transform the data for aggression and depression for the older gay men and lesbians combined group, the older gay men-only group, and the older lesbian-only group. univariates analysis complete data was collected from all our 100 participants and then conducted univariate statistical analyses on all three groups to calculate means, standard deviations, ranges, and alphas for each measure and groups are shown in tables 4, 5 & 6. bivariate analysis bivariate data analyses were conducted, to assess the strength of the relationships between our demographic variables and our variables of interest for the older gay men and lesbian combined group, older gay men-only group, and older lesbian-only group. the correlations are presented in tables 7, 8 & 9 t-test analysis an independent-sample t-test was conducted to compare the total scores of each variable based on the group to determine any significant differences between older gay men and older lesbians. our t-test results indicated a significant difference (t [98]= -3.25, p = .002) between resilience scores for gay men (m = 69.56, sd = 21.00) and lesbians (m = 80.80, sd = 12.60) and for depression scores (t [98]= 2.90, p = .005) for gay men (m = 11.32, sd = 8.23) and lesbians (m = 7.26, sd = 5.51). however, aggression scores (t [98] = 1.91, p = .060), for gay men (m = 25.16, sd = 15.69) and lesbians (m = 19.62, sd = 13.28) were not significantly different. in our sample, older gay men significantly reported lower resilience scores (cohen’s d = 0.65) and higher depression scores (cohen’s d = 0.60) than older lesbians, indicating medium effect sizes. multivariate analysis: moderation analysis for the multivariate analyses, three moderation analyses were conducted, to test our overall model, using the older gay men group, and lesbian combined group, the older gay men-only group and the older lesbian-only group to examine which of our variables of interest serve as predictors of depression, as well as, if resilience moderates the relationship between aggression and depression. the results are shown in tables 10, 11 & 12. {near here}. the first moderation analysis (table 10moder griggs & vosvick 53 resilience moderates aggression and depression ation analyses of older gay men lesbians combined); (f [4, 95] = 34.10, [δ] r² = .15, p < .001) indicated that in addition to aggression (β = .30, p <.001) and resilience (β = -.69, p <.001), being single (β = .31, p <.001) significantly predicted depression accounting for approximately 57% of the variance in depression (adj. r² = .57, p <.001). furthermore, resilience significantly moderated the relationship between aggression and depression (β = -.55, p <.05) in our model, δr2 = .15, f change = 34.93, p<.001, in our sample (n = 100) of older gay men and lesbians. the second moderation analysis (table 11moderation analyses of the older gay men-only group); (f [4, 45] = 16.92, [δ] r² = .10, p < .001) indicated that aggression (β = .33, p <.001) and resilience (β = -.53, p <.001) significantly predicted depression accounting for approximately 57% of the variance in depression. furthermore, resilience significantly moderated the relationship between aggression and depression (β = -.33, p <.05) in our model, δr2 = .10, f change = 11.02, p<.001, in our sample (n = 50) of older gay men. however, being single was a significant predictor of depression in blocks 1 & 2 (β = .38, p <.05) (β = .22, p <.05), but in block 3 it fell out of significance when the interaction effect was added to the model (β = .19, p <.058). the third moderation analysis (table 12moderation analyses of the older lesbian-only group), (f [4, 45] = 15.51, [δ] r² = .03, p < .001) indicated that being single (β = .42, p <.001) and resilience (β = -.40, p <.001) significantly predicted depression accounting for approximately 54% of the variance in depression (adj. r² = .54, p <.001). however, aggression was not a significant predictor of depression (β = .13, p =.228) therefore resilience did not moderate the relationship between aggression and depression (β = -.18, p = .100) in our model, δr2 = .03, f change = 2.82, p<.001, in our sample (n = 50) of older lesbians. the variance inflation factors (vif) and tolerance (tol) were examined with each analysis to check for multicollinearity and found none. discussion this study investigated the relationships between aggression, being single, resilience, and depression in three groups: older gay men and lesbians combined, older gay men-only group, and older lesbian-only group. these three groups were chosen because older gay men and lesbians’ life experiences may differ and by combining them into a single group, important differences may be missed; and three models better explained the data (coburn & eakin, 1993). for all three groups, this study hypothesized that aggression and being single are positively associated with depression, and resilience is negatively associated with depression. this study also hypothesized that aggression, being single and resilience account for a significant proportion of variance in depression; and that resilience moderates the relationship between aggression and depression. older gay men and lesbians combined group for the older gay men and lesbian combined group, our results support all our hypotheses. in our sample of older gay men and lesbians, being single was a significant predictor of depression which supports previous literature that single older gay men and lesbians reported a sense of emptiness in their lives because of a lack of companionship (kuyper & fokkema, 2010). when compared to partnered older sexual minorities, single older sexual minorities reported an increase in depressive symptoms (fredriksen-goldsen & muraco, 2010). having a spouse or partner may be a valuable source of companionship and emotional support (cutrona, 1996). additionally, when compared to single older gay men and lesbians, partnered older gay men and lesbians reported more positive attitudes towards aging and improved well-being (heaphy, 2009). in our sample of older gay men and lesbians combined, aggression was a significant predictor of depression. this finding is consistent with previous literature that aggression in older gay men and lesbians is positively associated with negative mental outcomes such as depression (mason et al. 2014; parham, 2004). while aggression may be a common reaction to human rights violations (silove et al., 2009) when expressed outwardly in a nonproductive manner aggression is considered a maladaptive coping strategy (miller et al., 1996) associated with increased depressive symptoms in both gay men and lesbians (kopper & epperson, 1996). however, aggression expressed in a manner that motivates an individual to take positive action towards a greater good is associated with adaptive coping (russell & richards, 2003). resilience was also a significant predictor of depression in our sample of older gay men and lesbians combined. this finding supports previous research that indicates, resilience is associated with positive health outcomes, well-being, life satisfaction, adap 54 tive coping skills, and a decreased risk of depression (wagnild, 2003; wagnild & young, 1993). even though older gay men and lesbians experienced a lifetime of adversity, the majority are not only able to “bounce back” from adversity but may develop more adaptive coping strategies which are associated with increased resilience (hill & gunderson, 2015). furthermore, resilience significantly moderated the relationship between aggression and depression in our sample of older gay men and lesbians combined. this finding supports previous research that indicates, resilient older gay men and lesbians may possess characteristics that allow them to confront and overcome obstacles and challenges (snyder et al., 1991). even if they feel anger or aggression towards events of discrimination, negative emotions can exist concurrently, and be associated with increased resilience, if aggression motivates an individual to express their emotions in a constructive manner or take positive action towards a greater good (foster, 2000). older gay men-only group next for our second model, the older gay men-only group, our results support our hypotheses, except being single was not a significant predictor of depression when the interaction effect was entered into the model, which indicated a difference from the results of the older gay men and lesbian combined group. this finding is consistent with previous literature that aggression in marginalized groups is associated with depression and other negative mental health outcomes (mason et al. 2014; parham, 2004). resilience was also a significant predictor of depression in our older gay men only group. this finding supports previous research that greater resilience is associated with greater well-being, life satisfaction, and decreased risk of depression (fredriksen-goldsen & muraco, 2010; king & orel, 2012). furthermore, resilience significantly moderated the relationship between aggression and depression in our older gay men-only group. possibly because emotional openness and the ability to accept and process emotions in an insightful manner was reported as a factor associated with resilience (kwon, 2013). however, being single for older gay men did not significantly predict depression in our sample, once the interaction effect was added to the model, although being single did approach significance. this may be due to our sample size. older lesbians-only group then for our model with the older lesbians-only group, our results support our hypotheses, except aggression was not a significant predictor of depression thus resilience did not significantly moderate the relationship between aggression and depression. in our sample of older lesbians, being single was a significant predictor of depression. this finding is consistent with previous literature that reports lesbians in a supportive relationship report higher self-esteem and decreased depressive symptoms when compared to single lesbians (wayment & peplau, 1995). resilience was also a significant predictor of depression in our sample of older lesbians which is consistent with previous research (averett et al., 2011). many older lesbians have strong social networks, advocate for the lesbian community, and are less likely to live alone when compared to older sexual majority women and older gay men (averett et al., 2011). however, aggression was not a signif icant predictor of depression possibly because of the restriction in the range of aggression. a subscale of aggression is physical aggression and individuals may fail to endorse these items due to social desirability. because the experiences of older gay men and lesbians can be quite different an independent-samples t-test was conducted. significant differences were found between resilience scores for older gay men and lesbians, with older gay men reporting lower resilience than older lesbians. this result may be due to the fact that gay men are more likely to live alone and less likely to have a partner when compared to older lesbians (fredriksen-goldsen, 2011). furthermore, depression scores for gay men and lesbians were also significantly different with older gay men reporting more depressive symptoms. this finding suggests older gay men might experience more adverse effects of sexual minority stress than older lesbians (herek, 2002). however, aggression scores for gay men and lesbians were not significantly different. previous literature shows mixed results for gender differences in aggression in the sexual majority (allen & haccoun, 1976; averill, 1982). no significant difference may suggest that some lesbians experience similar aggression as gay men (parham, 2004). group differences at the t-test level, the results indicated significant differences between resilience and depression with older gay men reporting lower resilience and higher depression. older gay men report more internalized homophobia than older lesbians (fredriksen-goldsen, 2011), possibly because society is more accepting of lesbians than gay men (heaphy, 2009). griggs & vosvick 55 resilience moderates aggression and depression lastly, resilience was the strongest predictor of depression for older gay men, while being single was the strongest predictor of depression for older lesbians. these results highlight the importance of investigating older gay men and lesbians in separate models. important differences would have been missed had this study combined the groups into one model, as does most current literature. conclusion this study examined how aggression, being single, and resilience are associated with depression in older gay men and lesbians, using resilience as a moderator. this study used three groups to investigate group differences between older gay men and lesbians. significant differences between older gay men and older lesbians’ aggression, resilience, and depression scores did exist. the older gay men and lesbian combined group, indicated that in addition to aggression and resilience, being single significantly predicted depression. furthermore, resilience significantly moderated the relationship between aggression and depression in older gay men and lesbians. clinical implications because older gay men and lesbians experience a lifetime of sexual minority stress (meyer, 2003), clinicians should focus on interventions aimed at transforming aggression into motivation for self-advocacy. therapeutic interventions should promote adaptability, self-reliance, advocacy skills, proactive coping, selfcare, spirituality, gender role flexibility, hope, and hardiness; all of which are reported to foster greater resilience (craig et al., 2014; colpitts & gahagan, 2016). also, a further understanding of what factors predict resilience in the older gay and lesbian community may help clinicians develop better therapeutic interventions. limitations while this was a challenging sample to recruit, this study achieved the needed sample size but acknowledges this sample has limited generalizability. a more diverse sample size would provide an in-depth understanding of the intersectionality of oppression based on different minority identities. because this was a computerized study taken on provided computers, there were limitations in the ability to reach a more socioeconomically and ethnically diverse sample. as with any self-report survey, some responses may be influenced by self-report bias and social desirability. also, because our sample is from texas our results may not generalize to older gay men and lesbians living in more liberal states. finally, due to correlational design causation cannot be inferred. future research future researchers should investigate factors that predict resilience in older gay men and lesbians. researchers should also compare resilience, aggression, and depression in a sample that is representative of the older transgender and bisexual population as well as one that is more ethnically diverse. also, due to limited current literature on the gender differences of sexual minorities, future research should investigate the group differences between gay men and lesbians. references allen, j. g., & haccoun, d. m. 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(1989). stress, self-esteem, and 60 griggs & vosvick mental health: how does gender make a difference? sex roles, 20, 429–444. https://doi. org/10.1007/bf00288001 61 resilience moderates aggression and depression table 1 demographics of older gay men and lesbian group combined note. *median. 62 table 2 demographics of older gay men only group note. *median. griggs & vosvick 63 resilience moderates aggression and depression table 3 demographics of older lesbian group combined note. *median. 64 table 4 univariates for older gay men and lesbians group combined griggs & vosvick 65 resilience moderates aggression and depression table 5 univariates for older gay men only group 66 table 6 univariates for older lesbians only group griggs & vosvick 67 resilience moderates aggression and depression table 7 bivariate for older gay men and lesbians combined group 68 table 8 bivariate for older gay men-only group griggs & vosvick resilience moderates aggression and depression 69 table 9 bivariate for older lesbians-only group 70 table 10 moderation analysis older gay men and lesbians depression is the outcome variable note. adj. r² = .57, f (4, 95) = 34.10, (δ) r² = .15, p < .001 * p < .05, ** p < .01. griggs & vosvick 71 resilience moderates aggression and depression table 11 moderation analysis older gay men only depression is the outcome variable note. adj. r² = .56, f (4, 45) = 16.92, (δ) r² = .10, p < .001 * p < .05, ** p < .01. 72 table 12 moderation analysis older lesbian group depression is the outcome variable note. adj. r² = .54, f (4, 45) = 15.51, (δ) r² = .03, p < .001 griggs & vosvick 73 resilience moderates aggression and depression figure 1 simple slope analysis for older gay men aggression and depression 74 figure 2 simple slope analysis for older lesbians aggression and depression griggs & vosvick graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology graduate student journal of psychology copyright 2007 by the department of counseling & clinical psychology 2007, vol. 9 teachers college, columbia university issn 1088-4661 application of dialectical behavior therapy to disorders other than borderline personality disorder: a critical review ananda b. amstadter auburn university lindsay m. squeglia medical university of south carolina dialectical behavior therapy (dbt) has recently been used to treat disorders other than borderline personality disorder (bpd). despite dbt’s widespread use, no paper summarizes its use for conditions other than bpd; therefore, a synthesis of the literature is warranted. in this paper, we aim to (a) briefly summarize the treatment and its empirical basis for treating bpd; (b) explore the theoretical underpinnings of the application of dbt beyond bpd; (c) review studies that implemented dbt for other forms of psychopathology, such as eating disorders and posttraumatic stress disorder; (d) discuss dbt’s use for comorbid conditions; (e) examine the applicability of components of dbt to supplement other treatments; and (f) provide a summary of the state of the literature and directions for future research. our review suggests that although further randomized controlled studies are warranted to validate the efficacy of dbt for these and other disorders, the initial results seem promising. dialectical behavior therapy (dbt; linehan, 1993a; 1993b) was originally developed to treat severe behavioral manifestations of borderline personality disorder (bpd), such as emotional instability, suicidality, and parasuicidal acts (diagnostic and statistical manual of mental disorders 4th edition [dsm-iv]; american psychiatric association [apa], 1994). this comprehensive cognitive-behavioral treatment (cbt) package was originally developed to meet the intense treatment needs of those with bpd, as well as to rectify previous snares in the therapeutic thread associated with treating this disorder. prior to the development of dbt, there was a lack of empirically supported therapies for this hard-to-treat condition (scheel, 2000). in fact, in a review of empirically supported treatments, dbt was the only therapeutic method categorized as “probably efficacious” for treating bpd; no treatments were placed in the “well-established” category (crits-christoph, frank, chambless, brody, & karp, 1995). according to standards from the clinical psychology division of the apa, dbt warrants the label “empirically supported” based on the outcome data from randomized controlled trials (rcts) conducted with bpd women (robins & chapman, 2004). dbt remains the only data-supported outpatient treatment for bpd. since the development of dbt, numerous randomized clinical trials have supported its efficacy for the treatment of bpd, and several review papers summarize this literature (e.g., westen, 2000). we begin with a brief synopsis of the treatment package and a summary of the existing empirical correspondence concerning this article should be adressed to ananda b. amstadter; email: amstadt@musc.edu. support. recently, dbt has been used to treat a wide range of mental health phenotypes, and to date, a comprehensive review of this literature does not exist. therefore, in this paper, we aim to (a) briefly review the treatment and its empirical basis for treating bpd; (b) explore the theoretical application of dbt beyond bpd; (c) review studies that implemented dbt for other forms of psychopathology, such as eating disorders and posttraumatic stress disorder (d) discuss dbts use for comorbid conditions; (e) suggest the possibility of supplementing other treatments with components of dbt; and (f) provide an overall summary of the state of the literature and future directions for research. dialectical behavior therapy: an introduction biosocial theory from a dbt perspective, the clinical presentation of bpd is conceptualized through a biosocial lens (linehan, 1993a; 1993b). a biosocial theory of bpd demands attention to the joint outcome of biological disposition, environment, and the transaction between the two during one’s early learning history. it is posited that bpd individuals possess a biological vulnerability resulting in deficits in the emotion regulatory systems; specifically, an overactive limbic system (davidson, 1998). this over-activation of the limbic system is believed to predispose individuals to emotional vulnerability manifested by high sensitivity to emotional stimuli, elevated emotional intensity, and a slower return to baseline following emotional arousal (linehan, 1993a). in addition to the biological predisposition, bpd individuals often have invalidating environments in their 16 application of dbt beyond borderline personality disorder 17 formative years. from the biosocial perspective (linehan, 1993a), the environmental insult could be physical (e.g., sexual abuse, physical abuse, neglect) or emotional (e.g., emotional abuse, invalidation). the theory posits that the diathesis of biological vulnerability in combination with an environment that is erratic, abusive, and unpredictable, leads to the failure to learn adaptive means of regulating one’s emotions, which is one of the hallmark symptoms of bpd. this emotion modulation skills deficit has farreaching effects, and individuals with this condition also have extreme difficulty expressing their inner experiences. additionally, the biosocial theory suggests that the expression of emotions may be met by responses indicating that they are invalid, which leads the individual to believe that their emotions are not accurate representations of the truth and therefore, cannot be trusted. over time the biological deficit and the invalidating environment influence and exacerbate each other, making emotion dysregulation progressively more pervasive. the creation of dbt dbt was tailored to address three pitfalls common in the treatment of this population (linehan, 1993a). the first difficulty was treatment dropout or lack of therapeutic alliance due to therapists’ concentration on change. traditionally, cbts focused on change, which many bpd clients perceived as invalidating. to address this, acceptance-based interventions, which are often referred to as validation techniques, were added. theoretically, radical acceptance imparts to the client a message that the client is doing the best that can be expected given his or her situation. one main job of the therapist is to search for aspects of truth in the client’s response, which may at face-value, appear irrational and unfounded, and communicate this truth to the client as a form of validation. the role of validating the truth in a client’s situation engendered the adage that one must accept before one can change. the second difficulty was that bpd clients presented with many crises that demanded attention, as the crises were often of a life-threatening nature. because crisis management was the top priority, therapists did not have adequate time to address skill building, which would enable long-term change. group skills training sessions were thus added to teach and practice skills; this allowed for individual therapy sessions devoted to the application of skills. the third difficulty was that clients were inadvertently reinforcing the delivery of iatrogenic treatment (e.g., they were reinforcing the therapist for avoiding the discussion of their suicide and parasuicide attempts). linehan’s research team coded standard cognitive-behavioral therapy sessions with bpd clients and found that clients were reinforcing the therapist (e.g., positively by increased participation, negatively by halting attacks on the therapist) for switching from heated topics to more neutral topics. further, it was found that clients would punish the therapist for application of effective treatment strategies (e.g., self-harm after the therapist does not comply with client demands such as longer treatment sessions). in response to this pattern of unintentional reinforcement, dbt instilled a structure of treatment that reinforces the client for engaging in therapeutic enhancing behaviors, thereby enhancing both the clients’ and therapists’ abilities. dbt was thus developed from these modifications to standard cognitive-behavioral treatment. east meets west – the dialectic as it is a form of cbt, dbt utilizes many change principles that are common to other cbts such as contingency management, behavior analysis, exposure, problem solving, and cognitive restructuring (linehan, 1993a; 1993b). acceptance strategies are based on eastern zen contemplative studies and include mindfulness, assuming a non-judgmental stance, and validation tactics (dimeff & linehan, 2001). as the word ‘dialectic’ refers to the synthesis of two opposites, the addition of acceptance principles to a change oriented cbt not only afforded the name, but also forms the foundation of dbt. of note, the two opposites— acceptance and change—are not applied at the exclusion of the other. rather, the two poles are used in concert to achieve the goal of dbt: to build a life worth living. the primary tension within and across treatment sessions is to accept the client as he or she is (i.e., validating the client) while concurrently promoting change. treatment modalities comprehensive psychotherapy, according to linehan (1993a), must serve five functions: (a) foster the client’s motivation to change, (b) develop the client’s resources and skills, (c) allow for generalization of treatment effects to the client’s natural contexts, (d) configure the therapeutic environment such that the client’s and therapist’s competences are fostered, and (e) cultivate and maintain the therapist’s ability and desire to provide effective therapy. there are four treatment modes that serve the functions of dbt (linehan, 1993a). one treatment modality is individual psychotherapy, which typically entails 50-minute weekly sessions. individual therapy serves to increase the client’s motivation and ability to change (dimeff & linehan, 2001). a second modality is group skills training, on average meeting for two and a half hours weekly to foster skill building. phone consultation is another mode, used at the client’s will and serving to enhance skill application during crises. last, there is the therapist consultation team, held weekly or bi-weekly, to provide dbt therapists with peer supervision and support. in addition to helping to prevent therapist burnout, it also assists in adding treatment integrity, as therapists are reviewed on their adherence to the principles of treatment. dbt encompasses this entire treatment package. although linehan hopes to conduct dismantling studies to ascertain specific component effectiveness, amstadter and squeglia 18 the empirical support for dbt with bpd presently applies to the inclusion of all four treatment modalities. one of the main problems with traditional treatments for those with bpd has been that each therapy session serves only to manage the crisis of the moment; in contrast, there is structure imposed to the progression of dbt that is theoretically grounded in logical and behavioral principles (linehan, 1993a). individual therapy within dbt is organized into four stages. within stage one there is a hierarchy of priorities that structures each session, all aimed at moving from behavioral dysregulation to regulation. the basis of stage one is to increase safety by decreasing lifethreatening behaviors; a life worth living can only be built if the client is indeed alive. suicide and parasuicide, which is self-harm without intent to die, are addressed first. a thorough discussion of these serious behaviors is beyond the scope of this paper; the reader interested in learning more about the treatment of parasuicide and suicide behaviors is referred to the manual (linehan, 1993b). the second priority is to decrease behaviors that interfere with the progression of therapy, such as missed appointments and failure to complete homework. the third priority is to decrease behaviors that interfere with the client’s quality of life. the last priority is to increase skills to enhance the client’s life. this structure is intended to reinforce non-parasuicidal behavior. if the client does not engage in parasuicidal behavior, functional analyses of said behaviors do not need to occur, and the client’s session time is left for discussion of issues of the client’s choosing. stage two addresses the client’s emotional suffering that likely still exists despite the behavioral control gained through stage one. during this stage, issues such as posttraumatic stress are attended to. stage three is aimed at problems in living and attaining normal emotional experiences, both positive and negative. this stage is likely the most similar to standard outpatient treatment. stage four, which not every client enters, aims to help with insight building, spiritual connectedness, and to further life satisfaction. group skills training overall, the purpose of skills training is to cultivate and refine skills in modifying maladaptive ways of behaving, thinking, and experiencing emotions (linehan, 1993b). four modules of skills are taught in dbt group skills training. each module was designed to ameliorate a behavioral deficit or symptom often found in bpd. first, the mindfulness module was created to address difficulties in maintaining a sense of self, feelings of emptiness, and cognitive aberrations such as dissociation. second, the interpersonal effectiveness module centers on the chaotic interpersonal relationships that are often present in the lives of bpd individuals. third, the emotion regulation module was tailored to manage volatile affect, another characteristic of the disorder. lastly, the distress tolerance module was created due to the impulsive and self-destructive nature of bpd; it was meant to provide clients with alternate behaviors that are not of a destructive nature in the face of stress. in manualized dbt, skills groups cycle through all four modules twice because many clients are too behaviorally and emotionally dysregulated at the beginning of treatment to incorporate new proficiencies. it has been demonstrated that memory and comprehension are dampened by intense emotion (richards & gross, 2000). subsequently, clients may be in a more regulated state the second time around, after being in treatment for 6 months, and likely retain more than they did at first exposure. though the modules were created to treat specific behavioral difficulties pertaining to both bpd and an array of other psychological disturbances, they are also successful in refining skills of well-functioning individuals. in fact, skills trainers have been found to personally benefit from learning the dbt modules (m. m. linehan, personal communication, august, 2005). efficacy of dbt for bpd dbt as an outpatient treatment for a primary diagnosis of bpd has been examined in six rcts (koons, et al., 2001; linehan, armstrong, suarez, allmon, & heard, 1991; linehan, schmidt, dimeff, craft, kanter, & comtois, 1999; linehan, dimeff, reynolds, comtois, shaw welch, & heagerty, et al., 2002; turner, 2000; verheul, van den bosch, keoter, de ridder, stijnen, & van den brink, 2003) in addition to a two year rct follow-up of dbt as therapy for suicidal behavior and borderline personality disorder (linehan, et al., 2006). women ranging in age from 18 to 70 who met criteria for bpd served as participants in all of the rcts. in three studies, the participants were also substance dependent (linehan et al., 1999; linehan et al., 2002; turner, 2000). across studies, dbt was associated with decreased parasuicidal behaviors, medically severe parasuicidal behaviors, inpatient days, and treatment dropout, and increased global and social adjustment as compared to the control group, which were either treatment as usual community treatment by experts (linehan et al, 2006), or client centered therapy (turner, 2000). furthermore, these group differences were by and large maintained one year post-treatment (e.g., linehan, heard, & armstrong, 1993). in sum, these investigations support the efficacy of dbt for this population. notably, support for dbt has been yielded from the linehan lab as well as from other research groups. application to other disorders dbt was designed to treat borderline patients, and its effectiveness has primarily been studied in regards to that disorder. clearly, sufficient empirical support for generalization of treatment efficacy is needed prior to dbt being adopted as a treatment for other disorders. yet, from a theoretical perspective, sufficient support exists to warrant the study of this treatment for other disorders. our review of application of dbt beyond borderline personality disorder 19 the literature has afforded four theoretical reasons to support the study and perhaps subsequent implementation of dbt to populations other than bpd. first, given the robust treatment effects found with such a difficult-to-treat population, it is likely that dbt might be even more effective for less clinically severe client populations. second, given dbt’s ability to positively affect outcome variables such as impulsivity, disruptive behavior, distress, and depression in bpd clients (e.g., linehan et al., 1991), it can be hypothesized that dbt will also be effective in treating these discrete behaviors in clients with other disorders. third, a core component of dbt is skills training and, independent of diagnosis, adaptive coping skills may be beneficial for clients to learn (lynch, 2000). fourth, and perhaps most importantly, is the concept of emotion regulation. dysfunctional behaviors present across diagnoses can be thought of as maladaptive coping skills or poor attempts at emotion regulation. for example, binge eating, substance abuse, and parasuicidal behavior can all be conceptualized as emotion regulation attempts (telch, agras, & linehan, 2000). following this line of reasoning, dbt has recently been applied to other disorders (e.g., eating disorders, depression) in which affect regulation is an issue. eating disorders in clinical practice, dbt has been used to treat many categories and variants of eating disorders (mccabe & marcus, 2002), including bulimia (safer, telch & agras, 2001), binge eating disorders (bed) (telch et al., 2001), and comorbid bpd and eating disorders (palmer, birchall, damani, et al., 2003). binge eating disorder (bed) to date is the only eating disorder in which systematic outcome studies have been conducted (i.e., telch et al., 2001), and results from these studies have provided promising empirical support for the use of dbt over treatment as usual. from a theoretical perspective, many lines of reasoning suggest that dbt would be effective in treating eating disorders. one such angle concerns the similarities between bpd and eating disorders. a hallmark symptom of bpd is life-threatening behaviors (i.e., suicide attempts, parasuicide); similarly, symptoms of eating disorders may be lifethreatening. specifically, a main criterion for anorexia nervosa is being less than 85% of expected weight, which presents a health risk (apa, 1994). further, purging behavior, which may be present in both anorexia and bulimia, has been shown to have detrimental health effects (safer et al., 2001). dbt has specific strategies to decrease lifethreatening behaviors. another similarity between bpd and eating disorders is ambivalence. a common dialectic is that clients fear living with the disorder for life while simultaneously fearing change. mccabe and marcus (2002) noted that clients with anorexia nervosa are often initially resistant to therapy and have difficulties maintaining treatment gains. specific techniques in dbt have been designed to work with ambivalence without resulting in invalidation of the client’s perspective (linehan, 1993a). techniques such as using pros and cons, devil’s advocate, and a myriad of social psychological principles of persuasion center on the balance of acceptance and change, with a constant focus on commitment (linehan, 1993a). another similarity between dbt and eating disorders is what linehan terms “apparent competence” (linehan, 1993a). this term suggests that bpd clients are often composed on the exterior and suffering internally. likewise, mccabe and marcus (2002) noted that clients with eating disorders are often successful and intelligent. in other words, clients appear competent, but have basic deficits at regulating their painful inner experiences, creating a discrepancy that engenders more distress. to counteract this discrepancy, dbt has been developed from a skills deficit perspective and therefore addresses ostensible competence by providing basic skills training to all clients. a fourth similarity between work with bpd clients and eating disorders clients concerns therapist’s reactions, including burnout and emotional over-involvement. mortality may occur, which can be difficult for therapists to accept. the consultation team in dbt provides support for therapists and ensures treatment credibility (linehan, 1993a); like bpd therapists, eating disorders therapists would most likely benefit from such consultations. lastly, and perhaps most importantly, an emotion regulatory function of maladaptive behaviors may be a common similarity between bpd and eating disorders. this is best explicated by examining binge eating disorder (bed). bed, a condition in which an individual consumes a markedly large amount of food in a small amount of time without compensatory behaviors (apa, 1994), has been theoretically conceptualized from two standpoints. one is housed within general cbt theory, assuming that bed results from extreme attempts at weight control and dieting; a cyclical pattern is thought to occur from extreme deprivation to extreme eating episodes (wilfley & cohen, 1997). bed has been treated with standard cbt, yet some afflicted with the disorder do not show improvement (telch, et al., 2001). a second theoretical account of bed, which is rapidly accumulating empirical support, frames binge eating as an attempt to regulate negative emotions. from this perspective, binge eating serves as a reinforcing agent, as negative emotions are temporarily relieved (heatherton & baumeister, 1991). for example, in a recent study of women with bed, negative mood induction led to an increase in binge eating, which then led to a decrease in the elicited emotion (telch & agras, 1996); results implied that binge eating was reinforced as an emotion regulatory strategy. in this manner, binge eating can be conceptualized as a similar behavior to regulatory behaviors in bpd, such as parasuicide. wiser and telch (1999) posited that in both disorders, negative emotional states are viewed as unbearable and are therefore followed by maladaptive modification attempts. in her work with bpd patients, linehan (1993a; 1993b) adopted a deficit approach and argued that bpd individuals lack sufficient ability to regulate their volatile emotional amstadter and squeglia 20 states adaptively. similarly, wiser and telch (1999) stated that bed clients lack ample skills to regulate their emotions. an adaptation of the dbt protocol to treat bed is a natural fit: nearly half of clients with this disorder are treatment resistant (wilfey & cohen, 1997), and binge eating can be viewed as a regulatory behavior (telch & argas, 1996). an uncontrolled pilot study, using a modified version of linehan’s (1993b) protocol, was conducted to investigate the possible usefulness of dbt for this population (telch et al., 2000). dbt skills were tailored to bed to constitute a 20-session group therapy protocol. only group skills training sessions were conducted; individual therapy sessions, phone consultation, and consultation groups were not included. tenets of dbt were customized for this program; instead of a traditional order of topic discussion (lifethreatening, therapy interfering, etc.), this program instilled a hierarchy fitting bed. the hierarchy was as follows, in order of decreasing severity: treatment interfering behavior, binge eating, mindless eating, preoccupation with food, capitulating, and irrelevant behaviors (e.g., behaviors that make binging more likely). during each session, clients were encouraged to discuss their most severe behavior on this hierarchy. mindfulness skills were thought to address the central assumption that binge eating occurs due to a negative emotional arousal coinciding with a lack of emotional control (wiser & telch, 1999). if binge eating is repeatedly occurring to avoid emotional experiencing, it may become an automatic response to negative emotional arousal. mindfulness, by definition, increases awareness of emotions and experiences and suggests a nonjudgmental stance towards internal experiences (linehan, 1993a; 1993b). therefore, it is believed that mindfulness may break the association between negative emotional states and binge eating. teaching clients to focus on their experiences connects them to their internal experiences and provides behavioral evidence that they can, in fact, sit with “intolerable” emotions. further, the nonjudgmental stance serves to decrease possible emotional reactions to binges, such as shame or guilt, which may trigger more distress and more binging episodes. the emotion regulation module was thought to increase emotional awareness and to teach clients more adaptive means of dealing with their emotional experiences, replacing binging. these skills were thought to not only help in the short term, but also to be prophylactic in that they likely decrease negative emotions and increase positive emotions, thereby making the conditions in which binging occurs less frequent. distress tolerance skills were taught to address coping with circumstances not able to be changed. for those with bed, the key of this module was to increase tolerance of internal or external events that may be triggers for binging without engaging in the maladaptive behavior. the interpersonal effectiveness module in the original dbt protocol was not utilized. eleven women with bed served as participants in this uncontrolled pilot study of dbt (telch et al., 2000); all eleven women completed treatment and, under the protocol outlined above, positive effects were found. post-treatment data indicated that binge eating ceased (i.e., no episodes for four consecutive weeks) in 82% of participants and that, on average, emotion regulation skills improved. therapeutic gains were maintained at threeand six-month assessments. due to the promising outcome of the uncontrolled trial, an rct was conducted to further ascertain the efficacy of dbt for bed (telch, et al., 2001). female bed patients, randomly assigned to dbt of wait-list, served as subjects. groups, each of which consisted of 22 patients, did not differ on demographic variables, binge eating severity, selfesteem, depression, or mood regulation at pre-treatment. the dbt condition entailed 20 sessions of group skills training using a protocol identical to the one used in the uncontrolled trial (telch et al., 2000). following the completion of treatment, those in the dbt condition had significantly fewer days of binge eating and fewer binge episodes than did those in the wait-list condition. in fact, a large percentage of those in the dbt condition (89%) did not have any binge eating for four weeks straight, whereas only a small percentage (13%) of those in the wait-list condition met this criterion. dbt was also associated with lower concerns about weight, shape, and eating. furthermore, treatment decreased the participants’ urges to eat to regulate their anger. at the threeand six-month follow-up, respectively, 67% and 56% of dbt participants continued to abstain from binge eating. following the completion of treatment for the dbt condition, 14 of the 22 participants in the wait-list condition accepted the offer to begin dbt treatment. of these participants, 90% had ceased binge eating at treatment completion, and 80% and 67% maintained this status at the threeand six-month follow-up, respectively. theoretically, dbt might be effective for the treatment of bed as it teaches more adaptive emotion regulation skills, thereby providing alternative behaviors to binge eating for regulating emotion. if dbt was effective, therefore, it would be expected that decreased negative affect and increased emotion regulation skills would be present post-treatment. partial support for this hypothesis was observed. dbt’s superiority to no-treatment in reducing binge eating seemed to be moderated by dbt’s reduction of patients’ urges to binge eat when angry, though not their urges to eat when anxious or depressed. furthermore, lower depression scores were not found post-treatment. in sum, dbt may be effective due to providing alternative skills at regulation of specific emotions, such as anger. though dbt yielded a higher percentage of treatment responders than reported in previous cbt trials for bed (wilfley & cohen, 1997), future research should directly compare cbt with dbt. additionally, implementing the other components of dbt, such as phone consultation, may further add to treatment gains and should be studied. extending dbt’s applicability to other eating disordered patients, palmer et al. (2003) conducted an uncontrolled outcome study with women having comorbid diagapplication of dbt beyond borderline personality disorder 21 noses of bpd and an eating disorder (n=7), although their exact diagnoses were not provided in the article. after 18 months of standard dbt, no client met criteria for a specific eating disorder, although 4 clients met criteria for eating disorder not otherwise specified. furthermore, selfharming behaviors decreased, as did hospitalizations. although this study has notable limitations, such as lack of a control group, inadequate reports of diagnoses, and inadequate outcome variables, results suggest the usefulness of dbt to treat those with comorbid bpd and eating disorders. geriatric depression although there is evidence of pharmacotherapeutic effectiveness for some elderly individuals with depression, many individuals do not respond to behavioral, cognitive, or brief psychodynamic psychotherapy. for example, in one study, approximately 30% of elderly adults with depression did not respond to treatment (thompson, gallagher, & breckenridge, 1987). furthermore, elderly adults are the most likely age group to complete a suicide (mcintosh, 1992). dbt has been demonstrated to be effective with hard-to-treat clients, particularly those at risk of suicide (linehan, cochran, & keltner, 2001), and for this reason, it may be an effective treatment for the depressed elderly. following these reasons, lynch, morse, mendelson, and robins (2003) sought to test the efficacy of an adapted dbt program for depressed geriatric clients. according to lynch (2000), the main difference between standard dbt and dbt for depression is that the latter focuses on behaviors functionally pertinent to depression, including inflexible coping and dependency. several modifications to the standard dbt protocol were made. in standard dbt, weekly individual sessions occur in conjunction with phone consultation throughout the week (linehan, 1993a; 1993b). lynch and colleagues (2003) combined these two components to create scheduled weekly 30-minute phone consultations. this adaptation attempted to decrease the clients’ dependency on the therapist and to reduce travel for a population where mobility may be a concern. second, the skills group met weekly for two-hour sessions; all four modules of skills were taught and were tailored to late-life depression. for example, the mindfulness module entailed a psychoeducational component on late-life depression with a focus on radical acceptance (e.g., accepting physical declines that cannot be changed); the emotion regulation module focused on behavioral activation, which in dbt terms is opposite to emotion action; the distress tolerance module had a focus on tolerating physical pain; and the interpersonal effectiveness module focused on decreasing dependency, saying no, and effectively asking for assistance when needed. all skill modules were taught twice within the 28 weeks of treatment. thirty-four individuals (85% female) over the age of 60 who met criteria for unipolar depression served as participants (lynch et al., 2003). participants were randomly assigned to a medication-only condition or to a dbt plus medication condition. all participants were on an antidepressant prescribed by a physician; the majority of participants received a selective serotonin reuptake inhibitor. following treatment, both groups showed significant decreases in interviewer-assessed depression, but only the dbt group showed a significant decrease in depression on self-report measures. at treatment completion, 71% of the dbt participants were in remission, compared to 47% of the medication-only participants. six months following treatment, significantly more dbt participants (75%) were in remission as compared to medication-only participants (31%). furthermore, post-treatment, only dbt participants showed significant increases in active coping and decreases in dependency and sociotropy. taken together, the data from this study indicate that a modified dbt program may be a beneficial extension to medication treatment for the depressed elderly. this study’s findings, that dbt and medication decreased depression to a greater extent than medication alone, is at odds with findings regarding dbt for bpd clients, where dbt typically decreases depression, but not to a greater degree than the comparison treatment (e.g., linehan et al., 1991). perhaps one year of treatment for personality disordered clients moves them through stage one (i.e., decreases behavioral dysregulation) and stage two (i.e., decreases “silent suffering” such as ptsd), but does not always entail reaching stages three and four (i.e., engendering normal emotional experiencing, and greater spiritual advancement, respectively). it is possible that lynch et al.’s (2003) findings of a group difference in depression might be accounted for by the fact that the depressed elderly clients possess a higher level of socioemotional functioning than bpd clients. in other words, perhaps dbt for clients without such extreme difficulties may move quickly through stages one and two, leaving more time for stage three in which depression is addressed. multi-disordered clients in addition to its application to eating disorders and geriatric depression, dbt has been used in treating multidisordered clients. spoont, sayer, thuras, erbes, and winston (2003), in a largely descriptive article, discuss the application of dbt to a veterans affair (va) medical center. the authors note that there are two populations within a va center that are not adequately served: women and treatment-resistant men. women, many of whom have been sexually victimized while in the military (coyle, wolan, & van horn, 1996), were traditionally sent to group counseling with predominantly male group members (spoont et al., 2003). although significant effort is put into treating combat-related ptsd, there remains a group of treatmentresistant veterans who are chronically ill. dbt was thought to be the treatment of choice, as these treatment resistant veterans shared characteristics with bpd individuals. these common characteristics included excessive hospitalization amstadter and squeglia 22 history, substance abuse, impulsiveness, mood volatility, and interpersonal turbulence (rosenheck & fontana, 1999). a dbt program was implemented to treat these two populations. modifications to linehan’s (1993a; 1993b) protocol were made, including holding phone consultations only during business hours, providing a skills tutor for cognitively disadvantaged clients, creating a “step-down” group for graduated clients needing more services, and changing the length of skill group training sessions to 90 minutes over a period of 3, rather than 6, consecutive months. in an informal outcome survey, most clients and therapists reported that dbt was helpful (i.e., they derived at least some overall benefit from the treatment). no gender differences in reaction to the treatment were found. integration of dbt techniques into existing treatments dbt was created to treat the multifaceted symptoms from which bpd clients suffer; as a result, in addition to its overall effectiveness as a treatment package, dbt has specific components that can be applied to existing treatments. as bpd clients posed such a clinical challenge, linehan’s experience treating them has afforded a number of techniques to ensure client participation and retention (1993a). a number of clinical researchers and therapists have written about implementing aspects of dbt (i.e. modifying action tendencies) into existing evidence-based treatments (e.g., barlow, allen, & choate, 2004). alternatively, many have suggested broadening the scope of dbt to cover multiple impulse control disorders, including, but not limited to, substance abuse and binge eating disorders (van den bosch, verheul, schippers, & van den brink, 2002). exposure treatment for posttraumatic stress disorder (ptsd) will be used to demonstrate the supplementation of dbt components to facilitate treatment. exposure therapy is an empirically supported treatment modality for ptsd sufferers (e.g., foa & kozak, 1986). despite the support for this treatment, a number of issues exist that can pose barriers to successful outcomes and may lead to an arduous process for both therapist and client. first, at the beginning of treatment, clients tend to display an increase rather than a decrease in symptoms (resick & schnicke, 1992). dbt strategies taught in the distress tolerance and emotion regulation modules could benefit clients dealing with increased symptomotology during the beginning stages of treatment. ptsd clients could be taught how to tolerate distress that they cannot change, and how to regulate their emotions surrounding aspects in which they do have a choice. second, perhaps also related to symptom exacerbation prior to symptom improvement, client retention is an issue. dbt has specific techniques, based in social psychological principles of persuasion, to obtain and maintain commitment. such strategies may improve retention for exposure therapy clients. third, emotional experiencing, in the form of activation of the fear structure, is a necessary ingredient for exposure treatment to be effective (foa & kozak, 1986); ptsd clients may have dissociative tendencies (resick & schnicke, 1992) circumventing emotional experiencing. teaching clients mindfulness skills such as observation and participation in emotional experiences could enhance emotional experiencing and thereby possibly make exposure more effective. fourth, there is recent evidence that numbing symptoms in ptsd may be a result of emotional avoidance, suggesting faulty emotion regulation (roemer, litz, orsillo, & wagner, 2001). teaching clients the emotion regulation module of dbt may afford them with alternative, and more adaptive, skills to use in this arena. there are other principles of dbt not necessarily related to exposure that may be advantageous for those with ptsd; one such issue involves treatment timing (becker & zayfert, 2001). stage one of dbt focuses on behavioral regulation. if a client with ptsd has a chaotic life and is dysregulated, going forward with exposure techniques may not be the best option, as they may elicit more distress. such clients may benefit from sessions addressing dysregulation prior to the commencement of exposure. another concept from dbt that can be applied to ptsd is that of radical acceptance (becker & zayfert, 2001). working with ptsd clients through a radical acceptance framework helps patients recognize that while the trauma cannot be undone, the emotional reactions to the trauma can be modulated. additionally, dbt has an emphasis on treating selfinvalidation, a behavior often present in ptsd clients. from a dbt framework, educating the client on ways in which he or she invalidates his or her experience would be a useful part of treatment. it should be noted that these concepts and techniques are not distinct to dbt, as dbt is a theoretically grounded approach that has common factors with other treatments as well. in addition to its relevance to ptsd, dbt has been applied to substance abuse treatments. in a recent study of bpd women who are also substance dependent, dbt was associated with significantly less substance use throughout the course of treatment, as well as at follow-up (linehan et al., 1999). however, another study found that though dbt could be effectively applied with borderline patients who had co-occurring substance abuse problems, this treatment was not more successful compared to standard cognitive behavioral therapy in reducing the substance use (van den bosch et al., 2002). this discrepancy may arise from the fact that the linehan group focused treatment primarily on the substance abuse, while the van den bosch group focused primarily on bpd. from their results, van den bosch and colleagues (2002) conclude that the current version of dbt does not generalize to behavioral domains not specifically targeted. however, they do support the idea that developing a multitargeted dbt program would broaden the focus of treatment to include a wide range of impulse control disorders, such as binge eating and substance abuse. application of dbt beyond borderline personality disorder 23 conclusion the dbt literature as a whole is encouraging, especially given its relatively recent development. dbt has only existed for about 13 years, and within that time, six rcts with bpd clients have been conducted, producing promising results of the treatment’s efficacy (koons et al., 2001; linehan et al., 1991; linehan et al., 1999; linehan et al., 2002; turner, 2000; verheul et al., 2003). all six rcts with bpd clients have demonstrated that dbt is more effective than the comparison treatment on a variety of outcome measures, such as decreasing parasuicidal behavior, inpatient days, hopelessness, and even substance use; these positive treatment effects were maintained at follow-up assessments (e.g., linehan, heard, & armstrong, 1994). further, numerous uncontrolled clinical trials have been published, and countless case studies continue to emerge (e.g., katz & cox, 2002). dbt has been successfully applied to disorders other than bpd. in regards to eating disorders, theoretical (e.g., mccabe & marcus, 2002; wiser & telch, 1999) and empirical (e.g., palmer et al., 2003; telch et al, 2000; telch et al., 2001) support exists to suggest dbt may be an advantageous treatment. bed is the only eating disorder with both uncontrolled and controlled clinical trials for dbt. in the rct for bed, a treatment comparison group was not included, and should be in subsequent research. systematic dbt studies should be conducted with both anorexia nervosa and bulimia nervosa to determine the usefulness of this treatment for these disorders. in addition to eating disorders, dbt has also been shown to be more effective in treating late-life depression than medication alone (lynch et al., 2003). furthermore, dbt has been adapted to va settings in which clients present with a number of bpd features (spoont et al., 2003). in sum, the current state of the literature suggests that dbt is an empirically supported treatment for bpd. additionally, there is limited evidence to suggest that dbt is an effective treatment for bed and geriatric depression. to date, dbt has only been studied as a treatment package. therefore, though there are theoretical reasons to supplement existing therapies with dbt components, the effects of augmentation still require empirical validation. the apparent applicability of dbt for disorders outside of bpd has surpassed the empirical evidence to support the efficacy of such approaches, underscoring the need for more research. references american psychiatric association (1994). diagnostic and statistical manual of mental disorders, fourth edition (dsm iv). washington: apa. barlow, d. h., allen, l. b. & choate, m. l. 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(1999). dialectical behavior therapy for binge-eating disorder. in session: psychotherapy in practice, 55, 755-768. counselor smiling effects on perceivers 1 graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university the effects of a counselor smiling on perceivers tyler duffield colorado state university the duchenne smile has been suggested to be a signaler of altruistic intentions. other nonverbal cues of altruistic intentions have also been found. the current study controlled for other nonverbal cues of altruism in investigating the duchenne smile in a counseling setting. participants, using the “zeroacquaintance video presentation paradigm” viewed actual counselors genuinely smiling (duchenne) and posing a smile (non-duchenne). the zero-acquaintance video presentation paradigm entails presenting perceivers video clips depicting target individuals performing a particular task and then assessing the videotaped individuals. a 2 (counselor gender) x 2 (smile) multivariate analysis of variance on perceived altruism levels of counselors revealed a significant main effect for smiling condition. genuine smiling counselors were rated significantly higher on perceived altruism levels than posed smiling counselors. much research has been conducted on functions and uses of smiling (brown et al., 2003; burt & perrett, 1997; d’augelli, 1974; dooley, 1978; ekman et al., 1985; ekman & freisen, 1982; frank, 1988; gazzaniga & smylie, 1990; giudice & colle, 2007; mehu, grammer, & dunbar, 2007; mehu, little, & dunbar, 2007; wylie & goodale, 1988). it is known that there are different types of smiles. one can force a smile, or pose a smile. a genuine smile, in contrast, is known as a duchenne smile. the duchenne marker is the contraction of the orbicularis oculi muscle (ekman & freisen, 1982). the duchenne marker is named after duchenne de boulogne who first discussed the contraction of the orbicularis oculi muscle in relation to smiling in 1862 (giudice & colle, 2007). the contraction of the orbicularis oculi, or change in the muscle by shortening or tensing of the muscle, has multiple effects. its effects on the face are the narrowing of the eye aperture, or reduction in the amount of the eye exposed, “crow’s feet” on the external side of the eye, raising of the cheek, and lowering of the eye cover fold (giudice & colle, 2007). the duchenne (felt) smile is a spontaneous expression of positive emotion (ekman & freisen, 1982). a spontaneous emotion-based smile has greater displacement of the left-hand corner of the mouth than a posed smile due to right-hemisphere involvement (wylie & goodale, 1988). posed smiles (smiles without an underlying emotional basis) are less intense on the left side (gazzaniga & smylie, 1990). for this reason, humans scrutinize the left side of the face more than the right side when assessing facial expressions (burt & perrett, 1997). also, genuine smiles have extremely short durations, whereas posed smiles are significantly longer in duration (ekman & freisen, 1982).1                                                              correspondence: tyler duffield, tyduff25@rams.colostate.edu the current study examined smiling in a “mock” counseling context, in that the counseling sessions used volunteers as the clients and not the counselors’ actual clients. filming of these simulated sessions occurred in the counseling rooms of a local clinic. two doctoral students (one male, one female) in counseling psychology served as counselors and were filmed (as is their training program’s procedure for counselor evaluation) during the simulated counseling sessions. the primary research question focused on the extent to which the client interprets altruism from a genuine-smiling counselor. eldakar, wilson, and o'gorman (2006) defined an altruist as an individual who helps others as an end in itself. altruism is scientifically defined as instinctive behavior that is detrimental to the individual, but favors the survival or spread of that individual's genes, as by benefiting its relatives (altruism, n.d.). by definition, altruism is identified in an individual’s behavior, or the act of helping. therefore, to be quantified as an altruist is dependent on behavior. this study, however, continued investigation in the signaling of altruistic dispositions (brown et al., 2003; frank, 1988; mehu et al., 2007). trivers (1971, as cited in mehu et al., 2007, p. 135) suggested the role of pro-social emotions as a solution to commitment issues between unrelated individuals. frank (1988) predicted that the cues to altruism should be under involuntary control, and that humans have cognitive architecture designed by natural selection to assess altruism and selfishness in others. according to both models, the nonverbal cues related to positive emotions are seen as genuine signals of altruistic dispositions because they are not easy to fake because of their contingency with physiological processes (mehu et al., 2007). also, since the duchenne smile is believed to be a spontaneous emotional expression (ekman & friesen, 1982; gazzaniga & smylie, 1990), it is reasonable to expect that the duchenne smile is an indicator of altruism. research does suggest that the duchenne smile could be a reliable 20 effects of counselor smiling   21 indicator of altruistic dispositions (brown et al., 2003; mehu et al., 2007). brown et al. (2003) found significant nonverbal differences between altruists and non-altruists. after completing an altruism scale, 10 altruists comprising the top 10% of the altruism scale and 10 non-altruists comprising the bottom 10% of the altruism scale were video-taped giving a self-presentation (e.g. stating name, likes and dislikes). “concern for others” was then assessed on a sixpoint likert-type scale by a group of thirty perceivers viewing the videotapes (brown et al., 2003). four nonverbal differences between altruists and non-altruists were of particular theoretical interest, including felt smiling (orbicularis oculi muscle activity or duchenne smile), concern furrows (corrugator supercilii muscle activity drawing the eyebrow downward and medialward, producing the vertical wrinkles of the forehead), smile duration, and smile symmetry. these four nonverbal behaviors are particularly difficult to fake since they are linked to spontaneous emotional expression (ekman & freisen, 1982; gazzaniga & smylie, 1990). results indicated that these cues corresponded to increased “concern for others” ratings by the separate group of perceivers. this suggests that likelihood to cooperate [i.e., altruism as defined by brown et al. (2003)] is signaled nonverbally, and the putative cues may be under involuntary control as predicted by frank’s (1988) theory of altruism signaling (brown et al., 2003). these findings show that components of the duchenne smile (orbicularis oculi activity, smile duration and symmetry) are a form of altruism signaling. while investigating whether a link can be drawn between duchenne smiling and the five major personality dimensions, mehu et al. (2007) found duchenne smiles produced a much greater impact on generosity ratings than non-duchenne smiles. this finding is believed to support the assertion that the duchenne marker is involved in the detection of altruism (brown et al., 2003; mehu et al., 2007). fifty individuals were photographed and their pictures were used as stimuli in a face perception experiment. two pictures were taken for each individual: a picture showing a neutral face and a picture showing a smiling face. each smiling face was coded by two certified facial action coding system (facs; ekman, freisen, & hager, 2002) coders and smiles were classified into duchenne and non-duchenne. participants were asked to rate neutral (control condition) and smiling (experimental condition) stimulus faces on ten attributes: attractiveness, generosity, trustworthiness, competitiveness, health, agreeableness, conscientiousness, extroversion, neuroticism, and openness to experience. results showed differences between neutral and smiling faces were larger when stimulus faces displayed a duchenne rather than a nonduchenne smile, with the strongest impact ratings on generosity and extroversion. the effect of smile type on attributions of generosity appeared to be restricted to male faces though (mehu et al., 2007). a principal component analysis indicated that the effect of duchenne smiles does not necessarily generalize to a range of positive attributes (e.g., attractiveness, agreeableness, etc.), but could be specific to sociability (extroversion) and altruism (generosity). mehu et al. (2007) suggest that these findings emphasize the importance of the duchenne smile in the evaluation of sociability and altruism. the association between generosity and altruism draws from robert’s (1998, as cited in mehu et al., 2007, p. 143) study in which he found positive judgments of generosity by receivers could lead them to invest resources in a coalition. mehu et al.’s (2007) finding that the duchenne smile had a strong impact on attributions of generosity suggests that duchenne smiling could provide an important advantage in cooperative interactions. the association between duchenne smiles and generosity received support in mehu et al.’s (2007) study showing a connection between self-reported altruism toward a friend and the frequency of duchenne smiles during an interaction involving the sharing of material resources with that friend. similar findings have been found, but also show that smiling is not the only nonverbal cue for helping or altruism. for example, dooley (1978) found that independent judgments of what he referred to as empathic helping skills were moderately associated with several nonverbal behaviors, including head nodding, facial expressivity, smiling, and hand and arm movements. these findings are related to d’augelli’s (1974) results with the group assessment of interpersonal traits (gait). the gait was a group activity which entailed asking participants to individually present a meaningful personal concern to the group. another group member was then expected to engage the subject in a four-minute helping interaction. each subject was required to engage in both disclosing and understanding. during the gait, two trained observers recorded the frequency of nonverbal behaviors of the helper. these subject interactions were the basis of evaluations of the helper's nonverbal behavior and his helping. d’augelli (1974) found that nodding and smiling frequencies were positively related to peer and observer ratings of empathy and warmth. product-moment correlations were calculated between nonverbal behaviors and ratings of the helper made by the observers, by other participants, and by the person receiving help. however, no more than 10% of the common variance was accounted for in any of the obtained correlations; therefore, the impact of nonverbal behavior is questionable (d’augelli, 1974). dooley (1978) found larger empathic helping skills variance accounted for by nonverbal variables, and thus attributed a somewhat more important contribution of nonverbal behaviors to empathy ratings than d’augelli (1974). brown et al. (2003) also found head nodding to be unexpectedly correlated with altruism level, but suggested a possible type i error. the d’augelli (1974) and dooley (1978) studies make suggestions for future research, which is addressed in the current study. specifically, d’augelli (1974) suggested that more research needs to be conducted on extended duffield  22 interactions of actual counselors and clients and focus on the impact of nonverbal behaviors on clients. in addition, dooley (1978) questioned if his findings could generalize to counselors in professional and paraprofessional roles. he also suggested further research to find discrepancies, particularly in language, between his study and d’augelli’s (1974). to the knowledge of this researcher, the duchenne smile has not been researched in a counseling context. the present study investigates the duchenne smile as an altruism signaler in a profession designed to help individuals. the hypothesis is that duchenne activity by two counselors (one male, one female) will affect perceived altruistic levels of counselors by perceivers. it is also predicted that the female counselor will have higher ratings of altruism levels in the duchenne and non-duchenne smiling conditions. females are known to be more expressive of their feelings (elkin, 1979) and are quicker to relate interpersonally (feldman, crouch, & rodriquez, 1994), on average, relative to men. women are also generally better at sending and interpreting nonverbal cues (mayo & henley, 1981; rosenthal & depaulo, 1979). the independent variables were form of smiling, including duchenne and non-duchenne smiles, and the counselor’s gender. the dependent variables were perceivers’ ratings of altruism in the counselor as measured by the counselor effectiveness rating scale (cers) and the counselor effectiveness rating scale, revised (cersr). both scales were used because the cers used language appropriate to altruism assessment, but lacked psychometric estimates, whereas the cersr has available reliability and validity estimates. method participants seventy introductory psychology students comprised this study’s perceivers. eighteen males and fifty-two females participated. participants enrolled in this study to fulfill activity points as required by the introductory psychology course at colorado state university. fifteen participants viewed the video clip from the “male counselor/duchenne smile” condition. twenty-one participants viewed the video clip from the “male counselor/non-duchenne” condition. sixteen participants viewed the video clip from the “female counselor/duchenne” condition. eighteen participants viewed the video clip from the “female counselor/nonduchenne” condition. all four conditions were conducted in succession in one evening. participants enrolled in the study through the online portion of their introductory psychology course for one of four available study time slots. stimulus materials two doctoral students (one male, one female) in counseling psychology served as counselors, under their program’s psychological services center, and were filmed during simulated counseling sessions. film was obtained from one female counselor for a duchenne condition and non-duchenne condition. film was also obtained from one male counselor for a duchenne condition and nonduchenne condition. both sexes were used to assess potential gender interactions. webcams already installed in the counseling rooms in the psychology department were used to obtain video clips. two simulated counseling sessions were filmed of each counselor. filming of the counseling sessions occurred in the psychological services center’s counseling rooms using a volunteer for the client, not the counselors’ actual clients. counselors were simply asked to conduct themselves during the simulated counseling session as is protocol during their actual counseling. the simulated counseling sessions involved the volunteer client telling a comical anecdote to elicit smiling from the counselor. duchenne and nonduchenne activity were attained from each counselor during filming. the film was edited into four video clips approximately a minute long each in duration. each video clip contained a single level of each of the two factors (male/female counselor and non-duchenne/duchenne smile) per condition for a total of four conditions. video clips were solely of the counselors from the waist up and did not contain the audio portion. video clips were edited so head nodding and arm movements were minimal to control for other nonverbal cues of altruism. thus, efforts to control for a single, nonverbal altruistic behavior were implemented. these extraneous variables were all controlled for except occasional head nodding in the “female counselor/ non-duchenne” condition. head nodding in this condition could not be controlled for due to concurrent occurrence with posed smiles throughout the video clip. aside from dialogue not being of interest, silent video clips also controlled for dialogue as a possible confound to nonverbal altruism ratings by using the “zeroacquaintance video presentation paradigm”(brown et al., 2003), which is described below. procedure study participants engaged in the “zero-acquaintance video presentation paradigm.” the “zero-acquaintance video presentation paradigm” in nonverbal behavior experiments (see ekman, 1985) entails presenting participants with video clips depicting target individuals performing a particular task. participants then assess the videotaped individuals (brown et al., 2003). a 2 (counselor gender: male or female) x 2 (type of smile: duchenne or non-duchenne) between-subjects research design was used. participants were randomly assigned to one of the four conditions. participants entered a effects of counselor smiling   23 seminar room with a twenty-five person capacity, containing a 48-inch flat screen television and viewed the video clip with the researcher present. participants were made aware before viewing that the person on the video clip was an actual counselor during a counseling session. participants in each condition viewed their condition’s video clip and then were administered the counselor effectiveness rating scale, revised (cersr) and the counselor effectiveness rating scale (cers). instrument the original cers was developed by atkinson and carskaddon (1975) to assess perceived counselor credibility as a composite of several concepts. the scale consisted of five concepts; each rated on three, seven-point bipolar, semantic differential scales (atkinson & carskaddon, 1975). the three scales consisted of: good-bad, valuableworthless, meaningful-meaningless (atkinson & carskaddon, 1975). the five concepts included in the scale were (a) the counselor's knowledge of psychology, (b) the counselor's ability to help the client, (c) the counselor's willingness to help the client, (d) the counselor's comprehension of the client's problem, and (e) the counselor on the videotape as someone i would go to see if i had a problem to discuss (atkinson & carskaddon, 1975). the first revision to the cers was conducted by furlong, atkinson, and casas (1979), whose modifications included adjectives related to counselor attractiveness (ponterotto & furlong, 1985). participants in this study rated a counselor in a condition corresponding to the condition of atkinson and carskaddon (1975) on the concepts of expertness, trustworthiness, understanding, sincerity, and utility (e.g., the counselor on the videotape as someone i would go to see) (ponterotto & furlong, 1985). the next revision (cersr) and first reliability and validity estimates (prior cers use was presumably based off face validity) were conducted by atkinson and wampold (1982), who developed three semantic differential items for the expertness, attractiveness, and trustworthiness dimensions, plus one semantic differential item for counselor utility (someone i would see for counseling). all concepts were subsequently rated on a single, 7-point bipolar scale (1 = bad, 7 =good) (ponterotto & furlong, 1985). internal consistency reliability coefficients (coefficient alpha) across the expertness, attractiveness, trustworthiness, and total score dimensions were .88, .78, .75, and .90, respectively, and intercorrelations among subscales ranged from .54 to .76 (ponterotto & furlong, 1985). the cers scores were also correlated with counselor rating form (crf) ratings, yielding a concurrent validity coefficient of .80 for the cers (ponterotto & furlong, 1985). in the current study, cers and cersr items were analyzed independently and as a global measure of altruism. an inter-item analysis of reliability yielded a cronbach’s alpha of .91 of the eight cers and cersr items used. results a 2 (counselor gender) x 2 (smile) manova on perceived altruism levels of counselors revealed a significant main effect for smiling condition, f(8, 58) = 3.083, p < .05 (see table 1). the main effect for counselor gender was not significant, f (8, 58) = 1.933, p > .05, nor was the effect for the interaction of gender and smiling condition, f (8, 58) = 1.044, p > .05. therefore, the hypotheses that male and female counselors would differ in perceived altruism ratings, and that female counselors would have higher ratings of altruism levels in both smiling conditions were not supported. however, as hypothesized, genuine smiling counselors were rated significantly higher on altruism ratings than non-genuine smiling counselors. refer to table 2 for means and standard deviations of the ratings. univariate anovas assessing the effect of each of the eight altruism dependent variables revealed significant effects for every item (p < .05) except for item 4 (counselor’s sincerity), f (1, 65) = 1.733, p > .05 (see table 1). a genuine smiling counselor’s ability to help the client and willingness to help the client were rated significantly better, more valuable, and more meaningful, as compared to that of a non-genuine smiling counselor. participants also rated genuine smiling counselors higher on the item, “counselor as someone i would see for counseling, than non-genuine smiling counselors. no significant difference was found in ratings of the counselor’s sincerity between genuine and non-genuine smiling counselors. the items from the cers and cersr were then combined into a single, global altruistic variable, and a univariate anova was performed, resulting in a significant main effect of smiling condition on altruism, f (1, 65) = 11.994, p < .05. genuine smiling counselors were rated higher on altruism than were non-genuine smiling counselors. these results contribute to an overall, more robust measure of the significant effect of smiling condition on ratings of altruism. duffield  24 table 1 multivariate effects by gender and smiling condition and univariate effects by smiling condition on altruism items (cers) multivariate tests f df η² univariate tests (dependent measures) f df η² gender 1.93 8, 58 .21 cers2a 12.53* 1, 65 .16 smiling condition 3.08* 8, 58 .30 cers2b 10.03* 1, 65 .13 gender x smiling 1.04 8, 58 .13 cers2c 4.73* 1, 65 .07 cers3a 10.87* 1, 65 .14 cers3b 4.22* 1, 65 .06 cers3c 8.71* 1, 65 .12 cers4 1.73 1, 65 .03 cers10 9.04* 1, 65 .12 note. cers2a = gender counselor’s ability to help client, good/bad. cers2b = counselor’s ability to help client, valuable/worthless. cers2c = counselor’s ability to help client, meaningful/meaningless. cers3a = counselor’s willingness to help client, good/bad. cers3b = counselor’s willingness to help client, valuable/worthless. cers3c = counselor’s willingness to help client, meaningful/meaningless. cersr4 = counselor’s sincerity. cersr10 = counselor as someone i would see for counseling. *p < .05. table 2 means and standard deviations for altruism ratings of counselors measure condition male female non-duchenne duchenne non-duchenne duchenne m sd m sd m sd m sd cers2a 4.86 1.46 5.57 1.22 3.61 1.61 5.31 1.20 cers2b 5.00 1.45 5.43 1.22 3.78 1.80 5.13 .885 cers2c 4.90 1.26 5.00 1.30 3.78 1.80 5.13 .885 cers3a 4.57 1.57 5.71 1.44 4.66 1.75 5.94 1.12 cers3b 4.95 1.40 5.50 1.40 4.56 1.50 5.44 1.41 cers3c 4.71 1.42 5.50 1.51 4.28 1.71 5.63 1.26 cers4 4.67 1.71 4.43 2.03 3.83 1.25 5.19 1.97 cers10 4.09 1.79 5.14 1.99 2.94 1.39 4.38 1.59 note. cers2a = gender counselor’s ability to help client, good/bad. cers2b = counselor’s ability to help client, valuable/worthless. cers2c = counselor’s ability to help client, meaningful/meaningless. cers3a = counselor’s willingness to help client, good/bad. cers3b = counselor’s willingness to help client, valuable/worthless. cers3c = counselor’s willingness to help client, meaningful/meaningless. cersr4 = counselor’s sincerity. cersr10 = counselor as someone i would see for counseling. effects of counselor smiling   25 discussion counselors displaying duchenne (genuine) smiles were rated significantly higher on altruism ratings than nonduchenne (posed) smiling counselors. these results emulate brown et al.’s (2003) findings that suggest that the likelihood to cooperate is signaled nonverbally. this finding also is congruent with brown et al.’s (2003) evidence, suggesting that the duchenne smile contains the involuntary components to be a form of altruism signaling. results are in accordance with mehu et al.’s (2007) findings that the duchenne smile could have specificity to judgments of altruism as well. this study used the utility question of the cersr (counselor as someone i would see for counseling) to exemplify the duchenne smile as an altruism signaler. participants indicated that these counselors were someone they would see for counseling; ratings of genuine smiling counselors were higher than non-genuine smiling counselors. slightly larger levels of altruism were expected in the female counselor condition, based on studies addressing interpersonal aspects across gender (elkin, 1979; feldman, crouch, & rodriquez, 1994; mayo & henley, 1981; rosenthal & depaulo, 1979). gender was used as a factor to increase internal and external validity, and also to eliminate a possible confound of participants perceiving the counselors differently based on gender. however, in this study, counselor gender was not found to differentially influence participants’ ratings of the counselors’ altruism. these findings contradict dooley’s (1978) belief that his findings would not generalize to counselors in professional and paraprofessional roles. although not sufficient evidence to disprove dooley (1978), findings would suggest that the nonverbal behavior of smiling would generalize to a counseling setting. this study addressed d’augelli’s (1974) suggestions to focus on the impact of nonverbal behaviors on clients. although not clients, participants’ ratings suggest that the nonverbal behavior of duchenne smiling may impact actual client’s perception of whether the counselor wants to help him or her. the results have implications for the client-counselor relationship. therapeutic intervention would likely be more effective, or improved, if a counselor nonverbally displayed altruistic intentions dually with counseling protocol and techniques. it would possibly increase the counselor’s value as a social partner by enhancing the client’s judgment of altruistic intent in the counselor (mehu et al., 2007). logically, a counselor who nonverbally communicates altruistic intent throughout therapy will have a better relationship with his or her client, and could possibly increase the likelihood of positive outcome. the difficulty of these findings is that counselors cannot be trained to incorporate into their counseling a behavior that is a spontaneous emotional expression (ekman & freisen, 1982; gazzaniga & smylie, 1990). counseling programs, however, can begin to consider incorporating genuine smiling, an advantageous nonverbal expression, into their counseling techniques. furthermore, this study provides evidence that a duchenne smile functions as an altruism signaler in a context not yet investigated, a simulated counseling setting. additionally, this research suggests this function might have possible implications for improving therapeutic intervention. a limitation of this study was that the distinction between duchenne/non-duchenne smiles was not assessed by an expert; rather, it was differentiated by the author. also, this study was only a reflection of the effects of a counselor smiling on clients as rated by non-client perceivers. it cannot be assumed that a client in the counseling dyad will react in the same way that an outside perceiver viewing a simulated counseling session would to a genuine smiling counselor. clients are in a different context, have a relationship with the counselor, and are presumably in counseling because they are experiencing some level of distress. thus, attempts to generalize to an actual counseling context must be tentative. however, these significant results do warrant further investigation. a more in depth technique is needed to investigate these findings in an actual counseling dyad. a longitudinal study examining a longer duration of therapy would also be an appropriate next step. acknowledgments the author would like to thank his advisor dr. bryan dik for his assistance and guidance throughout this research. the author would also like to thank dr. randall swaim for his revision suggestions. the author would like to thank the graduate students who volunteered for the video taping and brandy eldridge for her invaluable help with csu’s psychological services as well. finally, the author would like to thank definite productions and brad scott for editing the video clips. references altruism. 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(1988). left-sided oral asymmetries in spontaneous but not posed smiles. neuropsychologia, 26, 823-832.  15 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university serving whom? an exploration of cultural taxation themes in latinx graduate students madasen briggs, m.s., jonathan cajas, b.a., audon archibald, ph.d., and yolanda flores niemann, ph.d., department of psychology, university of north texas �ȣǹƞȣȗƺǹ�ƞƺπƺƞǩȅǿ�ȗǔǟǔȗș�ƞȅ�ƞǧǔ�ǔπƞȗƺ�ȗǔșȓȅǿșǩljǩǹǩƞǩǔș�শǔঀǡঀॹ�ǩǿljȗǔƺșǔǐ�șǔȗκǩljǔ�ǔπȓǔljƞƺƞǩȅǿșॹ�șǔȗκǩǿǡ�ƺș�ȣǿȅгljǩƺǹ�ǐǩκǔȗșǩƞρ� consultants) placed on members of marginalized racial groups within academia. however, the extant literature on cultural taxation does not clearly indicate the extent to which that research applies to graduate students who often ǟȣǹйǹǹ�șǩǿǩǹƺȗ�ƞƺșƿș�ƺș�ǿǔǿljǔȗș�ȅǟ�ƺljƺǐǔǿǩƺ�ƺǿǐ�ǟƺljȣǹƞρঀ�'ȣȗƞǧǔȗǿȅȗǔॹ�ƞǧǔ�ƺljƺǐǔǿǩlj�ljȅǿƞǔπƞ�ȅǟ�ƺ�/ǩșȓƺǿǩlj�^ǔȗκǩǿǡ� institution (hsi) is particularly relevant to this line of work as this designation, while projecting an image that an institution is inclusive, is not directly representative of the institution’s commitment to equitable practices. the goal of the present research is to identify how latinx graduate students are potentially taxed and whether their experiences of cultural taxation are analogous to the taxation that faculty experience. transcripts from 20 interviews with latinx students at an hsi were analyzed via qualitative thematic analysis to identify potential themes of this sample’s experiences with cultural taxation. findings suggest that latinx graduate students’ cultural taxation converge in some ways with faculty patterns, but with key exceptions. major themes from students’ responses include a sense of ǩǿljȗǔƺșǔǐ�ǐǩșƞƺǿljǔ�ƺǿǐ�ǹƺljƿ�ȅǟ�șȣȓȓȅȗƞ�ǟȗȅǿ�ȅǿǔঢ়ș�ǧȅǿǔ�ǐǔȓƺȗƞǿǔǿƞॹ�ƺș�λǔǹǹ�ƺș�ǐǩгljȣǹƞǩǔș�ǩǿƞǔǡȗƺƞǩǿǡ�ǐǩκǔȗșǩƞρ�ƺǿǐ� ǩǿljǹȣșǩȅǿ�λȅȗƿ�ljǹǔƺǿǹρ�ǩǿƞȅ�ȅǿǔঢ়ș�ǡȗƺǐȣƺƞǔ�ljƺȗǔǔȗঀ�eǧǔșǔ�йǿǐǩǿǡș�șȣȓȓǹǔǿǔǿƞ�ǔπǩșƞǩǿǡ�ljȣǹƞȣȗƺǹ�ƞƺπƺƞǩȅǿ�ǹǩƞǔȗƺƞȣȗǔ�ljρ� ǧǩǡǧǹǩǡǧƞǩǿǡ�ƞǧǔ�ǔπȓǔȗǩǔǿljǔș�ȅǟ�ƺǿ�ȣǿǐǔȗȗǔljȅǡǿǩφǔǐ�ȓȅȓȣǹƺƞǩȅǿ�λǩƞǧǩǿ�ƺljƺǐǔǿǩƺ�ƺǿǐ�ȓȗǔșǔǿƞǩǿǡ�ǩǿǩƞǩƺǹ�йǿǐǩǿǡș�ǟȅȗ� taxations imposed on this group. keywords: cultural taxation, graduate students, latinx students, identity taxation, thematic analysis cultural taxation refers to the elevated workload expected of academics from marginalized communities (padilla, 1994). this elevated, but rarely compensated, workload often includes participation in diversity and equity work due to a faculty member’s presumed knowledge of diversity, regardless of its relevance to their research expertise (padilla, 1994; joseph ૭�/ǩȗșǧйǔǹǐॹ� �আ��ǹǔκǔǹƺǿǐࢲࢲࢱࢳ ǔƞ� ƺǹঀॹ� �ষঀࢹࢲࢱࢳ �ǿȅǿǡ� ƞǧǔ�ǿȅșƞ�ǩǐǔǿƞǩйƺljǹǔ�ǟȅȗǿș�ȅǟ�ƞƺπƺƞǩȅǿ�ǩǿljǹȣǐǔॸ�ljǔǩǿǡ� expected to serve as an expert on all matters of diversity even when they are not relevant to one’s expertise, being called on to educate the majority group on diversity issues outside of one’s job description, serving on an ƺгȗǿƺƞǩκǔ�ƺljƞǩȅǿ�ljȅǿǿǩƞƞǔǔ� ƞǧƺƞ�ȅǿǹρ� ȗǔșȣǹƞș� ǩǿ� ȗǔljommendations that have already been unmet, serving as a spokesperson from an ethnic community to the ȣǿǩκǔȗșǩƞρॹ� șƺljȗǩйljǩǿǡ� ƞǩǿǔ� ƞȅ� șǔȗκǔ�ƺș� ƺ�ǿȣǹƞǩljȣǹƞȣȗƺǹ� problem solver, and being asked to serve as a translator or interpreter (padilla, 1994; gutiérrez y muhs et al., 2012; boyd et al., 2017; njie-carr et al., 2020). in practice, cultural taxation could also be inclusive of discriminatory practices such as the tokenization of a department’s marginalized members (amie, 2020). tokens are numerically or culturally underrepresented groups within an organization who are viewed as a symbolic representation of that group as a whole (niemann, 2016). an example of this phenomenon would be a faculty member of color being pointed to by administration as a symbol of a department’s commitment to diversity. while the perspectives and contributions of marginalized community members are vital to an organization’s success (page, 2007), involvement in such work that draws attention to their marginalized status can heighten the burden already in place by a standard academic teaching and research load. facȣǹƞρ�ǿǔǿljǔȗș�ǔπȓǔljƞǔǐ�ƞȅ�ǟȣǹйǹǹ� ƞǧǔșǔ�ǔπƞȗƺ�ǐǔǿƺǿǐș� have experienced stress, longer hours, and depression শ=ȅșǔȓǧ�૭�/ǩȗșǧйǔǹǐॹࢲࢲࢱࢳ�ষ�ƺș�λǔǹǹ�ƺș�ƺ�ǐǩгljȣǹƞ�ȗǔǹƺtionship with their professional identity (amie, 2020). the expectation that racialized1�ǟƺljȣǹƞρ�λǩǹǹ�ǟȣǹйǹǹ� these additional responsibilities becomes more insidious when considering that white academics continue to occupy about 75% of all faculty positions (nces, 2020; pew research, 2019). even with a gradual increase in the diversity of faculty, student bodies continue to be more diverse by comparison (pew research, 2019). already underrepresened, racialized faculty are also less likely to secure tenure or promotion in their institution, even after controlling for human capital, cultural taxation, and discipline (wijesingha & ramos, 2017). 11 for the purposes of this project, “racialized” refers to those who are marginalized according to their racial group. this term was selected for consistency for the purposes of this project, “racialized” refers to those who are marginalized according to their racial group. this term was selected for consistency throughout the paper, but we recognize that “racialized” is an imperfect term that could falsely imply that whiteness is not factored into the treatment of throughout the paper, but we recognize that “racialized” is an imperfect term that could falsely imply that whiteness is not factored into the treatment of someone according to their racial group.someone according to their racial group. 16 increased expectations of racialized faculty impose barriers by taking time away from more personally important tasks, such as the research that is necessary to advance their careers (domingo et al., 2022). unfortunately, the combination of stagnant performance and increased responsibilities can lead to decreased work satisfaction, longer promotion times, and increased position resignation (domingo et al., 2022). this translates to decreased representation among racialized faculty, which can negatively impact racialized student success and retention (tram et al., 2020). outcomes for students can include decreased program satisfaction ǐȣǔ�ƞȅ�ȣǿǿǔƞ�ǔπȓǔljƞƺƞǩȅǿșॹ�ǹƺljƿ�ȅǟ�йǿƺǿljǩƺǹ�șȣȓȓȅȗƞॹ� and an inability to connect with faculty mentors who may not understand cultural needs (tram et al., 2020). eǧǩș�ǐȅǿǩǿȅ�ǔаǔljƞ�șȓǔƺƿș�κȅǹȣǿǔș�ƞȅ�ƞǧǔ�ǩǿȓȅȗƞƺǿljǔ� of racialized faculty’s presence in academia and students’ vulnerability, particularly graduate students, who rely on a close relationship with faculty members. while faculty have received much research attention, the extant literature is limited in directly addressing the unique positioning and circumstances of graduate students as a potentially culturally taxed population. nearly thirty years ago, padilla (1994) called ǟȅȗ�ǩǿκǔșƞǩǡƺƞǩȅǿș�ȅǿ�ƞǧǔ�ǔаǔljƞș�ȅǟ�ljȣǹƞȣȗƺǹ�ƞƺπƺƞǩȅǿ�ȅǿ� marginalized graduate students. padilla notes that graduate students face unique challenges in the pursuit of ǔƞǧǿǩlj�șljǧȅǹƺȗșǧǩȓॹ�йǿǐǩǿǡ�ǿǔǿƞȅȗșǧǩȓ�ƞǧƺƞ�λȅȣǹǐ�ƺljcompany that work, and the inability to access all of an institution’s resources (padilla, 1994). however, clariйljƺƞǩȅǿ�ǩș�ǿǔǔǐǔǐ�ȅǿ�ƞǧǔ�λƺρș�ǩǿ�λǧǩljǧ�ǡȗƺǐȣƺƞǔ�șƞȣdents with marginalized racial and ethnic identities are ƺаǔljƞǔǐ�ljρ�ƺǿǐ�ljȅȓǔ�λǩƞǧ�ljȣǹƞȣȗƺǹ�ƞƺπƺƞǩȅǿॹ�șȓǔljǩйljƺǹǹρ� in how they relate to the faculty model proposed by padilla. some culturally informed models identify common graduate student experiences, such as imposter phenomenon amongst black graduate students at a predominately white institution (stone et al., 2018). however, these models have typically failed to incorporate the perspective of latinx2 graduate students, a group sorely in need of targeted work given their status as the largest ethnic minority group in the united states. testimonies from graduate students and early career academics reveal the immediacy with which we must address the interplay of graduate student status, identity, and cultural taxation (templeton et al., 2021). lerma and colleagues (2020) elaborated upon forms of cultural taxation in student populations in the form of “racialized equity labor.” this labor refers to the actions taken by marginalized students within an organization to address racial inequity that is then appropriated by those with more organizational power. the stress and demands from this cycle can force already marginalized individuals to relinquish additional ȗǔșȅȣȗljǔșॹ�șȣljǧ�ƺș�ƞǩǿǔॹ�λǧǩljǧ�ǿƺρ�ȗǔмǔljƞ�ȓȅȅȗǔȗ�ȓǔȗformance in professional and academic settings (lerma et al., 2020). however, lerma’s innovative work 1) did not distinguish between the work of undergraduate and graduate students and 2) sought out particǩȓƺǿƞș� șȓǔljǩйljƺǹǹρ� ǟȅȗ� ƞǧǔǩȗ� ǩǿκȅǹκǔǿǔǿƞ� ǩǿ�ȣǿǩκǔȗșǩƞρ� ljǧƺǿǡǔ� ƞǧƺƞ� ljǔǿǔйƞș�ǿƺȗǡǩǿƺǹǩφǔǐ� șƞȣǐǔǿƞșঀ� 2ƞ� ǩș� ȣǿclear how racialized equity labor, and by extension, the labor appropriation cycle outlined by lerma (2020), occurs amongst graduate students who may objectively have more power but also may have more complex tethers to their universities than undergraduates (grady et al., 2014). like marginalized faculty, graduate students are often expected to put their own needs or goals aside for those of the department (grady et al., 2014). furthermore, members of latinx communities already face unique challenges integrating into higher education, such as increased psychological and acculturative stress (wang et al., 2016), and the highest likeǹǩǧȅȅǐ�ȅǟ�ǧȅǹǐǩǿǡ�йȗșƞেǡǔǿǔȗƺƞǩȅǿ�șƞȣǐǔǿƞ�șƞƺƞȣș�ljȅǿpared to their black and white peers (pnpi, 2021). beyond student status: the importance of gender and culture beyond student status, members of marginalized communities experience cultural taxation based ȅǿ� ȗƺljǔ� ƺǿǐ� ǡǔǿǐǔȗ� ǩǿƞǔȗșǔljƞǩȅǿș� শ/ǩȗșǧйǔǹǐ� ૭� =ȅseph, 2012; diaz & bui, 2016). making space for these identity intersections within research is critical to appropriately framing people’s experiences with nuance and avoiding the homogenization of an entire group’s experiences. at the intersection of race and gender, women of color are often looked to as supporting pillars of their communities through the perpetual association with women, inherent communality, and nurturing expectations (gutiérrez y 22for the purposes of this project, latinx is used during each research stage as a gender-neutral term to refer to those of latin american for the purposes of this project, latinx is used during each research stage as a gender-neutral term to refer to those of latin american descent (e.g., latino, hispanic, mexican american, chicano, puerto rican, cuban american, etc.). the authors want to recognize descent (e.g., latino, hispanic, mexican american, chicano, puerto rican, cuban american, etc.). the authors want to recognize that, while the term has gained popularity within university student populations and higher education research, latinx is an imperfect that, while the term has gained popularity within university student populations and higher education research, latinx is an imperfect term thatterm that may contribute to the homogenization of individual cultures (salinas & lozano, 2017). may contribute to the homogenization of individual cultures (salinas & lozano, 2017). briggs et al. 17 cultural taxation themes in latinx graduate students muhs et al., 2012; velásquez et al., 2004). culturally taxing experiences for women of color in the professorate are further compounded by gendered ascriptions and ongoing professional disparities in academia. women faculty are canonically more involved in departmental or university service work than their male colleagues (niemann, et al., 2020; njie-carr, et al., 2020; o’meara et al., 2017), which partially explains why women, on average, publish less and receive fewer research grants than men (wijesingha & ramos, 2017). adding to their challenging experiences is the relatively small number of women of color in upper-level professor and administrative ranks (sánchez et al., 2021). � �ȣǹƞȣȗƺǹǹρ� șȓǔljǩйlj�ljǩȗljȣǿșƞƺǿljǔș�ǿƺρ�ƺǹșȅ� șǧƺȓǔ� experiences. mexican americans face marginalization within the united states that may lead to steep social consequences, such as feelings of alienation and ‘othering’ perpetrated through negative stereotypes (hester et al., 2020; olguin-aguirre et al., 2022). further, discrimination can be perpetrated through public policy that imposes limits on equitable access to quality education and health-related resources (brenes, 2019; shi et al., 2018). arbona and colleagues (2010) theorize that latinx individuals are especially vulnerable ljǔljƺȣșǔ� ƞǧǔǩȗ� ǩǐǔǿƞǩƞρ� ǩș� ȣǿǩȕȣǔǹρ� ƺаǔljƞǔǐ� ljρ� ƞǧǔ� șǩmultaneous experience of generational cultural practices and of american society outside of the home. although some latinx academics may feel comfortable navigating a bicultural perspective, others, particularly those who have recently immigrated to the united states, could face increased adversity that may lead to acculturative stress (berry, 1992; meca et al., 2017). the research outlined in this paper explores latinx graduate students’ experiences of cultural taxation at a hispanic serving institution (hsi). while an hsi designation requires that a minimum of 25% of students enrolled be hispanic (white house, n.d.), that does not guarantee representation at the graduate level. for example, latinx graduate enrollment at this southwestern public university (swpu) equals about half that of undergraduate enrollment, with even fewer faculty in place to support those graduate students (swpu factbook, 2020). although an hsi designation presents opportunities to apply for federal funding to serve latinx students, assessments indicate that universities often funnel these extra funds into colorblind programs that do not prioritize latinx students (vargas & villa-palomino, 2018). investigations of faculty’s cultural taxation within an hsi also indicate that this institutional designation does not protect against racism, marginalization, and taxation for faculty of color (martinez et al., 2017). beyond numerical enrollment, it is not clear what the term hispanic serving institution means to the experiences of latinx students. the goal of the present study is to 1) understand how latinx graduate students at an hsi identify with cultural taxation and related labor on campus and 2) identify how these experiences compare to faculty taxƺƞǩȅǿঀ�̂ ȓǔljǩйljƺǹǹρॹ�λǔ�ƺǩǿ�ƞȅ�ǩǐǔǿƞǩǟρ�ƞǧǔ�λƺρș�ǩǿ�λǧǩljǧ� existing understandings of cultural taxation align with latinx graduate students’ experiences of cultural taxation unique to this population. furthermore, we seek to understand how the intersections of race and gender play into latinx women graduate students’ experiences with cultural taxation. findings from this work will help identify where this sample of latinx graduate students falls in relation to existing cultural taxation literature. it is our hope that such knowledge will highlight ȓƺƞǧλƺρș�ȅǟ�ƺljƞǩȅǿ�ǟȅȗ�ȓȗȅǡȗƺǿș�ƺǿǐ�ǿǔǿƞȅȗș�ǩǿ�șȓǔljǩйlj� support of marginalized graduate students. additionally, the current work seeks to bolster the understanding of graduate students’ experiences as a population already subjected to exploitative practices surrounding their learning and labor (cohen & baruch, 2021). methods participants a total of 20 latinx graduate students participatǔǐॹ�ǩǿljǹȣǐǩǿǡࢳࢲ��λǧȅ�ǩǐǔǿƞǩйǔǐ�ƺș�λȅǿǔǿॹ�ƺǿǐ�ǔǩǡǧƞ� λǧȅ�ǩǐǔǿƞǩйǔǐ�ƺș�ǿǔǿঀ�^ƞȣǐǔǿƞș�ȗǔȓȗǔșǔǿƞǔǐ�ȅκǔȗࢱࢲ�� ǐǩаǔȗǔǿƞ�ǐǔȓƺȗƞǿǔǿƞș�ȅǿ�ljƺǿȓȣș�șǔǔƿǩǿǡ�ƺ�κƺȗǩǔƞρ�ȅǟ� degrees, including both master’s and ph.ds. students came from a blend of business, stem (science, technology, engineering, math), and social science programs with career tracks inclusive of both industry and academia. participants’ ages ranged from 22 to 48. participants came from a range of latinx backǡȗȅȣǿǐșॸࢶࢳ�ઔ�ȅǟ�ƞǧǔ�ȓƺȗƞǩljǩȓƺǿƞș�ǩǐǔǿƞǩйǔǐ�ƺș�ǧƺκǩǿǡ� mixed heritage (e.g., mexican and salvadorian, mixed ǩǿǐǩǡǔǿȅȣș�ƺǿǐ�eǔπǩljƺǿ��ǿǔȗǩljƺǿষॹࢱࢳ�ઔ�ǩǐǔǿƞǩйǔǐ� ƺș�/ǩșȓƺǿǩljॹࢱࢳ�ઔ�ǩǐǔǿƞǩйǔǐ�ƺș�@ƺƞǩǿπॹ�ƺǿǐ�ƞǧǔ�ȗǔǿƺǩǿǩǿǡ�ȓƺȗƞǩljǩȓƺǿƞș�ǩǐǔǿƞǩйǔǐ�ƺș�eǔπǩljƺǿ��ǿǔȗǩljƺǿ�ȅȗ� argentinian. data collection took place during the spring 2021 semester when many students had still not yet returned to face-to-face classes due to the covid-19 18 pandemic. while questions related to participant experiences did not specify a particular timeframe, student responses are a mix of both their pre-pandemic and pandemic experiences on campus. research design a series of one-on-one, open-ended interviews were conducted and analyzed qualitatively. open-ended questions were based on padilla’s (1994) cultural taxƺƞǩȅǿ�ǟȗƺǿǔλȅȗƿॹ�λǧǩljǧ�șȓǔljǩйǔș�ƺǿ�ǩǿljȗǔƺșǔǐ�ljȣȗǐǔǿ� of service and mentorship to students, colleagues, and the university faced by racialized faculty (jacobs et al., 2002). consideration was also given to other aspects of this phenomenon, such as its intersectional nature শ=ȅșǔȓǧș�૭�/ǩȗșǧйǔǹǐॹࢳࢲࢱࢳ�ষॹ�ƞȅ�ǔǿșȣȗǔ�ƞǧƺƞ�ǩǿƞǔȗκǩǔλș� were capturing the full breadth of graduate students’ experiences with cultural taxation (lerma et al., 2020; blake, 2018). all questions were iterated over a series ȅǟ�ǿǔǔƞǩǿǡș�ƺǿȅǿǡșƞ�ƞǧǔ�ȗǔșǔƺȗljǧ�ƞǔƺǿ�ȣǿƞǩǹ�ƞǧǔ�йǿƺǹ� set of 25 questions was reached (see appendix b for list of interview questions). an example item from this list is “in what ways, if any, was your service rewarded, validated, or noticed?” to not lead participants to șȓǔljǩйlj� ƺǿșλǔȗșॹ� ȕȣǔșƞǩȅǿș� ƺșƿǔǐ� ȓƺȗƞǩljǩȓƺǿƞș� ƺljȅȣƞ� ‘their identities’ as opposed to specifying a particular ȗƺljǩƺǹ�ȅȗ� ǔƞǧǿǩlj�ǡȗȅȣȓঀ�xƺȗƞǩljǩȓƺǿƞș�λǧȅ� ǩǐǔǿƞǩйǔǐ�ƺș� women were given an additional set of four questions to discuss their experiences within the intersection of race and gender in graduate school. an example item from this set is “do you feel as if expectations in your department are identical for men and women?” it is important to note that the research team who conducted interviews, subsequent analyses, and authored this manuscript identify as follows: white nonbinary person, cisgender latino/hispanic man, cisgender biracial mexican man, and cisgender mexican american woman. procedure the present project received institutional review board approval at a large southwestern public university (swpu) during the spring of 2021. study invitations were sent to all graduate students informing them of an opportunity for latinx graduate students to self-select into a study to discuss their experiences with race on campus. a request for latinx students was used in the mass mailer, but participants were asked to self-report their racial/ethnic identity if their identity was not fully encapsulated by the term latinx. students were also given the opportunity to șȓǔljǩйljƺǹǹρ� ȗǔȕȣǔșƞ� ƺ� @ƺƞǩǿπ� ǩǿƞǔȗκǩǔλǔȗ� ǐȣǔ� ƞȅ� ƞǧǔ� sensitive nature of the questions. following recruitment, all participants took part in individual interviews with a member of the research team. all 20 interviews were conducted via zoom, recorded, and transcribed live using panopto. after the interview stage concluded, the authors reviewed the transcriptions produced by panopto for any potential errors. data analyses followed braun and clarke’s (2006) six phases for thematic analysis, a qualitative data ƺǿƺǹρșǩș� ƞǔljǧǿǩȕȣǔ� ƞǧƺƞ� ǩǐǔǿƞǩйǔș�ȅκǔȗƺȗljǧǩǿǡ� ƞǧǔǿǔș� and patterns of meaning in a particular dataset. the phases for thematic analysis are: 1) familiarizing yourself with your data, 2) generating initial codes, 3) șǔƺȗljǧǩǿǡ� ǟȅȗ� ƞǧǔǿǔșॹ� �ষࢵ ȗǔκǩǔλǩǿǡ� ƞǧǔǿǔșॹ� �ষࢶ ǐǔйǿing and naming themes, and 6) producing the report. overall, due to the novelty of the work, we took a primarily inductive approach, meaning our codes and themes are derived from the semantic content of the data rather than coding the data according to pre-existing theoretical concepts (braun & clarke, 2012). while the research team was deeply familiar with pre-existing frameworks of cultural taxation, “our analytic lens does not completely override their [participants’] stories” (braun & clarke, 2012, p. 60). this analytic ƞǔljǧǿǩȕȣǔ�λƺș�ȓȗǔǟǔȗȗǔǐ�ljǔljƺȣșǔ�ȅǟ�ǩƞș�ƞǧǔȅȗǔƞǩljƺǹ�мǔπibility compared to other techniques such as discourse analysis which requires theoretical framing for the role and meaning of language (braun & clarke, 2012). � vǩƞǧ� ƞǧǔ� йǿƺǹ� ƞȗƺǿșljȗǩȓƞǩȅǿșॹ� ǔƺljǧ� ƺȣƞǧȅȗ� ǩǿǐǔpendently read and generated individual lists of codes for the data using nvivo (version 12). for this techǿǩȕȣǔॹ�ljȅǐǔș�ǩǐǔǿƞǩǟρ�ƺ�șȓǔljǩйlj�ǟǔƺƞȣȗǔ�ȅǟ�ƞǧǔ�ǐƺƞƺșǔƞॹ� and these codes are grouped into overarching themes. coding involved the individual labeling of data segments that were potentially relevant to the research question. these independent code lists were reduced collaboratively based on codes that all four research ƞǔƺǿ� ǿǔǿljǔȗș� ljȅǹǹǔljƞǩκǔǹρ� ƺǡȗǔǔǐ� λǔȗǔ� șȣгljǩǔǿƞǹρ� ȓȗǔșǔǿƞ�ƺǿǐ�ǿǔƺǿǩǿǡǟȣǹ�ǩǿ�ƞǧǔ�ǐƺƞƺॹ�ȗǔșȣǹƞǩǿǡ�ǩǿ�ƺ�йǿƺǹ� list of over 40 codes. after code generation concluded, the research team sorted these codes into themes through collaborative discussion (see table 1 for overview). themes for this project were organized groups of codes that represented patterns and shared meanings across the dataset. coder reliability was not as briggs et al. 19 cultural taxation themes in latinx graduate students sessed quantitatively; these numeric itatively; these numeric measures of intercoder reliability are more common in qualitative work guided by post-positivistic values. we aligned with a paradigm that emphasizes an organic approach to the data and each coder’s ǿƺƞȣȗƺǹॹ� ȗǔмǔπǩκǔ� ȗǔșȓȅǿșǔ� শ�ȗƺȣǿ� ૭� �ǹƺȗƿǔॹ� ষঀࢲࢳࢱࢳ results � 'ǩκǔ�ƞǧǔǿǔș�λǔȗǔ� ǩǐǔǿƞǩйǔǐ�ȣșǩǿǡ�ƞǧǔ�ƺljȅκǔ�ljȅǐing process. these themes are distance/isolation from support; power, labor, and ‘something’s gotta give;’ culturally taxing levies against latinx student identities; unique pressures on women; and reluctance to assign accountability and responsibility. in general, participants reported that they were not entirely supported by their departments and largely abstained from diversity labor. women participants reported undertaking more social and emotional labor than their male counterparts. finally, participants provided evidence that they experienced cultural taxation (e.g., feeling that they are made into a representative for all latinx peoples), but were hesitant to assign accountability to the parties contributing to these taxations. an in-depth description of each theme and some supporting data points are provided below. we provide a brief overview of how each theme relates or diverges from existing literature; these points are further explored in the discussion. throughout the following section, we refer to participants according to the identities they provided on their demographics quesƞǩȅǿǿƺǩȗǔ�λǧǩǹǔ�șƞǩǹǹ�ǿƺǩǿƞƺǩǿǩǿǡ�ƞǧǔǩȗ�ljȅǿйǐǔǿƞǩƺǹǩƞρঀ theme one: distance/isolation from support latinx interviewees acknowledged acute differences between the graduate and undergraduate ǔπȓǔȗǩǔǿljǔș� ȅǿ� ljƺǿȓȣșঀ� eƺǿρ� ȅǟ� ƞǧǔșǔ� ǐǩаǔȗǔǿljǔș� manifested as a physical and psychological distance from campus life and culture, as well as distance from potential campus support networks within and outside their department. this was compounded in no small amount by the realities of the covid-19 pandemic in the united states, with many students lamenting that working from home and the stressors of the pandemic exacerbated the pre-existing lack of support for latinx graduate students. one hispanic graduate student speaks up about how departmental support for students of color, in general, ǐȅǔș�ǿȅƞ�ǿǔljǔșșƺȗǩǹρ�йǹǹ�ǩǿ�ƞǧǔ�ǿǔǔǐș�ƞǧƺƞ�@ƺƞǩǿπ�ǡȗƺǐuates display based on their cultural backgrounds: ৚ॺljǔǩǿǡ�/ǩșȓƺǿǩljॹ�ǿρ�κǩǔλș�ƺȗǔ�ƺ�ǹǩƞƞǹǔ�ljǩƞ�ǐǩаǔȗǔǿƞঀ�2� don’t think [departmental support] is hispanic servǩǿǡॹ�2�ǐȅǿঢ়ƞ�ƞǧǩǿƿ�ǩƞ�ǟȣǹйǹǹș�ƞǧƺƞঀ�2�ƞǧǩǿƿ�ǟȅȗ�ǿǩǿȅȗǩƞǩǔș� as a whole, [swpu] does a great job with lots of inclusion, lots of opportunities for graduate students to work with faculty members… but for hispanics, they love to preach how they’re going to help and that they’re going to support you… but in the ways they actually do it’s very, very limited… [for example] when my father was dying of liver disease… and my mother, she had breast cancer at the same time, it’s like, hey, i can’t live on campus because i need to live close to my parents due to that whole cultural aspect of hispanic children taking care of their parents. so, i said “hey, i’m not going to be able to relocate,” and they șƺǩǐॹ� ৚kƿ� λǔǹǹ� ǩǟ� ρȅȣ� ljƺǿঢ়ƞ� ǟȣǹйǹǹ� ƞǧǩșॹ� ρȅȣঢ়ȗǔ� ȅȣƞঀ৛ faculty and administrators’ seeming inability to understand the responsibilities many students felt to their identity and community was not unique to this student. other students spoke more to how physical distance from campus life inhibited the formation of more support networks. for many of the latinx graduate student interviewees, the realities of being disconnected from the physical campus began long before the pandemic (erichsen & bolliger, 2011). one nonƞȗƺǐǩƞǩȅǿƺǹ�ǿƺǹǔ�ǡȗƺǐȣƺƞǔ�șƞȣǐǔǿƞ�λǧȅ�ǩǐǔǿƞǩйǔș�ƺș�ǩǿdigenous mexican responded “i mean, i’m so disconnected because i’m online. i really have no idea how swpu serves students of color. i don’t know honestly… there’s very little interaction, at least for me...” these feelings of isolation were further characterized by students often being in a position where their existing support networks were challenged by unique graduate student circumstances. this lack of face-toface support, physical distance from campus, and the lack of fellow latinx academics in one’s home department played a key role in why an interviewee believes many of their latinx peers drop out. in addition, even for students who mentioned that they had a support network in place, it was often not the case that the support network was housed within the university. these students often sought support outside of campus, such as in the form of an international latinx graduate support group, having been driven to this by the university’s failure to provide them the support they needed. these experiences with isolation speak to a key element of cultural taxation the feeling of a lack of 20 belonging in one’s department due to the to kenizing nature of the lack of support for your racial and ǔƞǧǿǩlj� ljƺljƿǡȗȅȣǿǐ� শ=ȅșǔȓǧ� ૭� /ǩȗșljǧйǔǹǐॹ� �ষঀࢲࢲࢱࢳ the common mentor/mentee model did not alleviate the isolation felt by many graduate students, especially when they sought guidance. for instance, a woman graduate student of mixed latinx ancestry speaks about how she does not have someone in her department she can approach: “unfortunately, no, i don’t…even with my research mentor, i have asked for a lower workload in the past because i feel very overwhelmed and basically got told no. i learned very early on that i can’t trust to reach out to faculty for support … i have to be very direct to be able to get the support that i need and when i’m not, it’s not as helpful. so, it’s hard. when i don’t know the questions to ask, then i end up not getting the help i need… and the growth that i’ve had, the progress i make, i always have to approach them for it. it’s always about self-advocacy, rather than them bringing it to you in a potential teachable moment.” some students were not willing to ascribe this lack of mentorship as a problem (i.e., students saying they hated to bother faculty or that they believed faculty were inherently too busy to be available for graduate students). however, students still indicated that they felt their mentors often failed to discuss information crucial to their degree advancement or failed to take notice of their major milestones. for instance, another half-hispanic, half-white woman graduate student contributes a sentiment shared by most of the graduate student participants under the mentor/ mentee model: “looking at my department, my advisor talks to me once a semester… a lot of students in my department especially feel that we have not been supported through the [graduate student] process.” this lack of mentorship is often present for junior full-time faculty members, but the adǐǩƞǩȅǿƺǹ� ȓȅλǔȗ� ǐǩаǔȗǔǿƞǩƺǹ� ǟǔǹƞ� ljρ� ǡȗƺǐȣƺƞǔ� șƞȣǐǔǿƞșॹ� șȓǔljǩйljƺǹǹρ� ǩǿ� ȗǔǹƺƞǩȅǿ� ƞȅ� ƞǧǔ� ljȅǿȓǹǔƞǩȅǿ� of their degrees, suggests a potential gap between student and faculty models of cultural taxation. theme two: power, labor, and ‘something’s got to give’ � xǔȗǧƺȓș� ƞǧǔ�ǿȅșƞ� șƞȗǩƿǩǿǡ�ǐǩаǔȗǔǿljǔ� ǩǿ�ǧȅλ�ljȣǹtural taxation manifests in graduate students, compared to other members of academia, is in labor expectations. while faculty often undergo heightened expectations of racialized equity labor that their non-white peers do not experience (padilla, 1994), respondents did not spontaneously express the same ǔπȓǔljƞƺƞǩȅǿঀ�vǧǔǿ�ƺșƿǔǐ�șȓǔljǩйljƺǹǹρ�ƺljȅȣƞ�ǧȅλ�ƞǧǔρ� participated in diversity labor and advocacy, surprisingly, most interviewees indicated that they did not commonly participate in racialized equity labor. their reasons included: fear of retaliation that threatened their positions in the department, lack of knowledge of where to begin advocacy work, and just wanting to ‘keep their heads down’ during the turbulence of ǡȗƺǐȣƺƞǔ�șljǧȅȅǹঀ�eǧǩș�ƺǹșȅ�ljƺȗǔș�ƺǿ� ǩǿƞǔȗǔșƞǩǿǡ�ǐǩаǔȗence with how other students’ experiences of cultural taxation often manifest. as outlined by lerma (2020), șƞȣǐǔǿƞș�λǧȅșǔ�ȓǔȗșȅǿƺǹ� ƺǿǐ�ȓȗȅǟǔșșǩȅǿƺǹ� ǹǩκǔș� șȣаǔȗ� for their involvement in racialized equity labor are often forced to let their academic performance drop due ƞȅ�ƞǧǔ�ǔаȅȗƞ�ǩƞ�ƞƺƿǔș�ƞȅ�șȣȓȓȅȗƞ�ljƺǿȓȣș�ljǧƺǿǡǔঀ� in contrast, respondents did not believe that a drop in academic or professional performance in exchange for engaging in racialized equity labor was a valid option. one female student with a mixed indigenous and mexican american identity states regarding proposed bans of critical race theory in u.s. schools, a politically charged discussion of which students were aware: “what makes me want to pause is being aware of legislature with what they want to do about race theory, so that does make me consider that there will be retaliation linked to [diversity] work… if this happens, it is going to come down to my professional or educational experiences being impacted… and i just can’t let that happen.” when they did engage in racialized equity labor, more often than not interviewed graduate students preferred to conduct it ‘behind the scenes’ or ǔκǔǿ� ȅаেljƺǿȓȣș� ǔǿƞǩȗǔǹρঀ� eǧǩș� ljƺǿǔ� ǟȗȅǿॹ� ǩǿ� ȓƺȗƞॹ� the disconnection they felt from the campus community (see theme 1) as well as not wanting to jeopardize their standing in their programs. the same woman graduate student who commented on the lack of adequate mentorship in theme 1 elaborates, “it’s hard to get involved… i think i’ve just kind of been working behind the scenes, here for support for people who have negative experiences on campus… i’ve been approached to be recruited for some leadership positions [in organizations that support students of color], but with my professional life and mental health, i just didn’t want to do it… i just want to graduate and move on.” briggs et al. 21 cultural taxation themes in latinx graduate students. respondents often had concerns about engag ing in racialized equity labor at the forefront of their experiences. that said, unlike undergraduates of color who are perhaps more likely to ‘give up’ their academic work to support diversity labor on campus, or racialized faculty who are compelled to participate in diversity labor as an aspect of their employment, our study respondents have trouble being as active ǩǿ� ljƺǿȓȣș� ǔȕȣǩƞρ� ǔаȅȗƞș� ƺș� ƞǧǔρ� λȅȣǹǐ� ǹǩƿǔ� ƞȅ� ljǔঀ it is here that we see a unique manifestation of how cultural taxation may have been realized for this șȓǔljǩйlj�șƺǿȓǹǔ�ȅǟ�@ƺƞǩǿπ�ǡȗƺǐȣƺƞǔ�șƞȣǐǔǿƞșঀ��ș�ǿȣljǧ� as they would like to participate in more diversity labor, many fear ‘rocking the boat’ and jeopardizing their position on campus. simultaneously, graduƺƞǔ� șƞȣǐǔǿƞș� ǿƺρ� ǿȅƞ� ljǔ� ƺаȅȗǐǔǐ� ƺș� ǿƺǿρ� ljǧƺǿljǔș� to engage in racialized equity labor as faculty (even if their participation is tokenizing and directly conducive to culturally taxing experiences). this lack of engagement can turn into a threat to one’s cultural ǩǐǔǿƞǩƞρ� ƺǿǐ� ƺаǔljƞ� ƞǧǔǩȗ� ȅκǔȗƺǹǹ� ǡȗƺǐȣƺƞǔ� șljǧȅȅǹ� ƞȗƺjectory as one indigenous mexican student puts it: “no, personally, i don’t engage in work on behalf of ljƺǿȓȣș�ǐǩκǔȗșǩƞρ�ǔаȅȗƞșॺ�2�ǹǔƺȗǿǔǐ�ƞǧƺƞ�ƿǔǔȓǩǿǡ�ȓǔȅple at ease gets you far, you’ve got to know how to keep people from calling the cops and, you know, not give them a reason to feel threatened, but when you start reƺǹǩφǩǿǡ�ƞǧƺƞ�ǐȅǩǿǡ�șȅ�ǐǔйǿǩƞǔǹρ�ljǧƺǿǡǔș�ρȅȣॺ�2ঢ়κǔ�ǹȅșƞ� șȅ�ǿȣljǧঀ�2ঢ়κǔ�ǧƺǐ�ƞȅ�șƺljȗǩйljǔ�ǿρ�ȅλǿ�ǩǐǔǿƞǩƞρ�ƞȅॹ�ρȅȣ� know, stay alive… worrying about everything that’s happened distracts me so much from grad school. you’d hope that this is something that only comes up every so often, but no, it comes up every day.” theme three: culturally taxing levies against latinx student identity � �� ȗǔljȣȗȗǩǿǡ� ǔǹǔǿǔǿƞ� ȅǟ� ȗǔșȓȅǿșǔș� λƺș� ǐǩгljȣǹƞρ� navigating their professional workload due to levies, or unique impositions, against latinx identities. students spoke about how their latinx identity, rather than their general identity as students of color, was ƺ� șȓǔljǩйlj� șƞȗǔșșȅȗ�λǧǔǿ�ǿƺǿƺǡǩǿǡ� ƞǧǔǩȗ� ǡȗƺǐȣƺƞǔ� ljƺreers. navigating their program responsibilities was ƺǹșȅ� ǐǩгljȣǹƞ� ǐȣǔ� ƞȅ� ƞǧǔ� ǿǩπǔǐেȗƺljǔ� ljƺljƿǡȗȅȣǿǐ� ȅǟ� many participants, who had their diversity-centric research interests undermined due to ‘not being hispanic enough’ for other scholars to take their work on latinx populations seriously. one student relayed an anecdote whereby a professor requested he change his research topic to something more ‘suitable’ to him due to ‘passing’ as a person of color. this highlights how many non-latinx academics may be incorrectly assuming what latinx students ‘should’ present as and how that should inform their academic interests. additionally, many interviewees highlighted how ‘latinx’ was not a term with a lot of explanatory power of their culƞȣȗƺǹ�ljƺljƿǡȗȅȣǿǐș�ǩǿ�ƞǧǔ�йȗșƞ�ȓǹƺljǔঀ�eǧȣșॹ�ǩƞ�λƺș�ȅǟƞǔǿ� ǐǩгljȣǹƞ�ƞȅ�ǿƺκǩǡƺƞǔ�ǟǔǔǹǩǿǡș�șȣȗȗȅȣǿǐǩǿǡ�ƞǧǔǩȗ�ǩǐǔǿƞǩƞρ� (a key feature of the faculty model of cultural taxation) λǧǔǿ� ƞȗǔƺƞǔǐ�ƺș� ƞǧȅȣǡǧ� ƞǧǔρ�ƺȗǔ� ড়ǡǔǿǔȗǩljঀঢ়�^ȓǔljǩйljƺǹly, interviewees expressed not wanting to be forced to be a representative of all latinx people. for instance, a graduate student from south america comments, ৚eǧǔρ�ljȅǿǟȣșǔ�ȅȣȗ�ǐǩаǔȗǔǿƞ�ljȣǹƞȣȗǔș�ƺǿǐ�ƞǧǔȗǔঢ়ș� ƞǧǩș� really racist notion that everything south of the u.s. is mexico… often times they would ask me about eǔπǩljƺǿ� șƞȣаঀ� 2� ƺǹλƺρș� ǧƺκǔ� ƞȅ� ljǹƺȗǩǟρ� ƞǧƺƞ� 2ঢ়ǿ� ǿȅƞ� mexican. it’s like constantly trying to tell them you’re not mexican and having to prove that we [people ǟȗȅǿ�ǿρ�ljȅȣǿƞȗρয�ǧƺκǔ�ǐǩаǔȗǔǿƞ�ljȣǹƞȣȗǔș�ƺǿǐ�ƞǧǩǿǡșॹ� and all i do is get asked ‘do you eat spicy food?’” interviewees also expressed concerns about the ǹƺljƿ� ȅǟ� șȣȓȓȅȗƞ� ǟȅȗ� йȗșƞেǡǔǿǔȗƺƞǩȅǿ� ƺǿǐ� ǩǿǿǩǡȗƺǿƞ� students, especially in the face of severe underrepreșǔǿƞƺƞǩȅǿ� ȅǟ� ƞǧǔșǔ� ȓǔȗșȅǿș� ƺǿȅǿǡșƞ� ǟƺljȣǹƞρ� ƺǿǐ� șƞƺа� in their graduate programs. these feelings of underrepresentation and lack of support were especially apparent in those that come from communities that were majority-latinx. for these students, campus life brought the additional stress of being separated from a community driven by commonalities to which they were accustomed, with accompanying feelings of isolation vis a vis a culturally taxing experience. students ƺǹșȅ� ȅǟƞǔǿ� ǐǩǐ� ǿȅƞ� ǧƺκǔ� ƺljljǔșș� ƞȅ� șȓǔljǩйljƺǹǹρ� @ƺƞǩǿπ� ǟƺljȣǹƞρ� ƺǿǐ� șƞƺа� λǧȅ� ȣǿǐǔȗșƞȅȅǐ� ƞǧǔǩȗ� ǔπȓǔȗǩǔǿljǔঀ� as a result, students found themselves facing additional levels of solitude (see theme 1) not necessarily felt by those who were more used to majority-white settings. for instance, a hispanic woman states, “i mean, i would not call myself a representative where i live in [city with latinx majority population] because it’s a minority majority…but as far as in [city of university] or as far as campus goes... ǿρ� ǿƺǿǔ� ǐȅǔșǿঢ়ƞ� йƞ� ǩǿॹ� 2� ǐȅǿঢ়ƞ� ƿǿȅλ� λǧǔȗǔ� ƞȅ� ǡȅॹ� ƺǿǐ� șȣǐǐǔǿǹρ� 2ঢ়ǿ� ǹȅȅƿǔǐ� ȣȓȅǿ� ǐǩаǔȗǔǿƞǹρঀ৛ this sentiment was echoed by other stud 22 dents who agreed that going from an environment where they are not looked upon as a representative of a race or culture into an environment where it is very easy to be perceived as one was jarring and disruptive to ƞǧǔǩȗ�λȅȗƿঀ�/ǔȗǔ�λǔ�șǔǔ�ƺ�ȗǔǹǔκƺǿƞॹ�ǿȅȗǔ�@ƺƞǩǿπেșȓǔljǩйlj� sentiment that may modulate how culturally taxing experiences are understood by latinx graduate students. many do not necessarily come from backgrounds where they built an understanding of their identity as coming from a ‘minority group,’ often traveling to academia from environments that were majority latinx. 2ƞ� ǩș� șȓǔljǩйljƺǹǹρ�λǩƞǧǩǿ� ƺljƺǐǔǿǩƺ� ƞǧƺƞ� ƞǧǔșǔ� șƞȣǐǔǿƞș� are exposed to, even at hsis, white-dominated space. theme four: unique pressures on women women-identifying interviewees were aware of the link between their identity as women, their latinx identity, and the social perceptions of these intersecting identities. pressures on these interviewees were further compounded by the awareness of professionalism or leadership expectations ƞǧƺƞ� șǔǔǿ� ƞȅ� ljȅǿмǩljƞ� λǩƞǧ� λȅǿƺǿǧȅȅǐ� ƺǿǐ� ǟǔǿininity. for instance, a woman respondent said, “but once you get into the ranks of leadership, that was always historically men. and so, you have to prove that while retaining your femininity and your womƺǿǧȅȅǐॹ�ρȅȣ�ljƺǿ�ljǔ�ƺǿ�ǔаǔljƞǩκǔ�ǹǔƺǐǔȗঀ��ǿǐ�ƞǧƺƞ�ǿƺρ� ǹȅȅƿ� ƺ� ǹǩƞƞǹǔ� ljǩƞ� ǐǩаǔȗǔǿƞ� ƞǧƺǿ� ǩƞ� λȅȣǹǐ� ȅǿ� ƺ� ǿƺǹǔঀ৛ however, the way women responded to these unique pressures varied. some women felt the need to șƞǩмǔ�ljǔȗƞƺǩǿ�ǟȅȗǿș�ȅǟ�ǔπȓȗǔșșǩȅǿ�ƞȅ�ƺǐǧǔȗǔ�ƞȅ�ƺ�ǿȅȗǔ� traditional archetype of professionalism. the mixedrace student who previously commented on isolation ƺǿǐ�ƿǔǔȓǩǿǡ�ƺ�ǹȅλ�ȓȗȅйǹǔ�ǩǿ�eǧǔǿǔșࢲ��ƺǿǐࢳ��ǔǹƺljȅȗƺƞǔșॹ “like facial expressions and like expressing emotion, like not wanting to come across too harsh, like continuing to be like smiley and happy…as women we have to like teeter the line of being like happy and smiley, but also not being, you know, too assertive… i think adjusting, knowing when to elevate their femininity to help in like graduate school or the workplace and knowing when to kind of dial it down to where it’s like, well, she’s just a woman… female students have been called too emotional by faculƞρॺ�йǿǐǩǿǡ� ƞǧƺƞ�ljƺǹƺǿljǔ�ǧƺș�ljǔǔǿ� ƞǧǔ�ǐǩгljȣǹƞ�ȓƺȗƞঀ৛ � 'ȣȗƞǧǔȗॹ� ƺ� @ƺƞǩǿƺ� șƞȣǐǔǿƞ� ȅаǔȗșॹ “i have made it a point to, like in my emails, to be more ǐǔйǿǩƞǔ� ǩǿ� ƞǧǔ�λƺρ�2� ƞƺǹƿ�ƺǿǐ� ǹǔșș�ƿǩǿǐঀ�@ǩƿǔঀ� 2�ǐȅǿঢ়ƞ� want to say submissive…but less submissive…i do feel the need to be more like of a dominant person or like, i don’t want to say manly, but like more just serious.” conversely, other women, even though they were aware that their womanhood and femininity might be hypervisible, refused to modify their behavior or expressions of femininity. “and like i said, i don’t and i wouldn’t want to suppress it because i’m mexican, i just can’t help myself.” one interviewee also describes the ways in which her identity as a woman is pressured externally both from family and the university: “women especially have this responsibility [caring for family]… and especially being from a from a hispanic ljƺljƿǡȗȅȣǿǐॹ�ƞǧƺƞঢ়ș�ǐǔйǿǩƞǔǹρ�ƞǧǔ�ljƺșǔ�ǟȅȗ�ǿρșǔǹǟॺ�ǿǐ� so it’s just really unfortunate because being a hispanic female, trying to go through graduate school, it’s almost like a double hit…not only am i hearing it from my traditional family members, ‘are you not helping take care of your parents or sick elderly parents?’ but i’m also hearing from the graduate school saying, ‘oh, no…this is our role. you have to stick to them.’” while some participants felt that their departments’ standards were equal for both male and female graduate students, other interviewees noted ƞƺǿǡǩljǹρ� ǐǩаǔȗǔǿƞ� șƞƺǿǐƺȗǐșॹ� ljȅƞǧ� șȅljǩƺǹ� ƺǿǐ� ȓȗȅljǔdural. when discussing faculty responses to female students’ work, one mexican woman interviewee said, “i think there has to be more behind the scenes work to present it and be taken the same way as if like a male student did.” regarding other departmental standards, another hispanic interviewee said, “i think men are given a little bit more academic freedom to express themselves, to pursue more things, to take on more and to take on more diverse research, whereas women are kind of put into a box.” these patterns primarily align with previously ǐǩșljȣșșǔǐ� йǿǐǩǿǡș� ǟȅȗ� λȅǿǔǿ� ȅǟ� ljȅǹȅȗ� ǩǿ� ƺljƺǐǔǿǩƺॹ� ǔǩƞǧǔȗ� ƺș� șƞȣǐǔǿƞșॹ� șƞƺаॹ�ȅȗ� ǟƺljȣǹƞρ�ǿǔǿljǔȗș� শ(ȣƞǩǔȗȗǔφ� ρ�eȣǧș� ǔƞ� ƺǹঀॹ� �আ�/ǩȗșǧйǔǹǐ�૭ࢳࢲࢱࢳ =ȅșǔȓǧॹ� �আࢳࢲࢱࢳ anantachai & chelsey, 2018; niemann et al., 2020). responses indicate that latinx women engage in labor intended to balance their personal identities with others’ expectations and face unique identity challenges as graduate students. this is evidenced in the frequency that interviewees discuss personal and cultural obligations to engage in these forms of labor in the context of not being adequately represented in one’s department amongst students and faculty. one latina interviewee briggs et al. 23 stated, “i’m the only one of me. i never saw anybody that i can really think of, i saw one other hispanic girl in all my classes this semester, but that was it.” that same interviewee also alluded to joseph and /ǩȗșǧйǔǹǐঢ়ș�শࢳࢲࢱࢳষ�ǐǩșljȣșșǩȅǿ�ȅǟ�ƞǧǔ�λƺρș�ƞǧƺƞ�ǿǔǡƺƞǩκǔ� ȓǔȗljǔȓƞǩȅǿș�ȅǟ�ƺгȗǿƺƞǩκǔ�ƺljƞǩȅǿ�ȓȗȅǡȗƺǿș�ljƺǿ�ljƺșƞ�ƺ� shadow on women when she says, “i did have once a guy tell me he thinks that women have more opportuǿǩƞǩǔșॺλǧǩljǧ�ƿǩǿǐ�ȅǟ�ljȅƞǧǔȗǔǐ�ǿǔ�ȅȗ�ǐǔйǿǩƞǔǹρ�ljȅƞǧered me because that’s not true.” multiple women also discussed how they felt their research or intellectual contributions were devalued because they involved discussions of race or diversity. one woman interviewǔǔ�λǧȅ�ǩǐǔǿƞǩйǔș�ƺș�vǧǩƞǔ�@ƺƞǩǿȅ�ƺǿǐ�eǔπǩljƺǿ�șƞƺƞǔșॹ� “that [area of expertise] gets downplayed…and then also being like a female and also being like latina, like not knowing what the issues actually are. even though ƞǧǔρ� ǐǩșȓȗȅȓȅȗƞǩȅǿƺƞǔǹρ� ƺаǔljƞ� @ƺƞǩǿȅș� ॺ�ǿǐ� șȅ� 2ঢ়ǿ� not being taken seriously on all those accounts.” theme five: reluctance to assign responsibility and accountability � �ǿȅƞǧǔȗ�ƞǧǔǿǔ�ǩǐǔǿƞǩйǔǐ�ljρ�ƞǧǔ�ȗǔșǔƺȗljǧ�ƞǔƺǿ�λƺș� the apparent reluctance of latinx graduate students to label their experiences and the actions of others as potential instances of racial prejudice or systemic problems. when asked if they had experienced prejudice or discrimination on campus, some participants qualǩйǔǐ�ƞǧǔǩȗ�ƺǿșλǔȗș�ƺș�ljǔǩǿǡ�ড়ǿȅƞ�șǔȗǩȅȣșॹঢ়�ljǔǩǿǡ�ȣǿșȣȗǔ� if it was prejudice, or otherwise not qualifying events as instances of racial prejudice, despite then proceeding to acknowledge that these events may have been racially motivated or inducive to harm for people of a latinx background. for instance, a student λǧȅ� ǩǐǔǿƞǩйǔǐ� ƺș� ǧƺǹǟ�eǔπǩljƺǿ� ƺǿǐ� ǧƺǹǟ�vǧǩƞǔ� șƺǩǐॹ�� “no, i really haven’t [experienced discrimination], for my race or ethnic background… but you know, there are aspects of your identity that causes others to discriminate or be prejudiced towards you… i guess like, λǩƞǧ� ǿρ� ƞǔƺljǧǔȗșॹ� ƞǧǔρ� șƺρ� ƞǧǩǿǡș� ƞǧƺƞ� ƺȗǔ� ȅаǔǿșǩκǔ� in a classroom [to latinx students] … i don’t know ǩǟ� ǩƞ� ljȅȣǿƞșॹ� ljȣƞ� ƞǧǔȗǔঢ়ș� ǐǔйǿǩƞǔǹρ� ljǔǔǿ� ǹǩƿǔ� ƞǧǩǿǡș� that have been said or done that are kind of crappy, ljȣƞ� ƺljƞȣƺǹǹρ� ǿȅƞ� ȗǔƺǹǹρ� ȅаǔǿșǩκǔ� ƞȅ� ǿǔ� șȓǔljǩйljƺǹǹρঀ৛ students also seemed hesitant to identify behavior as prejudiced when it was more systemic or covert in nature. interviewees often went to great lengths to proκǩǐǔ�ƞǧǔ�ljǔǿǔйƞ�ȅǟ�ƞǧǔ�ǐȅȣljƞॹ�ȅȗ�ȅȣƞȗǩǡǧƞ�ǐǔǿρ�ƞǧǔ�ȓȅșsibility their experiences may have been based on systemic issues. for instance, one mexican woman states, “i couldn’t really say [if i had experienced prejudice on campus] … but it’s not like they’re going to say, ‘we’re going to discriminate against you.’ but you see the inequalities, you see what’s happening with the person next to you and yourself… i see it, but i can’t prove it.” one other hispanic man describes that, “i’ve never experienced any racism or discrimination within campus… i was just given a bad set of cards in my hand and well, tough luck right? no one ever said life was fair. so sometimes you’ve got to put in the extra work, you got to put in the extra mile, but it’s not always easy, right? i think i remember sometimes where i was ǹǩƿǔ�ǿƺǿॹ�2�λǩșǧ�2�λƺș�ljȅȗǿ�ƺ�ǐǩаǔȗǔǿƞ�λƺρॹ�2�λǩșǧ�ǿρ� family would have prepared for me to come to a college where i didn’t have to worry about work…” when asked to elaborate on their experiences, several students cited examples that included, but are not limited to: feeling pressured to be more prepared for classroom discussion than white male colleagues who ‘got away’ with not doing their homework or the reading, being forcibly labeled with terms they actively did not associate with (such as chicanx or latinx), having to defend their interest in diversity research, having to defend their expertise in work unrelated to diversity, and feeling like prejudice they experienced was more a fact of reality for them rather than something with a solution that they or the university could pursue. one mexican woman student describes, “regardless of what i do… people are going to see the color of my skin, and they’re going to be prejudiced… but i know i can’t advocate for me or my people… this doesn’t feel like a place where the perception of you, or the perception of your classmates is ever going to change.” this very same student in an earlier response, however, professed that they believed the university to be doing very well in supporting students of color, claiming, “the university is basically doing all the things they can to really increase the visibility of the [student of color] population, and something i pride myself in as a student of the university.” in applying this absolution to cultural taxation, a key distinction between the latinx graduate, faculty, and undergraduate experiences may be unveiled here: graduate students may be more likely to undergo the mental and emotional labor associated with witnessǩǿǡ�ǩǿǔȕȣǩƞǩǔș�λǩƞǧȅȣƞ�йǿǐǩǿǡ�ljȣǹȓƺljǹǔ�ȓǹƺρǔȗș�ǩǿ�ȅǿǔঢ়ș� cultural taxation themes in latinx graduate students. 24 briggs et al. environment. this is not to say tgraduate students deny that action is important (see theme 2). rather, in light of a situation in which participating in diversity labor is something that is not made accessible, it may be safer for students to draw their focus away from areas in need of improvement. discussion the present study explores whether current understandings of cultural taxation, often modeled from faculty’s experiences, are applicable to latinx graduate students. findings suggest that there are aspects of padilla’s model of cultural taxation that apply, but that universal application across faculty and graduate stuǐǔǿƞș�ǿƺρ�ǿȅƞ�ljǔ�ƺȓȓȗȅȓȗǩƺƞǔঀ�eǧǔǿǔș�ǩǐǔǿƞǩйǔǐ�ǩǿ�ƞǧǩș� șƺǿȓǹǔ�șȣǡǡǔșƞ�ƞǧƺƞ�ƞǧǔȗǔ�ƺȗǔ�ȓȅλǔȗ�ǐǩаǔȗǔǿƞǩƺǹș�ƺƞ�ȓǹƺρ� that distinguish cultural taxation in graduate students ǟȗȅǿ�ƞǧƺƞ�ȅǟ�ȅƞǧǔȗ�ƺljƺǐǔǿǩlj�ȓȅȓȣǹƺƞǩȅǿșঀ�^ȓǔljǩйljƺǹǹρॹ� like faculty, present latinx graduate students outlined ǟǔǔǹǩǿǡș�ȅǟ�ǩșȅǹƺƞǩȅǿ�ƞǧƺƞ�λǔȗǔ�ȅǟƞǔǿ�ǩǿƞǔǿșǩйǔǐ�ljρ�ƞǧǔǩȗ� origination from majority-minority settings and the lack of latinx colleagues. students also cited fatigue due to perceived slights against their identities that stemmed from being asked to represent and/or work ƞȅλƺȗǐș� ǐǩκǔȗșǩƞρ� ǔаȅȗƞș� ƞǧƺƞ� ǿƺρ� ȅȗ� ǿƺρ� ǿȅƞ� ǧƺκǔ� been of interest to them professionally. however, diverging slightly from faculty’s experiences, we see powǔȗ�ǐǩаǔȗǔǿƞǩƺǹș�ȓǹƺρ�ƺ�ǿȅȗǔ�ǐǩȗǔljƞ�ȗȅǹǔ�ǐȣǔ�ƞȅ�șƞȣǐǔǿƞșঢ়� reliance on a direct supervisor with stark levels of control over their graduate experience (and, to an extent, ǹǩκǔǹǩǧȅȅǐষঀ�eǧǔșǔ�ȓȅλǔȗ�ǐǩаǔȗǔǿƞǩƺǹș�ƺȗǔ�ǟȣȗƞǧǔȗ�ǔπƺljerbated by strong ties to university administration, and all these tethers could inhibit the ease with which graduate students were able to participate in equity labor. � 2șȅǹƺƞǩȅǿ� ǩǿ� ȅǿǔঢ়ș� ǐǔȓƺȗƞǿǔǿƞ� ȗǔмǔljƞș� ȓƺƞƞǔȗǿș� in racialized faculty outlined by padilla (1994). both graduate students and faculty must overcome the isolation that accompanies statistical underrepresentation throughout the department. tokenism may also be an underlying commonality between faculty and graduate student experiences. among the consequences of tokenism are isolation, representativeness, lack of regard for race-based research areas, attributional ambiguity (which refers to not knowing how to interpret feedback), and loneliness (niemann, 2016), all of which λǔȗǔ� ȗǔмǔljƞǔǐ� ǩǿ� șƞȣǐǔǿƞșঢ়� ȗǔșȓȅǿșǔș� ǩǿ� ƞǧǩș� șƞȣǐρঀ � kȣȗ�șƺǿȓǹǔঢ়ș�ǐǩгljȣǹƞρ�ǩǿ�ǩǿljȅȗȓȅȗƺƞǩǿǡ�ǐǩκǔȗșǩƞρ� into their work while navigating departmental dynamǩljș�ǩș�ȗǔмǔljƞǩκǔ�ȅǟ�ȅƞǧǔȗ�ǡȗƺǐȣƺƞǔ�șƞȣǐǔǿƞșঢ়�ƞǔșƞǩǿȅǿǩǔșঀ� carbajal (2021) described the ways in which multiple members of his predominately white department referred to diversity and identity characteristics as nuisance variables. discussions surrounding diversity have a steep impact on departmental and program culture, particularly for graduate students (grady et al., 2014). further, when faculty members are dismissive ȅǟ�ȗǔǹƺƞǔǐ�λȅȗƿ�ȅȗ�ǔаȅȗƞșॹ�ǩƞ�ljƺǿ�ǐǩșljȅȣȗƺǡǔ�ƞǧǔ�ǡȗƺǐȣate student and add to the isolation they feel. unfortunately, this can lead graduate students to feel that they do not have a trusted resource who can identify with their experiences to help their navigation through academia and professional skill development (moore et al., 2020). a graduate student’s livelihood is also dependent on maintaining a positive relationship with the department and, by extension, the administration. racialized graduate students not only hold this tenuous relationship but also must endure the additional costs of being a racialized person within a predominately white space (vargas & villo-palomino, 2018). levies or taxations against our sample of latinx students seem to stem from multiple sources. first, the homogenization of all identities that are supposed to be encompassed by the ‘latinx’ label places students in a precarious situation where they are motivated to defend themselves and their individual identity while ƺǹșȅ�ǿƺǩǿƞƺǩǿǩǿǡ� șȅljǩƺǹ�ǧƺȗǿȅǿρঀ�eǧǩș� ǩș� ȗǔмǔljƞǩκǔ�ȅǟ� impositions on racialized faculty who are presumed to serve as a ‘cure-all’ for diversity needs, recycling the racist notion that one person of color can serve as a single representative of a department’s diversity values (lopez, 1997; niemann, 2016). however, our sample engaged in an extra layer of mental and emotional labor that sought to eclipse the university’s role in inequitable practices. in application, this theme likely occurs simultaneously with both the theme of isolation and ƞǧǔ� ƞǧǔǿǔ� ȅǟ� ȓȅλǔȗ� ǐǩаǔȗǔǿƞǩƺǹșॸ� ǡȗƺǐȣƺƞǔ� șƞȣǐǔǿƞș� do not feel the necessary sense of community nor the motivational autonomy to go head-to-head with powerful players in the department or administration. therefore, to help calm their senses of personal or cultural obligation, they 1) do not seek out participation in equity labor that could put their security at risk and 2) do not place blame on those who could instigate their educational and professional destruction. concerning the taxation of latinx graduate women, nearly all women participants cited unique pres25 cultural taxation themes in latinx graduate students. sures to their combined gender and cultural identities during their time as graduate students. pressures associated with identity as it relates to womanhood and professionalism are a common challenge due to the antithetical associations between femininity and what is considered professional (lewis, 2011). women in working environments often feel pressured to endorse ǵȣșƞ�ǔǿȅȣǡǧ�λȅǿƺǿǹρ�ljǔǧƺκǩȅȗș� ƞȅ�ƺκȅǩǐ�ǐǩșljȅǿйȗǿing feminine stereotypes while simultaneously conforming to rigid standards of professionalism (rudman & phelan, 2008). while women hold more than half of all graduate degrees and outnumber men in assistant professorships, academia still perpetuates these disparate standards through the overrepresentation of men in both full professorships and administrative positions (lee & won, 2014). identity pressures are further exacerbated for women of color as they balance expectations based on both race and gender in addition to navigating often restrictive systems of professionalism (rudman & glick, 2001; eagly & carli, 2003; brescoll & uhlmann, 2008). these pressures may be exacerbated by latinx cultural values about the primary role of women as wives and mothers. future research should explore other marginalized racial and ethnic groups within the graduate student population to identify unique or overlapping needs and experiences as they relate to cultural taxation. vǧǩǹǔ� λǔ� ǐǩǐ� ǿȅƞ� йǿǐ� ǔπȓǹǩljǩƞ� ǔκǩǐǔǿljǔ� ȅǟ� @ǔȗǿƺঢ়ș� labor appropriation cycle in our sample, this framework should still be explored in samples of graduate students (i.e., those that are actively involved in leading ȣǿǩκǔȗșǩƞρ�ǐǩκǔȗșǩƞρ�ǔаȅȗƞșষঀ�eȅȗǔ�λȅȗƿ�ǩș�ƺǹșȅ�ǿǔǔǐǔǐ� to understand the unique position of women graduate students of color, particularly regarding academic and labor expectations. while there can be similarities amongst racialized groups’ experiences, researchers should take care to disaggregate their methods and analyses regarding race, gender, and cultural experiences. a simple step in this direction could be allowing participants the opportunity to provide their racial, ethnic, and gender identities in a free-response format rather than relying on normalized checkbox questionnaires that could limit participants’ expression. limitations there are limitations to this project that must be addressed. there may be other experiences within this population that were not presented by our limited sample. additionally, this work relied entirely on subjective qualitative analyses. while qualitative work allows for the nuanced depiction of participants’ lived experiences, these topics could be supplemented with quantitative work (e.g., a cross-university survey that could illustrate these experiences proportional to enrollment). similarly, while quantitative measures of intercoder reliability are often considered inappropriate for judging qualitative work (braun & clarke, 2013), our choice not to implement such a measure ǿƺρ� ǩǿмȣǔǿljǔ� ȅƞǧǔȗșঢ়� ȓǔȗljǔȓƞǩȅǿș� ȅǟ� ȅȣȗ� ǩǿƞǔȗȓȗǔƞƺƞǩȅǿșঀ� 'ǩǿƺǹǹρॹ� ǐƺƞƺ� ȅǿǹρ� ȗǔмǔljƞ� ƞǧǔ� ǔπȓǔȗǩǔǿljǔș� ȅǟ� latinx graduate students at one university in the southwestern united states. it is possible that manifestations of cultural taxation for latinx graduate șƞȣǐǔǿƞș�ljȅȣǹǐ�мȣljƞȣƺƞǔ�ƺljljȅȗǐǩǿǡ� ƞȅ� ƞǧǔ� ȗǔǡǩȅǿ�ƺǿǐ� racial and ethnic makeup of the surrounding areas. conclusion cultural taxation and related models must more inclusively account for the graduate student experience, including the psychological and physical toll that may result from tokenization, lack of cultural knowledge, and seeming practical irrelevance of the word “serving” for hsi designations. within these contexts, students are driven to not only advocate for themselves as they navigate their degree but to simultaneously avoid rocking the boat in the hopes that they ljƺǿ� ǡȗƺǐȣƺƞǔ� ƺǿǐ�ǿƺƿǔ� ƺ� ǐǩаǔȗǔǿljǔ� ǩǿ� ƞǧǔǩȗ� ǟƺǿǩǹǩǔș� and communities with their careers. furthermore, students may be driven to expend mental and emotional labor absolving their institutions of blame in the face of inequity due to their unique position as not-juststudents and not-quite-faculty. we invite scholars to incorporate mental and emotional burdens, as well as related phenomena like tokenism, into their conceptualization of cultural taxation. the cognitive work associated with processing a discriminatory or culturally exclusive environment (e.g., questioning one’s experiences and coping with isolation and discrimination) undoubtedly contributes to the invisible work conducted by marginalized members of the department. the dearth of culturally sensitive faculty mentors exacerbates the challenges of latinx students. for instance, despite being in an area of the country where nearly 40% of citizens self-identify as latinx, graduate șƞȣǐǔǿƞ�ǔǿȗȅǹǹǿǔǿƞ�ƺƞ�ƞǧǩș�ȓȗȅǵǔljƞঢ়ș�^vxh�ǹƺǡș�șǩǡǿǩйcantly behind this number at 15%, which also falls be26 factbook, 2020). starker still is how these numbers compare to the presence of latinx faculty. inclusive of lecturers, tenure-track, and tenured professors, only -�ǟƺljȣǹƞρ�ǩǐǔǿƞǩйǔǐ�ƺș�@ƺƞǩǿπॹ�ƺǿ�ȣǿǐǔȗࢱࢱࢱࢲ�ઔ�ȅǟ�ȅκǔȗࢷ representation that directly impacts the mentor-mentee model that many graduate programs employ. without knowledgeable mentors who can help latinx students navigate and interpret feedback and experiences, students may live in a state of attributional ambiguity. that is, they may not know whether their experiences are based on their accomplishments, successes, writing, skills, etc., or whether they are a function of racism, sexism, homophobia, and other biases. finally, universities and institutions should not only take care to ensure that graduate students have access to the resources and mentorship that they need, but also be aware that, even within the context of an hsi, students could be challenged by culturally taxing experiences due to tokenism, isolation, heightened need for self-advocating labor, and sacȗǩйljǩǿǡ� ȓƺȗƞǩljǩȓƺƞǩȅǿ� ǩǿ� ȣǿǩκǔȗșǩƞρ� ljǧƺǿǡǔঀ� 2ǿșƞǩƞȣtions must move beyond upholding diversity for accreditation and honor, or funding, as is the case with an hsi designation. it is time for university 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relationship between neuroticism and swb, as measured by satisfaction with life (swl) and affect balance (ab). in study 1, self-reports of the big five personality traits, swl, and ab were collected via mturk (n=1035). hierarchical regression analyses were used to predict swl and ab from interactions between traits. the relationship between neuroticism and swl was moderated by conscientiousness (b=.15, p=.02) and extraversion (b=11, p=.03), while the relationship between neuroticism and ab was moderated by conscientiousness (b=.09, p=.02) and agreeableness (b=.09, p=.03). positive personality traits (defined as extraversion, agreeableness, and conscientiousness within this study) were positively related to swb at high levels of neuroticism, but unrelated to swb at low levels of neuroticism. this was explored further using a student population in study 2 (n=151), and the results were partially replicated. this study highlights the importance of considering more than one trait at a time when predicting important outcomes such as swb. keywords: subjective well-being, satisfaction with life, positive and negative affect, big five personality traits, trait interactions, affect balance on july 4th, 1776 the continental congress approved a document declaring that all people have the right to “life, liberty, and the pursuit of happiness” (u.s. declaration of independence, 1776, para. 2). similar wording was used earlier that same year in the virginia declaration of rights which stated that everyone should be able to “[pursue] and [obtain] happiness and safety” (virginia declaration of rights, 1776, para. 1). aristotle claimed that when we are pursuing “honor, pleasure, intellect, [and] in fact every excellence” we are in reality using these pursuits to obtain happiness (aristotle, ca. 350 b.c.e./1994). these and many other works throughout history, religion, philosophy, and science display a seemingly universal human desire to pursue and obtain happiness. the pursuit of happiness naturally leads to the question “what makes us happy?”. if we can identify some of the conditions under which an individual is likely to be happy, we can work towards helping others achieve higher levels of happiness and general well-being. the term happiness has been notoriously difficult to operationalize (see gilbert, 2007; mogilner et al., 2011; myers & diener, 1995), and so many researchers instead prefer to use the term well-being. in the current study, well-being is defined as an individual’s subjective evaluations of their overall life satisfaction and their experience of positive and negative emotions. this is a common conceptualization of well-being that is typically referred to as subjective well-being (swb; diener et al., 2018). swb research typically uses self-report measures, which allow both affective and cognitive information to be gathered simultaneously (andrews & mckennell, 2005; horley & little, 1985; larsen et al., 1985), and focuses on subjective self-perceptions about one’s own life instead of using an external frame of reference (diener et al., 1997; diener et al., 2018). swb can be broken down into three separate components: the presence of positive emotions or affect (pa), the absence of negative emotions or affect (na), and general satisfaction with life (swl; diener et al., 2018). it is also common to create a single score of affect balance (ab) by subtracting na from pa (gutiérrez et al., 2005). structural equation modeling has been used to demonstrate that swb can effectively be broken down into these three separate but related components (arthaud-day et al., 2005, lee & oguzoglu, 2007; singh & jha, 2008). in many ways, swb can be conceptualized as a personality trait because it is relatively stable across situations and time, with situational and environmental factors only exerting a short-term impact (diener et al., 1999). several studies have shown that swb often acts as a homeostatic process, with individuals readily returning to some swb set point following a major life event that caused deviation from that set point (cummins et al., 2012; headey & wearing, 1989). stable environmental factors such as daily hassles and job satisfaction cannot fully account for the stability seen jacob r. gibson1, chloe pedersen-san miguel2, & tera d. letzring2 1 corresponding author at: 204 w. washington st. lexington, va. 24450. email: jgibson@wlu.edu 2 idaho state university; pocatello, idao 27 predicting satisfaction with life and affect balance in swb, so other factors must be involved (kozma et al., 2000). affect in particular has long-term implications, with one study f inding that positive emotion in college (as measured from the intensity of an individual’s smile in pictures from their college yearbook) signif icantly predicted well-being 30 years later (harker & keltner, 2001). finally, like traits, swb shows stability across situations such as work and recreation (diener & larsen, 1984) and also shows some state-like features that are sensitive to situational factors (kozma et al., 2000). the fact that swb shows so many features that are similar to personality traits suggests that there may be a relationship between personality traits and swb, which has been demonstrated in the literature (gutiérrez et al., 2005). the most commonly used model of broad personality traits is the five factor model, which includes the traits of extraversion (sociability, assertiveness, energy level), agreeableness (compassion, respectfulness, trust), conscientiousness (organization, productiveness, responsibility), neuroticism/negative emotionality (anxiety, depression, emotional volatility), and openness to experience (also sometimes called intellect or open-mindedness; intellectual curiosity, aesthetic sensitivity, creative imagination; goldberg, 1990; john et al., 2008; soto & john, 2017). the most empirically supported correlates of personality traits and swb are between extraversion and pa, and between neuroticism and na (costa & mccrae, 1980). there is also some evidence that openness is related to higher pa (mccrae & costa 1991). a meta-analysis of 148 studies found that neuroticism consistently predicts lower swl and higher na, agreeableness and extraversion predict higher pa, and conscientiousness is the best predictor of higher swl (deneve & cooper, 1998). the authors argue that extraversion and agreeableness impact swb by leading to more positive emotion, while conscientiousness leads individuals to set goals and work to achieve those goals, which leads to more swl. finally, mccrae and costa (1991) argued that openness was a positive predictor of both pa and na and that it led to more emotions overall. however, the meta-analysis by deneve et al. found openness to be the weakest predictor of swb compared to the other traits. this may be due to deneve et al.’s use of an expanded definition with openness to include cognitive variables (e.g., belief in a just world, mental absorption, and rigidity) or to the fact that openness is still the least understood of the five factors (see deyoung, 2015 for an attempt to rectify this problem). for this reason, openness was not included in the current study. overall, the mechanisms behind the connection between swb and personality traits are still not well understood. with regards to extraversion, it may be that extraversion is related to greater sociability which in turn is related to higher swb (bradburn, 1969; okun et al., 1984), but there is research that suggests sociability cannot account completely for this relationship (harris et al., 2017) and that even if extraverts are in nonsocial occupations, they still have higher swb than introverts (diener et al., 1984). there is also not a perfect relationship between extraversion and happiness. indeed, research has found support for happy introverts who seem to not be significantly different in many of their preferences (such as friendship relations and introspective activities) from happy extraverts, possibly due to extraversion playing a mediating role in how individuals pursue happiness (hills & argyle, 2001). another possibility not mentioned or investigated in previous research is the idea that personality traits can interact with each other in how they influence swb. for example, an agreeable extravert may act differently than a disagreeable extravert and therefore have different levels of swb. a good place to start when investigating the moderating role of various traits may be an examination of the strong and consistent relationship between neuroticism and swb. neuroticism is essentially a measure of negative emotions such as fear, anger, sadness, and anxiety (soto & john, 2017) and is sometimes referred to as negative emotionality. it may be no surprise that there is a strong negative relationship between neuroticism and swb, and other personality traits possibly serve moderating roles in the relationship between neuroticism and swb. the current work builds on past research linking personality and swb and looks at the moderating role of extraversion, agreeableness, and conscientiousness on the negative relationship between neuroticism and swb. neuroticism has been consistently linked with swb and has been shown to have a negative relationship with swl and pa and a positive relationship with na. conscientiousness, extraversion, and agreeableness all have positive relationships with well-being. 28 gibson et al. in swb, so other factors must be involved (kozma et al., 2000). affect in particular has long-term implications, with one study f inding that positive emotion in college (as measured from the intensity of an individual’s smile in pictures from their college yearbook) signif icantly predicted well-being 30 years later (harker & keltner, 2001). finally, like traits, swb shows stability across situations such as work and recreation (diener & larsen, 1984) and also shows some state-like features that are sensitive to situational factors (kozma et al., 2000). the fact that swb shows so many features that are similar to personality traits suggests that there may be a relationship between personality traits and swb, which has been demonstrated in the literature (gutiérrez et al., 2005). the most commonly used model of broad personality traits is the five factor model, which includes the traits of extraversion (sociability, assertiveness, energy level), agreeableness (compassion, respectfulness, trust), conscientiousness (organization, productiveness, responsibility), neuroticism/negative emotionality (anxiety, depression, emotional volatility), and openness to experience (also sometimes called intellect or open-mindedness; intellectual curiosity, aesthetic sensitivity, creative imagination; goldberg, 1990; john et al., 2008; soto & john, 2017). the most empirically supported correlates of personality traits and swb are between extraversion and pa, and between neuroticism and na (costa & mccrae, 1980). there is also some evidence that openness is related to higher pa (mccrae & costa 1991). a meta-analysis of 148 studies found that neuroticism consistently predicts lower swl and higher na, agreeableness and extraversion predict higher pa, and conscientiousness is the best predictor of higher swl (deneve & cooper, 1998). the authors argue that extraversion and agreeableness impact swb by leading to more positive emotion, while conscientiousness leads individuals to set goals and work to achieve those goals, which leads to more swl. finally, mccrae and costa (1991) argued that openness was a positive predictor of both pa and na and that it led to more emotions overall. however, the meta-analysis by deneve et al. found openness to be the weakest predictor of swb compared to the other traits. this may be due to deneve et al.’s use of an expanded definition with openness to include cognitive variables (e.g., belief in a just world, mental absorption, and rigidity) or to the fact that openness is still the least understood of the five factors (see deyoung, 2015 for an attempt to rectify this problem). for this reason, openness was not included in the current study. overall, the mechanisms behind the connection between swb and personality traits are still not well understood. with regards to extraversion, it may be that extraversion is related to greater sociability which in turn is related to higher swb (bradburn, 1969; okun et al., 1984), but there is research that suggests sociability cannot account completely for this relationship (harris et al., 2017) and that even if extraverts are in nonsocial occupations, they still have higher swb than introverts (diener et al., 1984). there is also not a perfect relationship between extraversion and happiness. indeed, research has found support for happy introverts who seem to not be significantly different in many of their preferences (such as friendship relations and introspective activities) from happy extraverts, possibly due to extraversion playing a mediating role in how individuals pursue happiness (hills & argyle, 2001). another possibility not mentioned or investigated in previous research is the idea that personality traits can interact with each other in how they influence swb. for example, an agreeable extravert may act differently than a disagreeable extravert and therefore have different levels of swb. a good place to start when investigating the moderating role of various traits may be an examination of the strong and consistent relationship between neuroticism and swb. neuroticism is essentially a measure of negative emotions such as fear, anger, sadness, and anxiety (soto & john, 2017) and is sometimes referred to as negative emotionality. it may be no surprise that there is a strong negative relationship between neuroticism and swb, and other personality traits possibly serve moderating roles in the relationship between neuroticism and swb. the current work builds on past research linking personality and swb and looks at the moderating role of extraversion, agreeableness, and conscientiousness on the negative relationship between neuroticism and swb. neuroticism has been consistently linked with swb and has been shown to have a negative relationship with swl and pa and a positive relationship with na. conscientiousness, extraversion, and agreeableness all have positive relationships with well-being. 29 predicting satisfaction with life and affect balance considering this, the following was hypothesized. hypothesis 1: neuroticism will have a negative relationship with swb. hypothesis 2: “positive traits,” or conscientiousness, extraversion, and agreeableness, will moderate the negative relationship between neuroticism and swb, with higher levels of each positive trait predicting a weaker relationship between neuroticism and swb. study 11 method2 participants data for study 1 were taken from three separate online studies that used amazon’s mechanical turk (mturk). participation was voluntary through the mturk website, and a 50-cent compensation was offered as payment for completing the study. only those who correctly answered at least 80% of attention checks and completed at least 80% of the procedure received payment and were included in the data analyses. this stipulation was clearly stated in the mturk posting and the informed consent document. a total of 1150 participants were recruited for this study, and 120 participants did not pass at least 80% of the attention checks or were removed because of missing data. the final participants included 1035 individuals (69.57% female, 29.95% male, .004% non-binary gender identity) from the united states between the ages of 18 and 78 (mage = 37.28, sdage = 12.65). race was 78.9% white, 7.2% black/african american, 5.2% asian, 8.0% other, and 0.6% no response. an a priori power analysis to determine the sample size for the current analyses was not conducted because the data were collected for other purposes. a sensitivity analysis was used to determine how large of an effect could be detected with the current sample size. g*power was set to “linear multiple regression: fixed model, r2 increase.” a power of .80 was selected with an alpha of .05. the sample size was set to match the current study and the number of predictors was set to 3 (neuroticism, [other trait of current interest], neuroticism * [trait of interest] interaction). this resulted in an f2 of .011 reliably detectable by the current power level and sample size3. 1study 1 was not pre-registered, but study 2 was. this can be found at: https://osf.io/qyv3g/?view_only=74c6fc489bf94e15bd66eef34e6cc422 2 all r script and data for this study can be found at https://osf.io/n5jhv/?view_only=b8f1af679dad4fe281701928b5c4ac27 3 all effect sizes in this study were calculated using (r2ab r2a)/(1r2ab). measures big five inventory (bfi). the bfi is a 44-item measure made up of brief descriptions of behavior, thoughts, and feelings (john et al., 2008). respondents indicate the extent to which these items describe themselves on a 5-point scale, ranging from “strongly disagree” to “strongly agree.” the bfi has adequate internal reliability (α = .75-.80) and test-retest reliability over a period of three months (r = .80-.90; rammstedt & john, 2005, 2007). it assesses the five major domains of personality: extraversion, agreeableness, openness, conscientiousness, and neuroticism. within the current study, all domains had adequate reliability (α = .82-86). satisfaction with life scale (swls). the swls is a 5-item measure of global cognitive judgments of satisfaction with one’s life (diener et al., 1985). responses are measured on a 7-point scale, ranging from “strongly disagree” to “strongly agree.” the swls has adequate internal reliability (α = .87) and test-retest reliability over a period of two months (r = .82; diener et al., 1985). within the current study, the scale had high reliability (α = .94). positive and negative affect schedule (panas). the panas is a 20-item measure of both positive and negative affect (watson et al., 1988). items include words that correspond to positive or negative emotions. the trait version of the scale was used, which asks participants to “indicate to what extent you generally feel this way, that is, how you feel on the average.” responses are on a 5-point scale ranging from “not at all” to “extremely.” the panas has good internal reliability for both scales (pa α = .88; na α = .77) and has demonstrated adequate reliability over a 2-month period (pa r = .68; na r = .71; watson et al., 1988). within the current study, the scale had high reliability (pa α = .94; na α = .94). to compute scores representative of affect balance, negative affect was subtracted from positive affect. thus, numerically positive scores indicate more positive affect than negative affect, while numerically negative scores indicate more negative affect than positive affect. procedure for study 1, participants responded to at least the three self-report measures described in the previ 30 gibson et al. ous section. they also observed recorded interactions and provided personality judgments of the person in each video (these data were not used for this paper). analyses hypothesis 1 analysis. the relationship between neuroticism and swb was assessed in two ways. first, we examined pearson’s correlation coefficient between neuroticism and swl, and neuroticism and affect balance. second, we examined regression models wherein neuroticism predicted swl and affect balance separately. most assumptions for correlational analysis were met in that variables appeared to have a linear relationship based on the examination of scatter plots and were normally distributed based on examination of histograms, skewness, and kurtosis. when examining outliers, five outliers were identified for the variable of affect balance, with participants having lower affect balance scores than 1.5 times the interquartile range below the first quartile. however, no significant differences were found throughout the analysis when these outliers were excluded compared to when the outliers were included. outliers did not appear to be due to measurement error and simply represented a few participants with particularly negative affect. for both of these reasons, outliers were included in the analysis. hypothesis 2 analysis. hierarchical regression analyses were conducted with swl and ab as the dependent variables in separate analyses to examine how the positive personality traits of extraversion, agreeableness, and conscientiousness moderated the relationship between neuroticism and swb (baron & kenny, 1986). age was significantly correlated with affect balance. all analyses were computed with and without control for age, but this did not change the interpretation of results, so the more parsimonious (without age) model was used. the analyses assessed the incremental explanatory power of the variables in each block. the variables were entered into separate hierarchical regression models in the following order: extraversion, agreeableness, and conscientiousness, respectively, as well as neuroticism, were entered in step 1. two-way interaction terms (neuroticism x extraversion, neuroticism x agreeableness, neuroticism x conscientiousness) were entered in step 2. according to baron and kenny (1986), a significant moderator effect is indicated by significant incremental variance in the dependent variable after the interaction terms are added to the regression equation. assumptions of multiple regression were not violated such that there appeared to be linear relationships between independent and dependent variables when examining scatter plots, normality and homoscedasticity of residuals when examining normal q-q and residual vs fitted plots respectively, and independence of residuals, as checked using vif values, which were well below acceptable levels. results descriptive statistics and correlations between the big five, swls, and ab are presented in table 1. consistent with previous research, and in support of hypothesis 1, neuroticism was negatively correlated with swl (r(1033) = -.38, p < .001, 95% ci [-.43, -.33]) and ab (r(1033) = -.63, p <.001, 95% ci [-.67, -.60]). additionally, neuroticism was negatively correlated with the positive personality traits of extraversion, agreeableness, and conscientiousness. in further support of hypothesis 1, simple linear regressions found that for swl, the overall regression was statistically significant (r2 = .14, f(1, 1043) = 176.95, p < .001), and neuroticism significantly predicted swl (b = -0.68, p < .001). and for ab, the overall regression was again statistically significant (r2 = .4, f(1, 1043) = 709.6, p < .001), with neuroticism significantly predicting ab (b = -0.95, p < .001). table 2 shows that, as expected from previous literature, in step 1, positive personality traits significantly predicted swl, while neuroticism was a negative predictor of swl. in step 2, adding interaction terms revealed extraversion (b = .12, p = .02, f2 = .005, r2 change = .004) and conscientiousness (b = .15, p = .02, f2 = .006, r2 change = .005) to be significant moderators of neuroticism on swl, while agreeableness was not a significant moderator (b = .06, p = .31, f2 < .001, r2 change < .001). table 3 shows that, in step 1, positive personality traits significantly positively predicted ab while neuroticism negatively predicted ab. in step 2, adding interaction terms to the model revealed that agreeableness (b = .09, p = .02, f2 = .005, r2 change = .003) and conscientiousness (b = .09, p = .02, f2 = .005, r2 change = .003) significantly moderated the effect of neuroticism on ab, but extraversion did not (b < .01, p = .92, f2 <.001, r2 change < .001). thus, hypothesis 2 was partially supported. to examine the interaction patterns, the interac31 predicting satisfaction with life and affect balance tion effects were plotted by simple slopes of swl and ab at high and low levels (±1sd from the mean) for neuroticism and positive personality traits. the interaction patterns for extraversion, conscientiousness, and agreeableness with the outcome variable swl are depicted in figures 1a, 1b, and 1c, respectively. figure 1a suggests that across all levels of neuroticism, higher extraversion is associated with higher swl. however, the difference in swl at high levels of neuroticism is much more pronounced than at low levels of neuroticism. figure 1b illustrates a similar story, with higher conscientiousness predicting higher swl across levels of neuroticism, but with larger differences between levels of extraversion at high levels of neuroticism as opposed to low levels of neuroticism. figure 1c shows a similar pattern in terms of higher neuroticism predicting lower swl, and lower levels of agreeableness predicting lower swl. however, figure 1c illustrates that agreeableness was not a significant moderator, such that individuals with both high and low levels of agreeableness have similar relationships between swl and neuroticism. in other words, highly neurotic individuals may benefit more in terms of swl from high levels of positive traits like extraversion and conscientiousness than individuals low in neuroticism, but this is not necessarily true for the positive trait of agreeableness. figures 2a, 2b, and 2c show the moderating effect of extraversion, conscientiousness, and agreeableness on the relationships between neuroticism and ab, respectively. figures 2b and 2c show the significant interaction effect, again showing that higher conscientiousness and agreeableness are related to higher ab, with the difference in ab being more pronounced at higher levels of neuroticism. on the other hand, figure 2a shows that the level of neuroticism does not interact with the level of extraversion to influence ab, with the difference in ab at high and low levels of neuroticism being similar regardless of level of extraversion. discussion overall, the findings for this study were a little mixed. in some instances, positive personality traits seemed to moderate the relationship between neuroticism and swb while in other instances they did not. it is possible that there is still a clear relationship between these variables, but more research is needed to help investigate this further. study 2 replication within the last decade, research in psychology has begun to increasingly stress the importance of replicating results. several studies have been published that call into question some seminal research that is taught in many introductory psychology classes (open, 2015). although the debate over the replicability of many of these studies continues, what is clear is that attempting to replicate results is important. for this reason, study 2 attempted to replicate the results in study 1 within a different sample and with different but conceptually similar measures. many things can impact the likelihood of a successful replication, including the a priori assumptions about what constitutes a successful replication (see asendorpf et al., 2016, for a discussion on recommendations for increasing replication). the most conservative and straightforward method is to compare the key parameters of the replication attempt to those in the original study, focusing specifically on the replication of statistical significance and the corresponding direction of effects. one main issue with determining a replication in this manner is that it creates a dichotomy where small differences in p-values could lead to a conclusion that the original results were not replicated. this is especially true when replication studies have less power than the original study (asendorpf et al., 2016), and therefore have a smaller probability of finding a statistically significant effect of the same magnitude (which is the case within this study). another way of determining the success of a replication is by looking at the overlap between confidence intervals (ci). if the parameters of interest from the replication study are contained within the ci of the original study, or if there is a significant overlap between the cis of both studies, a case can be made for the replicability of the original results. this method is less conservative than relying on statistical significance but is still sensitive to power differences between studies (asendorpf et al., 2016). this means that if a replication study is powered differently from the original study, results should be interpreted with caution. the current study used all of these methods. when comparing parameters from the replication to the original study, if the direction of the effect is the same, ci’s overlap, the replication parameters are contained within the ci of the original study, and both are statistically significant, a strong case for replication can be made. the fewer of these standards that a repli 32 gibson et al. cation effect meets, the weaker the case for replication. all results should be interpreted with this in mind. method data from this study were taken from a separate unrelated study that examined the impact of prior information on personality judgment accuracy (gibson 2019). participants participants were recruited using idaho state university’s psychology department participant pool. participation was voluntary, and participants were compensated with class credit. only participants who correctly answered 80% of attention checks were included in the data analysis. the final participants included 151 individuals (this number was determined based on power analysis for the original study; gibson 2019); 73% female, 26% male, <1% other gender identity) between the ages of 18 and 46 (mage = 21.44, sdage = 4.15). self-identified ethnicity in the form of a free-response question was 80.9% white/caucasian (non-hispanic), 11.1% hispanic/latinx, 1.9% asian, and 6.1% other. a sensitivity analysis was used to determine how large of an effect could be detected with the current sample size. g*power was set to “linear multiple regression: fixed model, r2 increase”. a power of .80 was selected with an alpha of .05. the sample size was set to match the current study and the number of predictors was set to 3 (neuroticism, [other trait of current interest], neuroticism * [trait of interest] interaction). this resulted in an f2 of .074 reliably detectable by the current power level and sample size. measures the following measures, while not inclusive of all the measures completed by participants in this study, are the relevant measures used in the following analysis4. the big five inventory-2 (bfi-2). the bfi2 is a 60-item measure made up of brief descriptions of behavior, thoughts, and feelings (soto & john, 2017). respondents indicate the extent to which these items describe themselves on a 5-point scale, ranging from “strongly disagree” to “strongly agree.” the bfi-2 has adequate internal reliability (α = .84-.91). it assesses the five major domains of personality: extraversion, agreeableness, open-mindedness, conscientiousness, and negative emotionality (previously labeled neuroticism). within the current study, the cronbach’s alpha reliabilities of each of the 12-item 4 participants also completed ryff’s psychological well-being scale and a measure of fixed and growth mindset of intelligence. domain scales were highly reliable (extraversion α = .82, agreeableness α = .82, conscientiousness α = .86, emotional stability α = .90, and openness α = .80). satisfaction with life scale. within this study, the cronbach’s alpha reliability of the 5 items within the swls measure was found to be highly reliable (α = .85). positive and negative affect schedule. within this study, the cronbach’s alpha reliability of the two scales was found to be highly reliable (pa α = .88, na α = .83). procedure participants were brought into a lab and asked to sit in front of a computer. after a short introduction video, participants completed the informed consent form and provided personality information using the bfi-2 (soto & john, 2017) via the self-report form. participants then watched video interactions of other individuals and judged their personalities, which is not relevant to the research question currently being explored. after completing this judgment portion, participants completed another set of self-report measures, including the panas (watson et al., 1988) and swls (diener et al.,1985). analyses all analyses were performed in the same way as in study 1. assumptions for correlational analysis and multiple regression analysis were not violated. results descriptive statistics and correlations between the big five domains, swl, and ab are presented in table 4. consistent with previous research and study 1, neuroticism was negatively correlated with extraversion, agreeableness, conscientiousness, swl, and ab. age was not related to either outcome, but gender was related to swl such that males had higher levels of swl than females. as in study 1, all models were run with and without a gender control and this resulted in no differences in interpretation of the results, so the more parsimonious model was used for results. table 5 shows that extraversion and conscientiousness significantly predicted swl, while neuroticism was a negative predictor of swl. in step 2, adding interaction terms revealed extraversion (b = .37, p = .02, f2 = .028, r2 change = .027) to be a significant moderator of neuroticism on swl, while conscientiousness (b = .31, p = .07, f2 = .022, r2 change =.015) 33 predicting satisfaction with life and affect balance and agreeableness (b = .24, p = .20 f2 = 011, r2 change = .008) were not statistically significant moderators. table 6 shows that, surprisingly, in step 1, only conscientiousness significantly positively predicted ab, while neuroticism negatively predicted ab. in step 2, adding interaction terms to the models revealed that agreeableness (b = -.26, p = .04, f2 = .029, r2 change = .022) significantly moderated the effect of neuroticism on ab, but extraversion (b = -.03, p = .79 f2 < .001, r2 change < .001) and conscientiousness (b = .01 p = .95 f2 < .001, r2 change < .001) did not. to examine the interaction patterns, the interaction effects were plotted in the same way as in study 1. the interaction pattern for extraversion with the outcome variable swl is depicted in figure 3. figure 3 suggests that at high levels of neuroticism, higher extraversion is associated with higher swl. however, the difference in swl at low levels of neuroticism between levels of extraversion is negligible. this mirrors the patterns found in study 1, with individuals high in neuroticism potentially benefiting more from possessing the trait of high extraversion. figure 4 displays the interaction pattern for agreeableness with the outcome of ab. this figure shows a distinctly different pattern than what was found in study 1. at high levels of neuroticism, the difference in ab is negligible, whereas, at low levels of neuroticism, the difference in ab at different levels of agreeableness is more pronounced, with high agreeableness predicting higher ab. this suggests that for individuals high in neuroticism, ab is low despite the presence of high levels of agreeableness. discussion as mentioned earlier, evidence in support of replication can come in many forms, some more stringent than others. within this study, multiple methods were used to examine how well study 2 replicated the results found in study 1, including 1) whether the effects were in the same direction in both studies, 2) whether the cis overlapped, 3) whether the replication parameters were contained within the ci of the original study, and 4) whether statistical significance was present across both studies. the more of these standards that a replication effect meets, the stronger the case for replication. table 7 concisely depicts these results. based on these findings, replication of the results found in study 1 is most clear when examining trait interactions that predict swl. predicting swl, both the extraversion by neuroticism interaction and the agreeableness by neuroticism interaction met three of the four replication standards. a weaker, but still legitimate case can also be made for the conscientiousness by neuroticism interaction within swl because both are in the same direction, and the cis overlap. when trait interactions were used to predict ab, the extraversion by neuroticism and the agreeableness by neuroticism parameter estimates from study 2 were in the opposite direction of those found in study 1. this means that there is a fairly weak case (at least within this replication attempt) for the replicability of these effects from study 1. a stronger case can be made for the conscientiousness by neuroticism effect, which met 3 of the 4 criteria for replication. general discussion people with different personalities can experience the same life events or situations and come away with vastly different positive or negative experiences (magnus et al., 1993). a long history of research linking swb and personality has demonstrated how various personality traits are related to our subjective sense of well-being. neuroticism has consistently been shown to have a negative relationship with swb, while extraversion, agreeableness, and conscientiousness have been shown to have positive relationships (costa & mccrae, 1980; deneve & copper, 1998; mccrae & costa, 1991). the current studies explored how the relationships between neuroticism and swb can be moderated by other traits. significant interactions among the personality traits and their relationship to swb have been demonstrated and need to be considered and explored further in future research. as with previous studies, this study replicated results showing that neuroticism is inversely related to swb through a negative correlation with both swl and ab, while extraversion, agreeableness, and conscientiousness were positively related to swb through a positive correlation with both swl and ab. neuroticism also showed a negative relationship with extraversion, agreeableness, and conscientiousness. when interactions among traits were considered, the results from study 1 indicated that only extraversion and consciousness moderated the relationship between neuroticism and swl, and that conscientiousness and agreeableness moderated the relationship between neuroticism and ab. the meta-analysis by deneve and copper (1998) theo rized that neuroticism causes people to experience 34 gibson et al. less swb overall. our results show how this effect could be reduced through other personality traits. we found that the effect of positive personality traits on neuroticism was larger at higher levels of neuroticism compared to lower levels of neuroticism. thus, as neuroticism increases, the observed effect of positive personality traits such as extraversion, agreeableness, and consciousness on the relationship between neuroticism and swb becomes more pronounced. study 2 was designed to examine the replicability of the effects found in study 1. the strongest case for replication can be made for the moderating effect of extraversion and the lack of moderation for agreeableness on the negative relationship between neuroticism and swl. in both cases, three lines of evidence supported the results found in study 1. there was also evidence for the moderating impact of conscientiousness. this suggests that, even in this different sample, the negative impact of neuroticism on swl is less for individuals high in extraversion or consciousness, but is not significantly impacted by levels of agreeableness. the impact of positive personality traits on neuroticism and ab relationships was mostly not replicated. in some cases (extraversion by neuroticism and agreeableness by neuroticism), the effects were in the opposite direction. the effects of the interaction of conscientiousness by neuroticism on ab were mostly replicated. there could be a number of explanations for these findings. first, the sample in study 2 was about 15% of the size of the sample in study 1, so it did not have as much power to detect small effects. study 1 could detect effects as small as f2 = .011, but study 2 could only detect effects as small as f2 = .074. study 2 also collected data only from college students and had less diverse demographics than study 1. a smaller and more homogenous sample could make it more difficult to detect effects due to lower variability. it is also important to keep in mind that college students differ from other adults in some important ways, such as being younger, and also differ from adults of the same age who have not gone to college in substantive ways such as a greater tendency to rationalize choices, higher levels of individualism, weaker motivations to conform, and less prosocial behaviors (henrich et al., 2010). future research on this topic would benefit from larger and more diverse samples to more directly examine how trait interactions are related to well-being across different age groups and groups with different experiences (such as attending college). another potentially important difference between the studies is that study 1 used the original bfi to assess personality traits, while study 2 used the bfi-2. this may have made a difference in the two studies, but the two measures have high convergent validity and trait scores tend to be highly correlated between the two (soto & john, 2017). for this reason, it is unlikely that this difference can account for the differences between the two studies. due to the larger sample size and greater diversity of the sample, study 1 is a more reliable study and the results from study 2 should be taken as only moderate evidence for the replicability, or lack thereof, of the findings. overall, there is some evidence that positive personality traits can attenuate the negative relationship between neuroticism and swb, specifically when it comes to swl. some of these differences could affect how personality is related to well-being, which would be a useful avenue for future research. research also suggests that swb is only one part of a broader construct of overall well-being (chen et al., 2013) and research may benefit by further investigating the relationship between personality traits and psychological well-being. one of the major limitations of this paper is that both studies are correlational and all measures were completed at only one time point, which means that cause-and-effect relationships cannot be identified. additionally, both studies suffer from self-selection bias. the types of individuals who decided to devote time to completing psychological surveys on mturk, and those who chose to take psychology classes, may not represent the broader population. future research should look at these effects in multiple groups and over longer periods of time to investigate the temporal validity of the results and causal directions of the relationships between personality traits and well-being. conclusion this research contributes to a more nuanced understanding of the complex interactions between well-being and personality. often personality traits are treated as if they operate alone, but individuals are complex. for example, an agreeable extravert will likely act differently than an agreeable introvert, so it is important to examine how traits interact with each other to influence important psychological outcomes and behavior. the predictions made in this study that conscientiousness, extraversion, and agreeableness would moderate 35 the relationship between neuroticism and swb were partially supported. positive personality traits were generally positively related to swb at high levels of neuroticism, but 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satisfaction with life (swl) note. n= 1035, values in brackets are the 95% confidence intervals. ***p < .001, **p < .01, *p < .05. 40 gibson et al. table 3 hierarchical regression analyses predicting affect balance (ab) note. n= 1035, values in brackets are the 95% confidence intervals. ***p < .001, **p < .01, *p < .05. 41 predicting satisfaction with life and affect balance table 4 descriptive statistics and zero-order correlations note. swl = satisfaction with life, ab = affect balance, ext = extraversion, agr = agreeableness, con = conscientiousness, neu = neuroticism/negative emotionality, gen = gender. n = 151, values in brackets are the 95% confidence intervals. **p < .01, *p < .05, †for gender, male = 0 and female = 1, non-binary individuals were excluded from the correlation matrix (but included in all other analysis) so that results could be interpreted properly (n=149 for gender correlations). 42 table 5 hierarchical regression analyses predicting satisfaction with life (swl) note. values in brackets are the 95% confidence intervals. ***p < .001, **p < .01, *p < .05 gibson et al. 43 predicting satisfaction with life and affect balance table 6 hierarchical regression analyses predicting affect balance (ab) note. values in brackets are the 95% confidence intervals. ***p < .001, **p < .01, *p < .05 44 gibson et al. table 7 lines of evidence for the replication in study 2 of the trait interactions found in study 1 note. ci = 95% confidence interval, ext = extraversion, agr = agreeableness, con = conscientiousness, neur = neuroticism/negative emotionality. an x in the shared significance column means that either both were significant, or both were not significant. *p < .05 in study 1. 45 predicting satisfaction with life and affect balance figure 1 the moderating effect of positive traits on the relationship between neuroticism and satisfaction with life note. *significant interaction effects. 46 gibson et al. figure 2 the moderating effect of positive traits on the relationship between neuroticism and affect balance note. *significant interaction effects. 47 predicting satisfaction with life and affect balance figure 3 the moderating effect of positive traits on the relationship between neuroticism and satisfaction with life note. *significant interaction effects. 48 gibson et al. figure 4 the moderating effect of positive traits on the relationship between neuroticism and affect balance note. *significant interaction effects. microsoft word vol10_maliceshilling#2af69b.doc 29 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 an exploratory study of the influences on response stability of the interactive dominic/terry questionnaire m. alice shillingsburg marcus institute emory school of medicine kevin ragsdale lee county youth development center steven k. shapiro auburn university jason sikorski central connecticut state university the dominic interactive is a pictorial structured child interview screener with features to address developmental issues that are often problematic for young informants. it includes items depicting nonsymptomatic activities as well as activities demonstrating dsm-iv (american psychiatric association, 1994) symptoms of several childhood disorders. we examined the reliability of the interactive dominic/terry, as well as potential factors influencing response stability, with a sample of 59 inpatient adolescents. response stability refers to the tendency for the same response to be given over time. analyses yielded good to excellent reliability for the majority of the scales. response stability was similar regardless of age, gender, or race. results also suggested an inverse relationship between verbal iq and rate of response change. overall, these preliminary results suggest that this instrument is suitable for children and adolescents of different racial backgrounds, although the impact of intelligence requires further investigation. children and adolescents referred to inpatient psychiatric facilities are frequently the focus of extensive medical and psychological assessment. the primary diagnostic tool often is the clinical interview even though interviewerand/or diagnostic criteria variance are common (silverman & ollendick, 2005). to overcome this limitation a number of diagnostic interviews, either highly structured or semistructured, have been developed (mcclelland, 2004). in the inpatient setting a “respondent-based” interview (angold & fisher, 1999) yielding information regarding the thoughts and feelings of the youth is desirable to complement observational material from staff reports. however, difficulties with traditional interview methods such as the use of abstract language, cumbersome author note: we thank todd smitherman, natalie arnette, and kanika bell for their assistance with data collection and j. p. valla for his helpful suggestions on previous drafts of this article. appreciation is extended to the participants and staff of lee county youth development center. this paper is based on a master's thesis conducted by the first author while at auburn university. correspondence concerning this article should be directed to steve shapiro, department of psychology, 226 thach, auburn university, alabama 36849-5214; shapisk@auburn.edu length, and references to time have been noted (edelbrock & bohnert, 2000; fallon & schwab-stone, 1994). studies have shown that up to half of adolescents are not interested in traditional interviews and one-third has difficulty paying attention (shaffer et al., 1993). adolescents have also reported difficulty understanding interview questions (edelbrock & bohnert, 2000). these factors may impede the utility of the information gathered. in order to increase interest and attention, a diagnostic interview may necessitate a concrete format to which young informants can relate. instruments showing pictures representing psychopathology, thereby combining auditory and visual modalities, seem appropriate. as demonstrated by furman and bierman (1983), presenting a combination of both auditory and visual information when posing questions to children as young as four years old results in increased comprehension of the question (see also bierman, 1984). this dual-modality approach is consistent with paivio’s dual-coding theory, which posits two distinct subsystems, an auditory and a visual system, that process cognitive information (paivio, 1986). such a combined approach has been shown to aid comprehension and learning, enhance children’s memory (pressley & miller, 1987; schneider & pressley, 1997), improve attention, and stimulate interest (calvert, 1999; peeck, 1987; pezdek & stevens, 1984). in addition, according to bender and levin (cited in pressley & miller, 1987) the dualmodality approach significantly improved learning in a shillingsburg, shapiro, ragsdale, & sikorsi 30 group of educable mentally retarded children. given previous research indicating that adolescents, similar to younger children, have difficulty paying attention during structured interviews, the combination of visual and auditory stimuli may also be beneficial when interviewing adolescents, particularly those with lower intelligence. among pictorial instruments, the dominic is one of the oldest and most widely tested (bidaut-russell, valla, thomas, bergeron, & lawson 1998; ederer, 2004; valla, bergeron, berube, gaudet, & st-georges, 1994). the dominic demonstrates robust psychometric properties in the general population and outpatient clinic children (cottler, reich, rourke, cunningham-williams, & compton, 2000; loney & frick, 2003; murphy, cantwell, jordan, lee, cooley-quille, & lahey, 2000). it has, however, not been validated with inpatient youths. the dominic interactive (valla, 2000) is part of a relatively new set of structured child interview screeners (dominic-r, interactive dominic/terry) developed in an attempt to resolve many of the problems with traditional face-to-face interviews (valla et al., 1994; valla, bergeron, bidaut-russell, st-georges, & gaudet, 1997; valla, bergeron, & smolla, 2000). this screening tool is a pictorial structured interview that, in addition to blending visual and verbal information, has a short administration time (1020 minutes), presents the child with simple response options, and does not include questions regarding time and frequency. as the interviewee views the pictures he or she simultaneously hears a voice describing the pictured activity. this interview portrays, in still-frame, a boy or girl named dominic (caucasian), or terry (african-american) engaging in various activities and situations. some of the activities and situations demonstrate non-symptomatic activities and are included on a strengths and competencies scale, which has received little empirical investigation. other activities and situations presented demonstrate dsmiv (american psychiatric association, 1994) symptoms of attention-deficit/hyperactivity disorder (adhd), oppositional defiant disorder (odd), conduct disorder (cd), major depressive disorder (mdd), separation anxiety disorder (sad), generalized anxiety disorder (gad), and specific phobias (sph). upon presentation of the items, the child either answers “yes” or “no” as to whether s/he acts similarly to dominic/terry (valla et al., 2000). currently, an incomplete set of versions is available across age, language, and race. thus, this instrument has considerable potential as a tool for cross-cultural applications. valla and colleagues (1994, 1997, & 2000) have reviewed the construction and psychometric properties of the paper-based version of the dominic and dominic-r. of 42 symptom scales (7 diagnostic-approximates, or “tendencies,” for six age groups) included on the dominic-r, 33 obtained an intraclass correlation coefficient (icc) above .70. seven were between .60 and .69 and 2 were below .60. the 2 symptom scales below .60, specific phobia and conduct disorder, were obtained from the group of 6-yearolds. internal consistency for both internalizing and externalizing tendency scales were .89. alphas for the individual symptom scales ranged from .64 to .83. bidaut-russell and colleagues (1998) introduced dominic-r versions depicting african americans (terry). using 36 referred and non-referred children, these researchers obtained test-retest kappas for terry tendencies from .70 to .76 and iccs between .77 and .88. cronbach’s alphas ranged from .78 to .90. these findings are commensurate with those obtained using the dominic-r and indicate that the measure can be used reliably with african american children. still, as noted by valla et al. (2000), it is necessary to further document the psychometric characteristics of the terry. this is consistent with the need to develop more ecologically sensitive instruments to facilitate identification with the material and enhance selfdisclosure (merrell, 2003). the computer-based interactive dominic was first introduced by valla, bergeron, and smolla (1997). unpublished research conducted by bergeron and smolla (2002), using 609 non-clinical and clinical french and englishspeaking children, report psychometric properties that were similar to or better than the paper version. valla et al. (2002), demonstrated the measure’s transcultural appropriateness and ability to discriminate between clinically referred and non-referred children, as well as referred children with and without a clinical judgment-based diagnosis. the psychometric characteristics of the interactive terry have not been reported. previous findings suggest that the dominic-r elicits responses that demonstrate better test-retest reliability than those yielded from the k-sads, the disc, and the disc-2 (valla et al. 1994). however, initial studies with the dominic-r using both outpatient clinic and community samples resulted in limitations in the calculation of some kappa values due to the low base rate of some symptoms. because the dominic already demonstrated acceptable psychometric qualities in other settings, and instruments tend to be more reliable in clinical settings (boyle et al., 1993; schwab-stone, fisher, piacentini, shaffer, davies, & briggs, 1993; welner, reich, herjanic, jung, & amado, 1987), the current study was not designed as a comprehensive validation study. instead, we first aimed to extend the reliability evidence of the interactive dominic to an inpatient setting and its parallel version (terry) with a sample of african americans. second, we were interested in examining whether measured intelligence affected response stability. a plethora of literature has documented adaptive behavior deficits (e.g., difficulties with hygiene care, daily living skills) and the full range of psychopathology in children presenting with intellectual deficits (see dykens, 2000 for a review). it follows, therefore, that children with intellectual delays would be well represented in inpatient psychiatric settings. comorbid cognitive delays and behavioral/ emotional problems pose particular assessment challenges (dykens, 2000; hodapp & dykens, 1996; singh, oswald, & ellis, 1998). indeed, previous reliability studies on traditional structured diagnostic interviews frequently influences on response stability 31 have excluded children due to low intelligence (edelbrock, costello, dulcan, conover, & kalas, 1986; herjanic & reich, 1982; moretti, fine, haley & marriage, 1985; welner et al., 1987). third, the influence of gender, age, race, test-retest interval, and attenuation was explored as possible factors affecting response stability. method participants participants were 59 inpatient adolescents consecutively referred between july 2002 and april 2003 to a residential treatment and diagnostic center, which provides short-term emergency shelter in east alabama. males (52.5%) and females (47.5%), african americans (46%) and caucasians (54%) were equally represented in the sample, and ranged in age from 12 to 17 (m = 14.3, sd = 1.63). inclusion criteria were: age between 12 and 17, informed consent/assent, and presence during the period of data collection. there were no exclusion criteria. the range of presenting problems was wide and these teens participated in a variety of treatment programs, in addition to an evaluation. measures interactive dominic/terry interactive (valla, 2000). we used the 6-11 version of the instrument with our inpatient sample since the african-american version (terry) is not yet available for adolescents. downward extensions of adult questionnaires have been widely criticized because children’s language comprehension may differ markedly from that of adults due to factors previously outlined. in the present study, however, the measure has been developed with young children, and the more recent adolescent version (smolla, valla, bergeron, berthiaume, & st-georges (2004), with few exceptions, utilizes the same formulations as the 6-11 version (j. p. valla, personal communication, july 2006). the child version of the dominic/terry yields diagnostic-approximate information (tendencies) based on a normative sample aged 6-11. cut-off points obtained with that sample were irrelevant for our adolescent participants and no attempt was made to study diagnostic prevalence estimates. wechsler intelligence scales. the wechsler intelligence scale for children, third edition (wisc-iii; wechsler, 1991) and wechsler adult intelligence scale, third edition (wais-iii; wechsler, 1997) represent the most widely used measures of intellectual abilities (kaufman & lichtenberger, 2000), and yield a full scale iq, verbal iq, performance iq, and four factor scores. reliability and validity of these instruments are well documented (sattler, 2001). procedures upon arrival at the facility each resident received a standard diagnostic battery, which among other measures, included a semi-structured clinical interview, the wisc-iii or wais-iii, and the interactive dominic/terry. nothing was mentioned regarding dominic's/terry's youthful appearance. interviewers presented the task using the standard prompt provided in the test. the test-retest interval for the dominic/terry ranged from 3 to 17 days (mdn = 7; m = 8.33; sd = 3.3). informed consent and assent were secured from the parents/guardians and adolescents, respectively, prior to the data being obtained in an anonymous fashion from the participants’ file. analyses the overall sample of 59 participants was used to determine the internal consistency (cronbach’s alpha) of the interactive dominic/terry tendency scales. of these 59 youths, 10 left the facility before completing retest. no differences on any study variable existed between youths with retests and those without. therefore, test-retest analyses were based on a sample of 49 adolescents (24 females [49%], 23 african americans [46.9%]). kappa coefficients were calculated to assess the test-retest reliability of symptoms. intra-class correlations (iccs) were computed to examine the test-retest reliability of the seven tendency scales, the strengths and competencies scale, and the total instrument. of these 49 subjects, 47 (23 females, 21 africanamericans) were administered the wisc-iii or wais-iii, depending on age (12-17; m = 14.4; sd = 1.62). we computed pearson product-moment correlations in order to examine the relationship between the amount of response change on the interactive dominic/terry and intelligence. response change at retest was calculated for every tendency scale and every participant. response change refers to the change from one response to another from the first to second administration. less response stability results in greater response change. the amount of response change was computed by summing the number of responses that were changed from test to retest and dividing by the number of possible responses per tendency scale. in order to further examine differences in terms of amount of response change and iq, participants were grouped according to iq. those with iqs of 79 and below were classified as “moderately or significantly below average,” those with iqs between 80 and 89 were classified as “below average,” and those with iqs of 90 and above were classified as “average or above.” we conducted an analysis of variance (anova) for each diagnostic scale with post-hoc comparisons (tukey hsd). these iq groups were also used to examine icc patterns among the seven tendency scales, the strengths and competencies scale, and the total instrument. univariate analyses explored other possible factors affecting response change, and examined shillingsburg, shapiro, ragsdale, & sikorsi 32 attenuation differences according to gender and two age groups (12-14 and 15-17). results acceptability of the pictorial approach participants were observed to be quite interested in the computer-based interview relative to other components of the assessment. there was no reaction to the age of dominic with the exception of two participants who commented on how young dominic/terry appeared. internal consistency cronbach’s alphas ranged from .66 (strengths) to .91 (adhd). alphas for the internalizing and externalizing tendency scales were both very high (.94). test-retest reliability iccs were calculated for the overall sample as well as for groups based on gender, race, and age. for the overall sample, iccs of the eight tendency scales ranged from .81 to .96. the icc for the total instrument was .97. except for the strengths and competencies scale and the specific phobia tendency scale, all iccs were above .90. iccs ranged from .79 to .97 for the younger group (12 to 14) and .84 to .96 for the older group (15-17). iccs for the two groups for each scale and the total test were similar; however, the younger group obtained an icc of .83 on the specific phobia tendency scale while the older group obtained an icc of .94. because the interactive dominic/terry provides slightly different characters based on gender and race, testretest reliability was examined depending on the version given (see table 1). iccs for both genders were similar except for the specific phobia tendency scale: males obtained a lower icc (.69) than females (.91) on that scale. iccs for the african american and caucasian groups were similar with the exception of the strengths and competencies scale where the african american group obtained a lower icc (.71) than the caucasian group (.91). of the 91 symptoms, kappas were .70 or above for 42 symptoms, between .60 and .69 for 17 symptoms, between .50 and .59 for 14 symptoms, and below .50 for 18 symptoms. using the classification approach offered by landis and koch (1977), the interactive dominic/terry yielded 27 symptoms with excellent reliability (above .75), 34 with good reliability (.59 to .74), 19 with fair reliability (.40 to .58), and 5 with poor reliability. six items had low base rates at both test and retest. intelligence and response stability full scale iq (fsiq) scores ranged from 54 to 116 (m = 84.13, sd = 12.76), verbal iq (viq) scores ranged from 52 to 126 (m = 84.02, sd = 14.23), performance iq (piq) scores ranged from 62 to 112 (m = 87.11, sd = 11.09), and verbal comprehension index scores ranged from 54 to 102 (m = 84.16, sd = 11.85). fsiq and piq were negatively correlated with response change for four of the eight tendency scales (sph: r = -.35 and -.34, p < .05; sad: r = -.40 and -.40, p < .01; cd: r = -.31 and -.29, p < .05; strengths: r = -.44, p < .01 and r = -.30, p <.05) and the overall instrument (r = -.50 and -.30, p < .01). significant negative associations were also obtained between viq and response change for all but one (odd) tendency scale (p < .05: sph r = -.31, sad r = -.35, gad r = -.29, mdd r = -.29, cd r = -.29, adhd r = -.29; p < .01: strengths r = -.48) as well as the overall instrument (r = -.53, p <.01). the verbal comprehension index was negatively associated with five tendency scales (sad r = -.42, p < .05; mdd r = -.38, p < .05; cd r = -.35, p < .05; adhd r = -.46, p < .01; strengths r = -.59, p < .01) and the overall instrument (r = .56, p < .01). table 1 intraclass correlation test-retest reliability of scales of the interactive dominic/terry based on gender and race males n=25 females n=24 african american n=23 caucasian n=26 tendencies icc a ci b icc ci icc ci icc ci sph .69 .29, .86 .91 .80, .96 .86 .68, .94 .89 .76, .95 sad .95 .88, .98 .94 .86, .97 .94 .86, .97 .95 .89, .98 gad .96 .91, .98 .91 .80, .96 .95 .89, .98 .93 .85, .97 mdd .95 .88, .98 .96 .91, .98 .97 .93, .99 .95 .89, .98 adhd .95 .88, .98 .97 .93, .99 .96 .91, .98 .96 .91, .98 odd .88 .72, .95 .94 .87, .98 .95 .87, .98 .89 .75, .95 cd .96 .90, .98 .88 .71, .95 .94 .86, .97 .94 .87, .97 overall total .96 .91, .98 .97 .94, .99 .98 .94, .99 .96 .92, .98 strengths .83 .62, .93 .80 .53, .91 .71 .31, .88 .91 .80, .96 a intraclass correlation coefficient b 95% confidence interval based on the anova between viq groups (“moderately or significantly below average,” “below average,” influences on response stability 33 and “average or above”), the lowest viq group tended to show higher response changes, but only significantly so on the cd and sad tendency scales as well as on the strengths and competencies scale (see table 2). similarly, all scale iccs remained above .90 regardless of viq group, except for the lowest viq group’s sph scale (.79) and the lower two viq groups’ strengths and competencies scale (.35 and .84, respectively). table 2 viq group differences in amount of response change mean amount of response change tendencies msba viq a n=13 ba viq b n=19 aa viq c n=15 f p tukey hsd sph .128 .076 .052 1.72 .191 ns sad .163 .145 .050 4.43 .018 msba, ba>aa gad .226 .140 .142 2.33 .109 ns mdd .181 .158 .093 2.64 .083 ns odd .188 .164 .178 .097 .908 ns cd .165 .071 .109 3.52 .038 msba>ba adhd .170 .130 .081 2.65 .080 ns overall total .177 .127 .089 7.39 .002 msba > aa strengths .231 .168 .053 8.40 .001 msba, ba>aa a moderately or significantly below average viq = 79 and below b below average viq = 80-89 c average or above viq = 90 and above note. sph=specific phobia, sad=separation anxiety disorder, gad=generalized anxiety disorder, mdd=major depressive disorder, adhd=attentiondeficit/hyperactivity disorder, odd=oppositional defiant disorder, cd=conduct disorder, strengths=strengths and competencies other factors affecting response stability age, gender, race, and test-retest interval were explored as possible factors affecting amount of response change. univariate analyses resulted in no significant differences for gender, age, or test-retest interval indicating that these factors did not affect response change. only one scale (strengths) resulted in a significant difference when comparing african americans (m = .19, sd = .14) and caucasians (m = .11, sd = .11), t (47) = 2.18, p < .05. attenuation is the tendency to change positive responses at the first administration to negative responses at the second administration. thus, attenuation is an important phenomenon to consider when examining response change. attenuation was seen for all scales. on the sph scale, mean rate of attenuation for males (m = 1.5, sd = 0.97) was lower than females (m = 2.71 sd = 1.23), t (47) = 2.33, p < .05. all other comparisons showed no differences. no correlation was found between age and attenuation. discussion the goals of the current study were to: 1) test the reliability evidence of the interactive dominic in an inpatient setting and its parallel version with african american youth; and 2) explore the relationship between response stability, intelligence, and demographic variables. reliability internal consistency statistics derived in the present study are generally commensurate with those obtained on the paper-based version (bidaut-russell et al, 1998; valla, bergeron, bidaut-russell et al., 1997), though notably higher values were found on the gad/oad scale (.86 versus .66) and the cd scale (.85 versus .64). furthermore, the test-retest reliability results of the present study are higher than those obtained previously by the authors of the interactive dominic/terry both for symptoms and symptom scales. iccs obtained in the present study also compare favorably with those obtained by valla and colleagues. such improved reliability was expected in an inpatient sample of older youth, since younger children tend to be less consistent in their reports than older ones (edelbrock et al, 1985). in addition, community samples are unlikely to endorse a sufficient number of the more severe symptoms (shaffer, fisher, & lucas, 1999), which influences statistical power. thus, the higher rates of symptom endorsement in our inpatient sample could have accounted for the higher reliabilities. consistent with this, test-retest reliabilities obtained in the present study with inpatient adolescents were considerably higher than those reported by fisher et al. (1997; see also shaffer et al., 2000), using the disc-iv on a sample of psychiatric outpatient children and adolescents (9-17 years old). in an early study of the child and adolescent psychiatric assessment self-report (capa-c) reliability, angold and costello (1995) also found typically higher iccs for inpatients relative to outpatients. our results compare favorably with these authors’ iccs for symptoms of major depression; in contrast, our iccs were considerably higher for symptoms of separation anxiety disorder, oppositional defiant disorder, and conduct disorder. few other studies of inpatients are available, making further comparisons difficult. regardless, no other diagnostic screening instrument has combined auditory and visual stimuli. audio computer-assisted self-interviewing has been shown shillingsburg, shapiro, ragsdale, & sikorsi 34 to foster adolescent disclosure of socially undesirable symptoms (turner et al., 1998). in addition, the voice disc-iv has shown utility in juvenile justice settings, where the use of evidence-based instruments is highly variable (wasserman, mcreynolds, lucas, fisher, & santos, 2002). attention should, therefore, be directed towards establishing the incremental utility of the dominic interactive as part of an evidence-based diagnostic evaluation process. the tendency scales on the interactive dominic/terry demonstrated acceptable reliability for both genders and for african-americans and caucasians, indicating that the instrument may be quite useful for children and adolescents of different racial backgrounds. similar to previous studies of the dominic (bidaut-russell et al, 1998; valla, bergeron, bidaut-russell et al., 1997), attenuation was seen for all tendency scales. this phenomenon has been documented by other interview developers as common (e.g., angold & costello, 1995; piacentini et al, 1999). the specific phobia (sph) and strengths and competencies scales demonstrated lower iccs and internal consistency than other scales, and of the items with poor reliability, four were on the strengths scale and three were on the sph scale. various types of specific phobias (e.g., dogs, bugs, heights) are represented on the sph scale, as opposed to the severity of any one specific experience required in the dsm-iv. specific phobias tend to diminish as children age (barrios & o’dell, 1998); thus, for our adolescent sample, endorsement base rate was very low. valla, bergeron, bidaut-russell et al. (1997), reported adequate internal consistency and good test-retest reliability for the sph scale in their sample aged 6-11 years. items on the strengths scale refer to having fun with friends, feeling good about school, and liking the place where the youth lives. affirmative responses may be expected from well adjusted children living in the community. however, due to the upheaval associated with a residential placement, this scale may not translate into inpatients’ current situation. as noted, african-americans obtained a lower icc on this scale compared to caucasians. this finding may indicate less cultural applicability of this scale to african-american youths’ perception of their strengths and competencies. previous studies did not report the psychometric properties of this scale. therefore, clarification of the utility and integrity of this scale is needed. response stability and iq our adolescent participants did not have a parental report available and were the sole providers of information during the diagnostic evaluation, in addition to historical records. this limited access to information is also a concern in juvenile justice settings (see wasserman et al, 2002). for adolescents of lower cognitive functioning who do not have parental report available to supplement their self-report, the method of eliciting information is crucial. the interactive dominic/terry was developed with the receptive and expressive limitations of children in mind. it relies less on the respondents’ verbal ability than sentencebased interviews that ignore limitations, and as a result, is likely less influenced by measured “verbal intelligence.” although age of our participants would suggest that a sentence-based interview is acceptable, the cognitive abilities of many participants suggest otherwise. verbal iq is still an associated factor in respondents’ ability to provide stable responses over time on the interactive dominic/terry. although there is an impact of iq on the dominic’s reliability, this impact seems minimal and should not preclude the use of this instrument with intellectually delayed individuals. systematic research on the impact of intelligence on reliability of traditional questionnaires and interviews is surprisingly sparse. the fact that many studies investigating the properties of sentence-based interviews exclude children based on cognitive ability suggest that those interviews (and other self report measures) may not have an adequate base of evidence on which to claim reliability. the format of the interactive dominic/terry may allow for useful diagnostic screening that might otherwise not have been possible. limitations and future directions the main limitation of our preliminary study is the small sample size. a larger sample size allows for better examination of symptoms rarely endorsed. further, larger samples of each race and gender would have been desirable. another clear limitation of the present study is the use of the 6-11 year old version of the instrument with an adolescent population. at the time of the current investigation, the adolescent version of the measure was in the process of being created and had not yet been made available. however, the authors of both versions of the measure indicated that with few exceptions the adolescent version used the same formulations as the 6-11 version (j. p. valla, personal communication, july 2006). one primary difference is the older appearance of the child in the adolescent version. given that only two of the participants made statements about the age of the child depicted, it is likely that this is an insignificant factor. in addition, given that diagnostic information was not relevant to the current study, cut-off scores based on a younger normative sample were not used. lastly, although the age of our participants would suggest that a sentence-based interview would be sufficient, the cognitive abilities of many participants and lack of an adolescent version suggests that use of the child version of the instrument was appropriate. this study did not examine the interactive dominic/terry and a dsm-iv-, sentence-based interview simultaneously, and thus the extent of the improvement presumably brought about by the combination of verbal and visual information with adolescents of lower cognitive functioning could not be determined. it would be important influences on response stability 35 to examine the relationship between verbal iq and both types of interview in order to determine whether the dual modality presentation improves response stability of low functioning adolescents. as noted by klein, dougherty, and olino (2005), most studies have not directly compared different diagnostic interviews in the same sample, thus making it difficult to identify advantages with particular instruments (see also angold & fisher, 1999). it might also be worthwhile to investigate whether order effects are present with the interactive dominic, consistent with findings that youths (and parents) report more symptoms for diagnoses assessed early in the more traditional structured interviews (jensen, watanabe, & richters, 1999). although an inverse relationship between iq and response change was seen with some scales for lower functioning individuals relative to higher functioning individuals, the impact seems minimal and may be less of a factor when using a pictoral interview compared to more traditional structured interviews. the current investigation did not directly compare the effects of iq on response stability using the two interview formats. future studies should directly compare these two modalities to determine the impact of iq when using a dual-modality approach compared to traditional interviews. lastly, although the length of the retest interval was examined as a potential factor affecting response stability, we did not specifically examine the effect on attenuation. future investigations should include this analysis to fully understand the effects of the length of the retest interval. clinical implications as implied above, this study provides preliminary evidence on the reliability of the interactive dominic/terry with both african-american and caucasian adolescent inpatient populations, yielding useful information in an efficient manner. this novel assessment approach based on both visual and auditory stimuli may be indicated with low functioning adolescents for whom traditional sentencebased interviews and inventories pose particular challenges. attention might also be directed towards establishing the incremental utility of the dominic interactive as part of an evidence-based diagnostic evaluation process. investigations of convergent and divergent validity and factors that influence the validity of obtained dominic/terry responses are essential. this information would provide support for the usefulness of this type of interview with an adolescent population. in addition, similar investigations of 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(2002). the voice disc-iv with incarcerated male youths: prevalence of disorder. journal of the american academy of child and adolescentpsychiatry, 41, 314-321. wechsler, d. (1991). wechsler intelligence scale for children – third edition (wisc-iii) manual. san antonio, tx: the psychological corporation. wechsler, d. (1997). wechsler adult intelligence scale – third edition (wais-iii) technical manual. san antonio, tx: hartcourt brace and co. welner, z., reich, w., herjanic, b., jung, k. g. & amado, h. (1987). reliability, validity, and parent-child agreement studies of the diagnostic interview for children and adolescents (dica). journal of the american academy of child and adolescent psychiatry, 26, 649-653. . graduate students journal of psychology copyr graduate student journal of psychology copyright 2004 by the department of counseling & clinical psychology 2004, vol. 6 teachers college, columbia university issn 1088-4661 a taxometric analysis of experimenter-induced response bias on self-report data jessica neubauer and robert e. mcgrath fairleigh dickinson university taxometric analysis was developed to help determine whether a latent variable best conforms to a dimensional or categorical (taxonic) model. one study (beauchaine & waters, 2003) found that the taxonic structure of ratings could be influenced through instructional set. their findings raise questions about whether taxometric analysis is necessarily identifying the organic structure of ratings-based latent variables. however, the study was limited to ratings of target individuals unknown to the rater. the present study was conducted to determine whether self-ratings are equally susceptible to manipulation. undergraduate students were asked to complete a battery of four selfreport personality measures which previous research indicated may tap a common latent variable. participants randomly received an instructional set that implied either a taxonic or dimensional structure for self-ratings. the results suggest that self-ratings may be more resistant to instructional set than ratings of others, as data from both groups conformed to a dimensional model rather than a taxonic structure. cut, and the means are then plotted. the resulting graph will vary in shape depending on whether the underlying construct is continuous or discontinuous. specifically, a psychologists have long recognized that many psychological measures offer, at best, a rough approximation of the latent variables they are intended to represent (cronbach & meehl, 1955). the very structure of psychological constructs is often not understood, making it impossible, for example, to determine whether a dimensional or categorical model provides a more accurate representation of these constructs. one consequence of such disparities is that psychologists develop measurement devices without a clear conceptualization of their underlying construct. determining the underlying structure of a psychological construct is one step toward making it a more tangible entity. taxometric procedures (meehl & yonce, 1994, 1996; waller & meehl, 1998) are a set of statistical analyses developed for the purpose of determining whether a latent variable of interest demonstrates an inherent dimensional or categorical structure when multiple indicators of that latent variable are available. several taxometric methods are currently available, including mean above minus below a cut (mambac), maximum eigenvalue (maxeig), and latent mode (lmode). latent taxonic structure will be represented in a graph by an inverted u, whereas a dimensional structure will manifest as u-shaped. as a consistency test for the results, the procedure can be repeated reversing the input and output variables. when more than two indicators are available, it is possible to conduct a mambac analysis twice for each possible pair. the maxeig method also requires that one indicator be designated the input variable, but it uses two or more other indicators as output variables. again, the input variable is sorted. subsamples are created based on equally spaced intervals along the input variable, and the eigenvalue, based on a factor analysis of the output variables, is calculated within each of these subsamples. in this case, the plot of eigenvalues as a function of interval should result in an inverted u shape for data that conforms to a taxonic model, whereas data that conforms to a dimensional model will be represented by a u shape. the procedure can be repeated using each available indicator as the input variable. mambac involves designating one indicator as the input variable and a second indicator as the output variable. the input variable is sorted, and a series of “cuts” are then made at each value along the input variable. the mean of the output variable is calculated, both above and below each latent dimensional or categorical structures can also be identified graphically when research data are subjected to a third taxometric procedure known as lmode. this procedure is based on a factor analysis of all available indicators, with the purpose of generating essentially error-free factor scores. a unimodal frequency distribution of these scores is indicative of an underlying dimensional structure, whereas two or more peaks suggest a taxonic structure. if enough indicators are available to allow selection of sub jessica neubauer and robert e. mcgrath, school of psychology, fairleigh dickinson university. correspondence concerning this article should be addressed to jessica neubauer, school of psychology t-wh1-01, fairleigh dickinson university, 1000 river road, teaneck, nj 07666-1914. e-mail: jessneubauer@aol.com 32 taxometrics and response style sets, multiple lmode graphs can be generated from subsets of indicators as a consistency check. studies have found taxometric analysis superior to alternative procedures, such as cluster analysis, as an indicator of taxonic structure (cleland, rothschild, & haslam, 2000; waller & meehl, 1998). the method has been used to evaluate the latent structure of various psychological constructs, including eating disorders (tylka & subich, 2003), sexual orientation (gangestad, bailey, & martin, 2000; haslam, 1997), antisocial behavior (skilling, quinsey, & craig, 2001), and depression (ruscio & ruscio, 2000). for example, using five non-behavioral indicators, tylka and subich (2003) found consistent evidence of a dimensional structure across clinical eating disorders. such results highlight the value of a statistical method that incorporates procedures for evaluating the consistency of conclusions about taxonicity. though numerous studies have demonstrated that the application of taxometric analyses may enhance understanding of psychological constructs, questions still remain as to how viable the results of such analyses are when they are based on data that has been collected via rating scales. a recent article by beauchaine and waters (2003) raises concerns about the degree to which the outcomes of taxometric analyses can be influenced by response set. here, undergraduates were asked to evaluate the quality of graduate school admission essays based on six criteria. raters were informed either that the “essays reflected a full range of graduate school performance,” or that they were “written by students who either struggled or excelled in graduate school” (beauchaine & waters, 2003, p. 6). the authors found consistent evidence that the structure of the ratings differed as hypothesized based on instructional set. analyses of ratings by individuals who were instructed that the essays’ authors reflected a full range of performance produced dimensional results, whereas those of raters instructed that authors either struggled or excelled produced categorical results. as a result, beauchaine and waters questioned whether taxonic structure can be manipulated through pre-existing expectancies. they concluded that “these results have potential implications for future taxometrics research and suggest that a sole reliance on rating-scale data may be ill-advised when testing taxonic hypotheses” (beauchaine & waters, 2003, p.10). in fact, though, their results are only relevant to ratings of others who are unknown to the raters. therefore, it is uncertain whether their conclusions apply when the rater has already developed an impression of the target prior to receiving the instructions. specifically, the application of their conclusions remains unclear when both the rater and target are the same individual, as is the case in self-report. since the studies listed above all used self-report as the basis for drawing conclusions about taxonicity, the present study was conducted to determine if the response bias detected by beauchaine and waters (2003) extends to selfreport rating scales as well. the results have important implications concerning the degree to which taxometric studies that involve self-report measures are reflecting inherent structure or rater perceptions. method participants a total of 115 undergraduate students at fairleigh dickinson university completed a battery of five self-report personality inventories. among those who provided demographic data, 70.8% (75) were females and 29.2% (31) were males. the sample was 49% caucasian, 25% african american, 9.6% hispanic, 9.6% asian, 1% native american, and 5.8% other. the mean age of the respondents was 20.47 years of age (sd = 4.39), with a range from 17 to 40. procedure participants were recruited from introductory psychology and freshman seminar courses and asked to complete four personality measures. these consisted of rosenberg’s (1965) self-esteem scale, the neuroticism scale of the eysenck personality inventory (eysenck & eysenck, 1968), the core self-evaluations scale (judge, erez, bono, & thoresen, 2003), and a generalized self-efficacy scale (judge, erez, bono, & thoresen, 2002). these scales were chosen because judge and colleagues (2002) have provided evidence that these measures all tap a common construct, despite the differences in their names. participants were randomly assigned to two groups. all participants were given standard instructions for the completion of self-report measures, with one exception. the taxonic instructions group consisted of 54 participants (47%) who were told, “previous studies suggest that most people either produce very high or very low scores on these types of scales.” the dimensional instructions group consisted of 61 participants (53%) who were told, “previous studies suggest that people produce a wide range of scores on these types of scales, from low to medium to high.” results when analyzed, pearson correlation coefficients suggest that the measures utilized correlate relatively well with one another, suggesting they are tapping a shared construct. the correlations between measures ranged from 0.32 to 0.71; each was significant at p < .001 (see table 1). the data from the taxonic instructions group and the dimensional instructions group were subjected to three taxometric procedures: mambac, maxeig, and lmode. without exception, each procedure yielded results indicating that the responses given conformed to a dimensional structure regardless of instructional set. graphs generated from the mambac and maxeig analyses failed to depict the inverted u shape characteristic of an underlying taxonic structure in either group. similarly, the lmode graphs for 33 neubauer and mcgrath discussion discussion both samples were unimodal, again failing to detect a taxon (see figures 1 and 2). each taxometric method allows for estimation of the taxonic base rate if a taxon exists. a high degree of variability in these estimates across analyses provides a secondary piece of evidence supporting a dimensional conclusion. in the taxonic instructions group, the mean estimated base rate from the mambac analyses was 0.50, while the mean based on the maxeig analyses was 0.77. lmode allows two independent estimates of taxon base rate. in the taxonic instructions group, these estimates were .06 and 1.00. these results suggest substantial variability in estimates of the taxon base rate, a finding that supports the conclusion that the distribution of scores in the taxonic instructions group conform to a dimensional structure. the results of the current study suggest that responses to self-report rating scales may not be as subject to manipulation via instructional set as beauchaine and waters (2003) suggest. even when given instructions suggesting a taxonic style of responding, students responded in a dimensional manner. the similarity in the style of responding across the two conditions supports the continued use of self-report rating scales for the purpose of assessment. the results of the current study suggest that responses to self-report rating scales may not be as subject to manipulation via instructional set as beauchaine and waters (2003) suggest. even when given instructions suggesting a taxonic style of responding, students responded in a dimensional manner. the similarity in the style of responding across the two conditions supports the continued use of self-report rating scales for the purpose of assessment. it is important to note, however, that the sample size available for this pilot study is insufficient to justify firm conclusions about the absence of taxonic structure. data continue to be gathered, and more extensive results will be made available at a future date. it is important to note, however, that the sample size available for this pilot study is insufficient to justify firm conclusions about the absence of taxonic structure. data continue to be gathered, and more extensive results will be made available at a future date. references references table 1 beauchaine, t. p., & waters, e. (2003). pseudotaxonicity in mambac and maxcov analyses of rating-scale data: turning continua into classes by manipulating observer’s expectations. psychological methods, 8, 3-15. beauchaine, t. p., & waters, e. (2003). pseudotaxonicity in mambac and maxcov analyses of rating-scale data: turning continua into classes by manipulating observer’s expectations. psychological methods, 8, 3-15. correlations between pairs of scales. rse epi epi cse cse gse gse rse rse 1.00 1.00 epi epi 0.32 0.32 1.00 1.00 cse cse 0.71 0.71 0.51 0.51 1.00 1.00 gse gse 0.71 0.71 0.48 0.48 0.70 0.70 1.00 1.00 note. rse = rosenberg self-esteem scale; epi = neuroticism scale of the eysenck personality inventory; cse = core selfevaluations scale; gse = general self-efficacy scale. all correlations are significant, p < .001. note. rse = rosenberg self-esteem scale; epi = neuroticism scale of the eysenck personality inventory; cse = core selfevaluations scale; gse = general self-efficacy scale. all correlations are significant, p < .001. cleland, c. m., rothschild, l., & haslam, n. (2000). detecting latent taxa: monte carlo comparison of taxometric, mixture model, and clustering procedures. psychological reports, 87(1), 37-47. cleland, c. m., rothschild, l., & haslam, n. (2000). detecting latent taxa: monte carlo comparison of taxometric, mixture model, and clustering procedures. psychological reports, 87(1), 37-47. cronbach, l. j., & meehl, p. e. (1955). construct validity in psychological tests. psychological bulletin, 52, 281302. cronbach, l. j., & meehl, p. e. (1955). construct validity in psychological tests. psychological bulletin, 52, 281302. eysenck, h. j., & eysenck, s. b. g. (1968). manual of the eysenck personality inventory. san diego, ca: educational and industrial testing service. eysenck, h. j., & eysenck, s. b. g. (1968). manual of the eysenck personality inventory. san diego, ca: educational and industrial testing service. -3 -1 0 1 2 3 4 0. 0 0. 2 0. 4 factor scores r el at iv e fr eq ue nc y lmode curve gangestad, s. w., bailey, j. m., & martin, n. g. (2000). taxometric analyses of sexual orientation and gender identity. journal of personality and social psychology, 78, 1109-1121. gangestad, s. w., bailey, j. m., & martin, n. g. (2000). taxometric analyses of sexual orientation and gender identity. journal of personality and social psychology, 78, 1109-1121. haslam, n. (1997). evidence that male sexual orientation is a matter of degree. journal of personality and social psychology, 73, 862-870. haslam, n. (1997). evidence that male sexual orientation is a matter of degree. journal of personality and social psychology, 73, 862-870. judge, t. a., erez, a., bono, j. e., & thoresen, c. j. (2002). are measures of self-esteem, neuroticism, locus of control, and generalized self-efficacy indicators of a common core construct? journal of personality and social psychology, 83, 693-710. judge, t. a., erez, a., bono, j. e., & thoresen, c. j. (2002). are measures of self-esteem, neuroticism, locus of control, and generalized self-efficacy indicators of a common core construct? journal of personality and social psychology, 83, 693-710. figure 1. l-mode results for taxonic instructions group. figure 1. l-mode results for taxonic instructions group. judge, t. a., erez, a., bono, j. e., & thoresen, c. j. (2003). the core self-evaluations scale: development of a measure. unpublished manuscript, university of florida. judge, t. a., erez, a., bono, j. e., & thoresen, c. j. (2003). the core self-evaluations scale: development of a measure. unpublished manuscript, university of florida. figure 2. l-mode results for dimensional instructions group. figure 2. l-mode results for dimensional instructions group. -3 -1 0 1 2 3 4 0. 0 0. 2 0. 4 factor scores r el at iv e fr eq ue nc y lmode curve meehl, p. e., & yonce, l. j. (1994). taxometric analysis: i. detecting taxonicity with two quantitative indicators using means above and below a sliding cut (mambac procedure). psychological reports, 74, 1059-1274. meehl, p. e., & yonce, l. j. (1994). taxometric analysis: i. detecting taxonicity with two quantitative indicators using means above and below a sliding cut (mambac procedure). psychological reports, 74, 1059-1274. meehl, p. e., & yonce, l. j. (1996). taxometric analysis: ii. detecting taxonicity using covariance of two quantitative indicators in successive intervals of a third indicator meehl, p. e., & yonce, l. j. (1996). taxometric analysis: ii. detecting taxonicity using covariance of two quantitative indicators in successive intervals of a third indicator 34 taxometrics and response style 35 (maxcov procedure). psychological reports, 78, 1091-1227. rosenberg, m. (1965). society and the adolescent selfimage. princeton, nj: princeton university press. ruscio, j. & ruscio, a. m. (2000). informing the continuity controversy: a taxometric analysis of depression. journal of abnormal psychology, 109, 473-487. skilling, t. a., quinsey, v. l., & craig, w. m. (2001). evidence of a taxon underlying serious antisocial behavior in boys. criminal justice & behavior, 28, 450-470. tylka, t. l., & subich, l. m. (2003). revisiting the latent structure of eating disorders: taxometric analyses with nonbehavioral indicators. journal of counseling psychology, 50, 276-286. waller, n. g., & meehl, p. e. (1998). multivariate taxometric procedures: distinguishing types from continua. thousand oaks, ca: sage publications, inc. a taxometric analysis of experimenter-induced response bias on self-report data participants procedure interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 30 social support and occupational stress among university employees saharay e. cosio old dominion university lynn olson and joseph p. francis regent university the negative impact of occupational stress can be observed both at the microand the macro-level, affecting not only employee quality of life, but also the overall productivity of an organization. this study investigated the role of two protective factors, social support and religiosity, on occupational stress among employees at a private christian university in the southeast. the sample consisted of 72 employees, primarily female (n = 53), caucasian (81%), and married (72%), and with a mean age of 40.4 years. specifically, the study evaluated the relationship between workrelated social support (jcq), nonwork-related social support (isel), and religious coping (rcope) on occupational stress (jcq). a significant inverse relationship was found between work-related social support and occupational stress. the implications of these findings and the limitations of the study are discussed. occupational stress is a concept that has been significantly researched in the past (abdel-halim, 1982; buunk, doosje, jans, & hopstaken, 1993; cummins, 1989). the literature clearly indicates that both physical and mental health is impacted by occupational stress (schirmer & lopez, 2001). several work-related factors that contribute to occupational stress include role overload, role conflict, and role ambiguity (abdel-halim, 1982; beehr, jex, stacy, & murray, 2000; fenlason & beehr, 1994). these factors are considered by individuals as being subjective or objective (curbow, spratt, ungaretti, mcdonnell, & breckler, 2000). according to beehr and colleagues (2000), these occupational stressors lead to strain. most studies on occupational stress have focused on how occupational stress adversely impacts physical strain (beehr et al., 2000), including coronary heart disease (byrne & espnes, 2008; fitzgerald, brown, sonnega, & ewart, 2005; kristensen, 1996; schnall, landsbergis, & baker, 1994; theorell & karasek, 1996), musculoskeletal disorder, diabetes, and cancer (kristensen, 1996; wright, 2007).  in contrast to evaluating physical and psychological consequences of occupational stress, other investigations have evaluated the effects of psychological, behavioral, and social strains on the level of occupational stress, such as depersonalization, job satisfaction, depression, emotional exhaustion, anxiety, boredom, and somatic complaints (abdel-halim, 1982; beehr et al., 2000; cooper & marshall, 1976; cummins, 1989; fenlason & beehr, 1994; schirmer & lopez, 2001). behavioral problems, such as an increase in alcohol consumption and smoking, have also been found among highly stressed employees (bacharach, bamberger, & doveh, 2008; byrne & espnes, 2008; kristensen, 1996; schnall et al.1994). saharay e. cosio, counseling services, old dominion university; lynn olson, regent university; joseph p. francis, school of psychology and counseling, regent university. correspondence concerning this article should be addressed to saharay e. cosio, counseling services, old dominion university, 1526 webb center, norfolk, va 23529. email: scosio@odu.edu. occupational stress may reduce an individual’s effectiveness and work performance (la rocco & jones, 1978). according to wright (2007), stress-related problems constitute approximately 75-90 percent of visits to primary care physicians. furthermore, stress-related problems such as “an array of new organizational structures and processes downsizing, lean production, flat management structures, long working hours and contingent employment,” may contribute to workplace injuries and/or serious health problems (wright, 2007, p.279). importantly, stress-related problems tend to cause negative effects not only on the employees, but also on the overall productivity of an organization (abdel-halim, 1982). for example, occupational stress contributes to an employee’s high absenteeism and turnover rates (beehr et al., 2000; cummins, 1989). data collected from the u.s. bureau of labor statistics showed that employees who are highly stressed or anxious tend to take more time off (wright, 2007). this higher rate of absenteeism among highly stressed individuals may lead to lower rates of productivity for the overall organization. in addition to the higher rates of absenteeism, organizations may pay more for employees’ health care benefits (wright, 2007). this increased expenditure on health care utilization results in approximately a 10% profit reduction for organizations (manning, jackson, & fusilier, 1996). thus, the ramifications of occupational stress are visible at the microlevel (i.e., employees) and macrolevel (i.e., organizations). various approaches and models have been developed with the aim of addressing the negative consequences of occupational stress. one such model is the demand control model (karasek, 1979). demand control model the demand control model (dc), also referred to as the job strain model, is a widely-used two-dimensional model of occupational stress (karasek, 1979; schnall et al., 1994). job demands and decision latitude are the two dimensions that comprise the dc model (karaseck, 1979). job demands are mailto:scosio@odu.edu cosio, olson, & francis 31 defined as “the stressors existing in the work environment” (martin, salanova, & peiro, 2007, p. 622). decision latitude is defined as “the primary measure of the concept of control and is defined as the combination of job decision-making authority and use of skills on the job” (schnall et al., 1994, p. 382). according to this model, decision latitude buffers against the negative effects of job demands (martin et al., 2007). individuals who have low decision latitude (low control) tend to be unable to change the conditions of the environment surrounding them (quick, nelson, quick, & orman, 2001). this lack of control may increase an individual’s vulnerability for occupational stress. numerous studies have used this model to measure an array of physical and psychological outcomes, such as mental strain, job satisfaction, and cardiovascular disease (karasek, 1979; karasek, triantis, & chaudhry, 1982; kristensen, 1995; van der doef & maes, 1999). these studies have generally supported the model and have shown an interaction between job demands and decision latitude. the dc model was later modified by karasek and theorell (1990) to include a third domain, work-related social support. this dimension relates to the emotional and instrumental domains of social support as it pertains to employee’s co-workers and supervisor(s) (rydstedt et al., 2007). according to a study conducted by guillet, hermand, and mullet (2010), of the three domains briefly described above, social support was the main correlate of and inversely related to employee occupational stress. protective factors various studies have been conducted in an attempt to find protective factors for occupational stress (abdel-halim, 1982; beehr et al., 2000; schirmer & lopez, 2001). several protective factors have been identified in the literature, such as locus of control (brunborg, 2008; cummins, 1989), selfefficacy (brunborg, 2008), attachment styles (schirmer & lopez, 2001), religion (somech & miassy-maljak, 2003), and social support (beehr et al., 1990; brunborg, 2008; cummins, 1989; schirmer & lopez, 2001). the present study looked at two of these protective factors: religion and social support. religion. religion, specifically religious coping, has been found to be a protective factor against occupational stress (beehr, johnson, & nieva, 1995; safaria, othman, & wahab, 2010). safaria et al. (2010) define religious coping as “the extent to which persons use their religious beliefs and practices to facilitate problem solving to prevent or alleviate the negative emotional effects of stressful circumstances” (p. 161). religious coping is a multifaceted construct that has been operationally defined in various ways. one way it has been defined is through religious behaviors, such as frequency of prayer, church attendance and scripture reading (frabricatore, handal, rubio, & gilner, 2004). other religious coping methods that have been examined in the literature include forgiveness (worthington, witvliet, pietrini, & miller, 2007) and spiritual support (krause, ellison, shaw, marcum, & boardman, 2001). the literature generally indicates that religion aids in how individuals appraise and process negative and stressful situations (safaria et al., 2010; somech & miassy-maljak, 2003). religion helps people process information in a way that induces “meaning and solutions when faced with unfavorable circumstances” (somech & miassy-maljak, 2003, p. 82). this meaning making helps an individual create a sense of optimism and hope (safaria et al., 2010). moreover, an individual’s religious values helps in forming effective coping strategies and solutions to his or her job stress by helping to “interpret the meaning of potentially threatening events” (somech & miassy-maljak, 2003, p. 85). according to a study conducted by krause et al. (2001) “positive support [also helps] increases positive religious coping responses” (p. 653). these positive religious coping responses have shown to decrease psychological distress (pargament, smith, koenig, & perez, 1998). the literature also suggests that negative religious coping styles can negatively contribute to an individual’s emotional, psychological and physical well being (pargament et al., 1998). overall, studies show that individuals who are able to make meaning out of their lives have better psychological well-being (park, 2007). currently, few studies in the literature have examined work and occupational stress among those who work in religious settings. this study looked at positive religious coping styles as a protective factor among individuals working in a religious setting. social support. there have been many inconsistencies within the literature regarding the relationship between social support and occupational stress and whether or not social support can be deemed a protective factor of occupational stress. part of these inconsistencies is due to the broad construct and the multifaceted factors of social support. social support has been conceptualized in various ways (i.e., components, forms, or sources) (see beehr et al., 1990). for this particular study, social support was operationalized using the different sources of social support, such as co-worker social support, supervisory social-support, and general social support. the two main sources that are widely investigated include co-worker social support and supervisory social support. cieslak and colleagues (2007) evidenced that supervisory social support tends to be more beneficial in buffering against occupational stress, corroborating a previous study conducted by cummins (1989). hypothesis occupational stress continues to be a rising concern in today’s society as it significantly impacts individuals within the work setting (wright, 2007). in addition, macroeconomic changes affect employees’ levels of occupational stress as marketplace stressors may lead to changes in the organization (i.e., increased job demands, job insecurity, or less decision latitude among employees) and generate concerns for employees (fenwick & tausig, 1994). according to fenwick and tausig (1994), for example, an employees’ perception of job insecurity may be altered by unemployment rates. social support and occupational stress 32 because today’s economic downturn results in economic changes both within the organizational structure and employees’ work roles (fenwick & tausig, 1994), finding protective factors to help buffer occupational stress is imperative. this is especially true because higher unemployment rates and employees’ inability to resist an organizational restructuring may increase employees’ level of job stress (fenwick & tausig, 1994). the aim of this study was to investigate how social support and religious coping relate to occupational stress among university employees. using the dc model as a framework, we hypothesized that occupational stress would be predicted by work-related social support, nonwork-related social support, and the religious coping styles of benevolent religious appraisal/spiritual support and religious focus. more specifically, we hypothesized that as the positive coping styles (work-related social support and nonwork-related social support) and religious coping styles increases, occupational stress would decrease. method this study used archival data from a previous study. the data set that was used came from survey packets completed by participants in a university fitness for life program, directed by the human resource department. of the 128 survey packets returned, only the packets that were fully completed were included in the current study (n = 72). the surveys that were used from this data set included the demographic questionnaire, the rcope, the interpersonal support evaluation list (isel), and the job content questionnaire (jcq). these measures have been used in previous studies that address the issue of occupational stress, social support and/or religious coping styles (cohen & hoberman, 1983; karasek, 1985; pargament et al., 2000). the rcope was used to assess positive religious coping styles, the isel was used to assess general social support and the jcq was used in this study because it was constructed based on the dc model and served as the framework for this study. participants participants for this study were employees at a private christian university in a major city in the state of virginia. as indicated in table 1, the mean age of the sample was 40.40 years (sd = 12.01), with a range of 24 to 66 years. of the 72 participants, 53 were women, 18 were men, and one participant did not respond. more than half of the participants reported being caucasian (81%), the majority reported being married (72%), and the majority reported a graduate level education. fifty seven percent of the participants reported previously participating in the fitness for life program. furthermore, the majority of the participants reported being staff (81%). measures demographic information. the demographic questionnaire consisted of items related to the participants’ general demographics. items included questions regarding the participants: age, gender, race, level of education, job title, and marital status. rcope. the rcope (pargament et al., 2000) is a theoretically based measure of five key functions that religion serves: meaning, control, comfort/spirituality, intimacy/spirituality, and life transformation. the rcope is a 105-item questionnaire that is rated on a 4-point likert scale ranging from 0 (not at all) to 3 (a great deal). it provides scores for 17 distinct subscales: 10 subscales measure positive religious coping and 7 subscales negative. in this study, we were interested in assessing the impact of religious beliefs and the use of spiritual cognitive reframing on occupational stress. we, therefore, focused on two subscales: benevolent religious reappraisal/spiritual support and religious focus. the benevolent religious reappraisal/spiritual support subscale assesses how individuals redefine the stressor through religion as benevolent and potentially beneficial. an example of an item on this subscale is “tried to see how god might be trying to strengthen me in this situation.” the religious focus subscale assesses how individuals engage in religious activities to shift the focus from the stressor. an example of an item on this subscale is “focused on religion to stop worry about my problems.” internal consistency assessment yielded a cronbach’s alpha of .8 for most subscales. for this study, the cronbach’s alpha for the total rcope was .94, for benevolent religious reappraisal/spiritual support was .86, and for religious focus was .71. construct validity has been table 1 demographics of participants characteristics n % race (n = 71) african american hispanic white other 3 2 59 7 4.2 2.8 81.0 9.7 marital status (n = 71) single married divorced widowed 14 52 3 2 19.4 72.2 4.2 2.8 level of education (n = 70) high school junior college college graduate 3 9 19 39 4.3 12.9 27.1 55.7 job title (n = 72) staff faculty 58 14 80.6 19.4 cosio, olson, & francis 33 assessed across population samples (i.e., factor structure) and measures of general adjustment (i.e., incremental validity) with good results. interpersonal support evaluation list. the interpersonal support evaluation list (isel; cohen & hoberman, 1983) provides a global measure of perceived social support across four subscales: tangible, appraisal, selfesteem, and belonging. the tangible subscale measures perceived availability of material aid, the appraisal subscale measures the perceived availability of someone to talk to about one’s problems, the self-esteem subscale measures the perceived availability of positive comparison when comparing ones’ self with others, and the belonging subscale measures the perceived availability of people one can do things with (cohen & hoberman, 1983). the isel consists of 40 items that are counterbalanced and rated on a 4-point likert scale. participants are asked to rate statements such as “when i feel lonely, there are several people i can talk to” using a format ranging from 0 (definitely false) to 3 (definitely true). retest reliability for the full measure has been reported as .87, and the retest reliability for the subscales ranges between .71 and .87 (cohen & hoberman, 1983). for this study, the cronbach’s alpha (α) for the isel was .99, which is considered excellent internal consistency. job content questionnaire. the job content questionnaire (jcq; karasek, 1985) is a 49-item scale that measures the social and psychological characteristics of jobs across four scales: decision latitude, psychological demand, supervisor support, and coworker support. in addition, the decision latitude scale comprises of two subscales; decision authority and skill discretion. the jcq is based on the demand control support model, the occupational stress model developed by karasek and theorell (1990). using a 4-point likert type response format ranging from 1 (strongly disagree) to 4 (strongly agree), participants rate statements such as “my job requires a lot of physical effort.” the alpha coefficient for this measure is acceptable (α =.74); in this study, the cronbach’s alpha was acceptable for both supervisory support and coworker support scales (α =.78 and α =.80, respectively). procedure the questionnaires from the data set were collected using self-administered paper-and-pencil questionnaires. the completed packet took approximately 45 to 60 minutes to complete. participation was voluntary and controlled for individuals who espouse christian faiths and work for a christian university, by only using completed packets from the participants that met these two criteria. each participant was given a coded packet that was counterbalanced to avoid ordering effects. the packets contained the following information: a onepage cover letter, a one-page instruction form, a consent form, the rcope, the isel, and the jcq. the cover letter explained the purpose of the study and requested participation. in the letter participants were assured of anonymity and were told that they could decline participation at any time without being penalized. in addition, they were provided with the researchers contact information in case they had any questions after the study. to ensure anonymity, a list of the participants’ names managed by the department of human resources was separated from the de-identified completed coded packets that were collected by the researchers. to further ensure the participants’ anonymity, they were not required to turn in their consent form. the participants were given 2 weeks to complete the packet if they decided to participate. the completed packet was turned into the human resources department. statistical analysis analysis of the participants’ demographic questionnaire was conducted to assess for any confounding variables that might impact the data. these variables were then noted and discarded if deemed appropriate to the study. to test the hypothesis that occupational stress would decrease as the positive coping styles (work-related and nonwork-related social support) and religious coping styles increase, we conducted two multiple regression analyses: work-related social support, nonwork-related social support, and religious coping styles were entered as the predictor variables and occupational stress as the dependent variable. the first regression model included the global score of work-related social support; the second regression model included the two categories of work-related social support: supervisory social support and coworker support. it was not possible to enter the work-related social support global scores and category scores in one regression model because it violated the assumption of multicollinearity in regression analysis. this violation was indicated by the tolerance level being less than .20 (garson, 2009). results the first multiple regression analysis tested the hypothesis that occupational stress would be predicted by work-related social support (i.e., the global score), nonworkrelated social support, and two styles of religious coping (benevolent religious appraisal/spiritual support and religious focus). the regression model was significant, f(4, 67) = 3.62, p < .05, accounting for more than 17% of the variance in occupational stress. employees’ work-related social support, nonwork-related social support, and benevolent religious appraisal/spiritual support and religious focus jointly and significantly predicted occupational stress (see table 2). as indicated by the squared semipartial correlation, workrelated social support better predicted the outcome variable than nonwork-related social support and religious coping style. work-related social support accounted for 13% of unique variance in occupational stress. the negative regression coefficient indicates that the likelihood of occupational stress decreases with an increase in work-related social support. social support and occupational stress 34 the second multiple regression analysis tested the hypothesis that occupational stress would be predicted by two categories of work-related social support (supervisory social support and coworker social support), nonwork-related social support, and two styles of religious coping (benevolent religious appraisal/spiritual support and religious focus). the regression model was significant, f(5, 66) = 3.00, p < .05, accounting for more than 18% of the variance in occupational stress. employees’ supervisory social support, coworker social support, nonwork-related social support, benevolent religious appraisal/spiritual support, and religious focus jointly and significantly predicted occupational stress (see table 3). supervisory social support was the only significant predictor and accounted for 8% of unique variance in occupational stress. the negative regression coefficient indicates that the likelihood of occupational stress decreases with an increase in supervisory social support. discussion the purpose of this study was to investigate the topic of occupational stress, work-related social support, nonworkrelated social support, and religious coping styles among university employees. occupational stress adversely affects an individual’s overall well-being (schirmer & lopez, 2001). protective factors, such as social support and religious coping, have been shown to buffer occupational stress (beehr et al., 1990; brunborg, 2008; cummins, 1989; schirmer & lopez, 2001; somech & miassy-maljak, 2003). this study examined whether there was a predictive relationship between social support, religious coping, and occupational stress. it was hypothesized that occupational stress would be predicted by work-related social support, nonwork-related social support, and religious coping styles: benevolent religious appraisal/spiritual support and religious focus. the results of this study indicated that work-related social support tends to contribute more to the decrease of occupational stress than nonwork-related social support. these results replicate other findings suggesting that employees may benefit more from work-related support than they do from nonwork-related social support when it comes to decreasing occupational stress (cummins, 1989). this study is also corroborates the dc model. the literature has shown that, within the dc model, work-related social support is seen as the primary buffer to an employee’s level of occupational stress compared to the other two dimensions. furthermore, within the workrelated social support variable, the results of this study indicated that supervisory social support tended to contribute more to the decrease of occupational stress when compared with coworker social support. these results are consistent with findings from other studies (cieslak et al., 2007; cummins, 1989). a possible explanation for the results found in this study may be attributed to the type of social support that supervisors are using. studies have indicated that social support is made up of four components: emotional/psychological support, instrumental/active support, informational support, and appraisal support (abdel-halim, 1982; fenlason & beehr, 1994; wheeler & larocco, 2009). wheeler and larocco (2009) suggest that co-worker social support tends to “provide emotional and informational support and that work supervisors most often provide instrumental and appraisal support” (p. 90). according to a study conducted by wong, cheuk, and rosen (2000) emotional support was not effective in alleviating occupational stress. alternatively, instrumental support was table 2 multiple regression of global work-related social support, nonwork-related social support, and religious coping styles on occupational stress variables occupational stress (dv) zero-order correlation zero-order correlation b β sr² 1 2 3 4 work-related social support -.375*** -.229 .020 .025 -.025** -.368 .13 nonwork-related social support .094 -.229 -.277 -.235 .017 .047 .00 benevolent religious appraisal .028 .020 -.277 .429 -.001 -.043 .00 religious focus .173 .025 -.235 .429 .013 .211 .04 means (sd) .94 (.19) 27.21 (2.80) 1.36 (.55) 19.06 (5.61) 5.86 (3.06) r² = .13 adjusted r² = .18 r = .42 note. 1 = work-related social support; 2 = nonwork-related social support; 3 = benevolent religious appraisal; 4 = religious focus. r² = the proportion of the variance in occupational stress which is accounted for by the predictor variables; adjusted r² = how much the model accounts for the variance in occupational stress; r = correlation between occupational stress and predictors variables. **p < .01 *** p < .001. cosio, olson, & francis 35 seen as effective in alleviating occupational stress (wong et al., 2000). although participants were obtained from a religious private institution, religious coping styles did not seem to provide a statistically significant buffer against occupational stress. the two religious coping styles that were used in this study were benevolent religious reappraisal/spiritual support and religious focus. the results suggest that employees may be using problem-focused versus emotion-focused coping (beehr et al., 1995). according to beehr et al. (1995), problem-focused coping activities tend to be more effective. thus, employees who are experiencing stress within the work place may gravitate towards a more problem-focused coping style. in our investigation of religious coping styles, participants endorsed benevolent religious reappraisal at a slightly higher rate than religious focus. benevolent reappraisal tends to be more of a problem-focused coping style while religious focus is an emotion-focused coping style. hence, other problem-focused coping strategies may have been preferred by the participants that were more specific to the nature of their work-related stressors. the type of coping style used by individuals tends to vary according to the stressor and the resources the individual brings to the situation (i.e., self-efficacy, locus of control, attachment style). although the participants were obtained from a private religious institution, religion is not the only coping style that individuals may use. furthermore, the two religious coping styles that were assessed in this study are not the only religious coping styles. there are many different ways that individuals may use religion to cope. in this study, only two of pargament’s 17 religious coping styles were assessed; participants may prefer another style of religious coping that was not directly assessed by this study. in conclusion, the results of this study indicate that supervisory social support makes the strongest predictor of occupational stress when compared to coworker social support, nonwork-related social support, and the religious coping styles of benevolent religious appraisal and religious focus. thus, the likelihood of occupational stress decreases with an increase in supervisory social support. implications occupational stress has shown to affect an individual physically as well as psychologically. however, protective factors such as social support and religious coping styles may help buffer occupational stress. hence, with the implementation of proper protective factors these negative outcomes of occupational stress will hopefully be moderated. organizations may want to consider instituting preventative practices to assure that an individual’s physical and psychological well-being is not being negatively affected by occupational stress. preventative practices that organizations may want to consider include providing employees with educational trainings aimed at reducing the employees’ level of stress. topics that could be considered for training include: communication and listening skills, developing better self-care strategies, and effective problemsolving skills (wright, 2007). this proactive approach from an organization may help relieve employees’ risk of occupational stress, which may in turn decrease absenteeism, table 3 multiple regression of supervisory social support, coworker social support, nonwork-related social support, and religious coping styles on occupational stress variables occupational stress (dv) zero-order correlation zero-order correlation b β sr² 1 2 3 4 5 supervisory support -.348*** -.256 -.163 -.025 .059 -.033** -.310 .08 co-worker support -.256** .319 -.212 .061 -.022 -.016 -.139 .01 nonworkrelated social support .094 -.163 -.212 -.277 -.235 .018 .051 .00 benevolent religious appraisal .028 -.025 .061 -.277 .429 -.002 -.053 .00 religious focus .173 .059 -.022 -.235 .429 .014 .223 .02 means (sd) .93 (.19) 13.79 (1.8) 13.42 (1.65) 1.36 (.55) 19.06 (5.61) 5.86 (3.06) r² = .12 adjusted r² = .19 r = .43 note. 1 = supervisory support; 2 = co-worker support; 3 = nonwork-related social support; 4 = benevolent religious appraisal; 5 = religious focus. r² = the proportion of the variance in occupational stress which is accounted for by the predictor variables; adjusted r² = how much the model accounts for the variance in occupational stress; r = correlation between predictor variables and occupational stress. **p < .01 *** p < .001. social support and occupational stress 36 turnover rates, and increase overall productivity. therefore, with a reduction of stress levels through the implementation of specific stress management interventions and more attentiveness to the needs of their employees, organizations will be able to reduce the cost of health insurance among employees. one specific intervention that organizations may want to consider is the relationship between employees and their supervisor. importantly, studies indicate that supervisory support tends to be a key contributor to decreasing occupational stress. the literature on supervisory support has looked at the benefits that supervisory trainings can contribute to the overall well being of their employees. for example, some studies have looked at the effect of active listening training for supervisors on employees’ level of stress. specifically, these studies have shown that active listening helps improve interpersonal relationships, enhances social support, and aids in reducing an employees’ level of stress (kubota, mishima, & nagata, 20014). another, intervention that has been addressed in the literature has been that of coaching (wright, 2007). according to wright (2007) coaching as an intervention can aid “…with better matches of employees and their jobs, with improving employee retention and productivity, with better transition times in organizational change, and can lead to decreased stress and morale” (p. 282). hence, proper supervisory training may be warranted to ensure that employees are obtaining the proper supervisory support and help in reducing occupational stress. limitations due to the correlational nature of the study a causal relationship among the variables was not established. other limitations of the study include methodological, sampling, operational, and measurement challenges. the issue of using a self-administered questionnaire is a limitation as it increases the chances of creating a nonresponse bias (abdel-halim, 1982). therefore, although self-administered questionnaires may help protect a participant’s anonymity it creates a disadvantage because individuals who return the questionnaires may be different from those who chose not to participate in the study, thus creating a bias sample. due to the nature of the design and the sample used in this study, results will have limited generalizeability. furthermore, the limited number of participants may have precluded the ability to identify an interaction effect among the two variables being analyzed: social support and occupational stress. due to the complexity of the constructs involved, operational issues are another limitation. the literature has been unable to clearly and accurately find an operational definition for the constructs of social support and occupational stress. there are many different components that comprise the construct of social support. various researchers have used different components of the constructs in operationally defining social support, making it difficult to systematically compare and contrast the studies. a final limitation was our utilization of global measures instead of measures specific to the occupation being studied. use of global versus specific measures of support may have diluted the potential impact of social support and coping on occupational stress. future directions as this topic continues to be of interest in the field of psychology as well as other diverse disciplines, various recommendations for future direction are suggested. first, it is recommended that better measures or clearer definitions be developed for both social support and occupational stress; 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(2007). stress in the workplace: a coaching approach. journal of prevention, assessment & rehabilitation, 28, 279-284. microsoft word vol10_donovickrodrig#2af7dc.doc 52 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 parenting practices among first generation spanish-speaking latino families: a spanish version of the alabama parenting questionnaire melissa r. donovick utah state university melanie m. domenech rodríguez utah state university the present study examined the applicability of the alabama parenting questionnaire to a spanishspeaking latino population. results of the reliability and concurrent validity testing suggest that the alabama parenting questionnaire may be a valuable tool for use with spanish-speaking latino families. the alabama parenting questionnaire in spanish assessed parenting practices among 50 first-generation spanish-speaking latino families of primarily mexican origin with a child between 4 and 9 years of age (n = 96 parents, n = 50 children). mothers and fathers completed questionnaires in spanish to assess parent and child behaviors. results show that over 80% of parents included in the sample endorsed high levels of monitoring; they also reported using physical affection as a way to praise their child and frequent engagement in conversation with their children about school activities. few parents used time-out or ignoring as methods of discipline, and very few reported using corporal punishment. parental involvement, positive parenting, and monitoring significantly predicted externalizing and total behavioral problems among latino children. the parent-child relationship is critical to early socialization and the development of the child’s social system. the u.s. is becoming increasingly multicultural and has experienced a recent growth in the latino population. a recent report indicated that over the past three decades, the latino population has become the largest ethnic minority population, comprising 12.5% of the population in the united states of america (takeuchi, alegría, jackson, & williams, 2007). yet, there are few empirically supported culturally appropriate parenting intervention and prevention programs available to serve the mental health needs of latino populations. furthermore, the theoretical frameworks that guide parenting theories are based on empirical data on white families. there is a growing literature supporting cultural adaptations of interventions, which involve taking into account cultural values so that the intervention is relevant, easily understood, and feasible to implement (domenech rodríguez & wieling, 2004; lau, 2006). cultural adaptations can include changes in the structure, process, and language of the intervention (bernal, bellido, & bonilla, 1995). a recent meta-analysis shows that culturally adapted interventions are significantly more effective than non-adapted ones (griner & lambert, 2006). surprisingly, however, little is known about the specific cultural values, beliefs, and parenting practices of latino families this research was supported by nimh grant ko1-mh066297 and utah state university new faculty grant to the second author. correspondence to: melissa donovick, 2810 old main hill, logan, ut 84321. email: melissa.d@aggiemail.usu.edu (hill, bush, & roosa, 2003), which may be used to reliably and consistently make culturally appropriate adaptations to interventions. therefore, further research is needed to examine common parenting practices among latino families and to better understand their relationship to child outcomes among latino families. this examination can contribute to the development and implementation of culturally appropriate parenting programs. it is essential that mental and health care providers gain a better understanding of parenting among latino families for both research and clinical purposes, and most importantly to better serve the mental health needs of the growing latino population. the current study examines parenting practices and their relation to child outcomes among first generation spanishspeaking latino families of primarily mexican origin. the parenting practices are examined using the alabama parenting questionnaire based on the social interaction learning theory framework in an effort to provide basic reliability data and examine its applicability to latino families. social interaction learning theory social interaction learning (sil) states that individuals influence each other in the transactions of everyday life, mainly through modeling, punishments, and rewards that comprise social interaction (patterson, 1982). forgatch and martinez (1999) describe the social interaction learning model as the process in which parents directly influence their child’s development by means of parental practices and indirectly by contextual factors that surround the famlatino parenting 53 ily environment. sil incorporates social interaction and social learning theories, and conceptualizes the parent and child relationship from one integrated approach that can be understood by examining the two contributing theories. first, sil, also known as coercion theory, describes the negative parent-child interaction processes that lead to negative outcomes for the child. for example, a parent may use nagging, scolding, and yelling in response to the child’s misbehavior, and the child responds by continuing to misbehave with increased aggression. the parent eventually concedes and does not follow through with disciplining the child. the child thus learns that she can get what she wants by not minding her parent. coercion theory posits that negative parent-child processes are learned over repeated trials and become over-learned (dishion, patterson, & kavanagh, 1992). these negative interactions escalate over time as the result of (negative) reinforcement from previous trials, creating a coercive pattern that becomes automatic. coercion theory places child conduct problems in the context of the parent-child relationship, thus underscoring the importance of parenting processes (dadds, maujean, & fraser, 2003). the second component to the sil theory is the social learning perspective, which states that behavior is regulated by consequences one anticipates for performing the behavior (bandura, 1965). when applied to parenting, the social learning perspective explains how parent-child interaction patterns are maintained over time and function within family systems (forgatch & bank, 2002). positive parenting practices stem from this theoretical framework, and are those that have been found to be related to positive child outcomes. according to sil theory, there are five core positive parenting practices: positive involvement, monitoring, effective discipline, problem solving, and skills encouragement. to successfully change the problem behavior of a child, one must change how the social environment reacts to the child (reid, patterson, & snyder, 2002), ideally increasing the positive parent-child interactions, while decreasing the coercive interactions to create a “balance” of five positive parent-child interactions for every negative one. the third component to the sil theory involves contextualizing parenting processes. the sil theory provides an integrated view of the parent-child interaction that takes into account the context in which that relationship is embedded. sil stresses the importance of contextual factors such as culture, family transitions, socioeconomic status, stress, social support, and neighborhood as influences on child behavior. according to the theory, the contextual variables exert their influence upon parents, whose parenting then impacts the child. for example, a parent who has recently lost her job may feel extremely stressed and concerned about the financial impact of her loss for her family; her distress may lead to poor choices in parenting (e.g., yelling instead of giving a good direction). this mediational model has been supported empirically (forgatch & bank, 2002). the five core positive parenting practices are related and the skills used to build one, also build others. positive involvement involves doing pleasant things together as a family and providing positive parental attention. monitoring refers to knowing where the child is, with whom, and what the child is doing. effective discipline refers to developmentally appropriate rule setting with mild consequences for violations; consistency and immediacy are critical to effective discipline. problem solving incorporates skills that parents use to resolve family disagreements, negotiate rules, and establish positive and negative consequences for behavior. finally, skills encouragement refers to parents’ success in promoting children’s desired behaviors through positive reinforcement. the core parenting practices outlined above have been integrated into a parent management intervention which has been effective in reducing problem behaviors in white families and children (kazdin &weisz, 1998). culture and the social interaction learning model the focus on context is a strength of the social interaction learning model. culture is one larger context in which parent-child learning processes takes place. cultural values and beliefs have been shown to play a role in the way parents socialize their children (harwood, scholmerich, schulze, & gonzalez, 1999; zayas, 1992). researchers have suggested that the socialization goals of a cultural group influence parenting cognitions and practices (bronstein & cote, 2003). therefore, it is possible that latino parents socialize their children differently than white children. normative parenting practices and optimal child outcomes for white children may not generalize to latino families. few studies to date have included the role of culture in parenting and even fewer studies have examined parenting practices among latino families. the remaining challenge is to apply the sil model of parenting to other cultures, and examine the core parenting practices (i.e., skills encouragement, effective discipline, monitoring, problem solving, and positive involvement) and their relationship to child outcomes among latino families. this knowledge will enable the development of culturally appropriate intervention and prevention methods for latino families. latinos and parenting some research suggests that latina mothers’ parenting practices are different than white mothers’ and reflect latina cultural values (e.g., harwood, 1992). harwood’s findings in the area of infant attachment provide evidence that latina mothers perceive and interpret infant behavior differently than white mothers. more specifically, harwood’s study finds that puerto rican mothers are more likely to control and structure the parent-child interaction as compared to white mothers. the higher structure and control is a caregiving activity thought to be in line with donovick & domenech rodríguez 54 puerto rican cultural values of proper demeanor and interdependence (harwood, 1992). very few studies have examined the sil five core parenting practices among latino families. however, research in the area of child development among latino families has provided information for similar parenting constructs. some studies have described latino parenting as more authoritarian (knight, virdin, & roosa, 1994), controlling, and relying on physical punishment (gutierrez, sameroff, & karrer, 1988), when compared to white families. alternatively, escovar and lazarus (1982) found that latino parents expressed high levels of open verbal and physical expressions of affection and nurturance. finkelstein, donenberg, and martinovich (2001) described latino parents as more permissive, as compared to white middle class and african american parents. yet another study suggested that latino families are not overwhelmingly authoritarian, as portrayed in past research findings and the media. instead, latino fathers were found to be warm and responsive and exerted minimal to low amounts of control (staples & miranda, 1980). more recently, an observational study to examine latino parenting styles with 4 to 9 year old children found uniformly high levels of warmth among both mothers and fathers regardless of the child’s gender (domenech rodríguez, donovick, & crowley, 2008). however, levels of autonomy-granting and demandingness varied across gender, with parents of girls exhibiting lower autonomy-granting and higher demandingness than boys. these authors found that, when all three parenting dimensions are taken into account, latino parents do not fit neatly into the mainstream categories of permissive, neglectful, authoritative, or authoritarian. it is clear that findings regarding a comprehensive characterization of latino parenting are inconsistent and fail to reach agreement at this time. the purpose of the current study is to examine parenting practices among first generation spanish-speaking latino families of primarily mexican origin, in an effort to determine common parenting practices and report basic validity data on the spanish version of the apq. we also examine the relationship between self-reported parenting practices and child outcomes among primarily mexican origin spanish-speaking latino families. method participants fifty spanish-speaking latino families of mexican origin (83%) or other latin american countries (e.g., columbia, el salvador; 17%) were recruited from a rural community in the western united states. intact families (two biological parents), single parent, and stepparent families with at least one child between 4 and 9 years of age participated in the study. if a family had more than one child between the ages of 4 and 9, then the parent had the option to select which child to focus on for the study. of the total sample, 44 families (88%) were two-parent intact families, two (4%) were two-parent stepfamilies, and four (8%) were single parents with three single mothers and one single father. a total of 47 fathers and 49 mothers participated in the study. the average age of children who participated in the study was 7 years old. thirty (60%) children were female. all parents were first generation latinos (i.e., foreign-born). although language ability was not assessed formally, nearly all parents reported to be primarily spanish-speaking with a few parents demonstrating minimal bilingual (spanish/english) skills. most families (96%) reported a yearly income of $19,000-$35,000, and about 4% reported earning more than $35,000. based on the acculturation rating scale for mexican americans (arsmaii; cuellar, arnold, & maldonado, 1995), most of the participants (80%) were categorized as traditional or separated, meaning that they retained their culture of origin and reported not being particularly integrated into mainstream american culture. some participants (18%) were bicultural (i.e., similar degree of functioning in culture-of-origin and mainstream culture) with two participants (1%) indicating assimilated or marginalized status. procedure the research study described here is part of a larger study to culturally adapt a parenting intervention for spanish-speaking latino families. as part of the protocol, parents completed a variety of self-report questionnaires on demographic characteristics, developmental expectations, parenting practices, and child outcomes during a single appointment at a university laboratory. although all measures were available in spanish and english, all participants chose to complete all measures in spanish. the questionnaires used that are relevant to this study are the alabama parenting questionnaire (apq) and the child behavior checklist (cbcl). the sample was recruited through local churches, announcements at schools and community parent support groups, flyers placed throughout the community, personal face-to face recruitment by bicultural research assistants, and word of mouth by participants. media outreach was also utilized, including a radio advertisement on a local station during spanish-language programming and a web posting. visiting latino neighborhoods, door to door solicitation, and utilization of personal networks have proven to be successful in recruiting latino families into research studies (harachi, catalano, & hawkins, 1997). however, for this study, word-of-mouth was the most powerful recruitment method with 46% (n = 23) of participants enrolling in the study after being approached by a friend or relative (domenech rodríguez, rodriguez & davis, 2006). interested families made initial contact with a bicultural, bilingual researcher via telephone. participants were informed of the study procedures, duration, location, and incentives. families were included in the study that had parents who were spanish-speaking, and had at least one latino parenting 55 child between the ages of 4 and 9. special efforts were made to ensure cultural sensitivity during the research study. for example, appointments were arranged at the convenience of the family members, including evening and weekend appointments. childcare was provided for families and, when needed, transportation was also provided. bilingual, bicultural staff was present for all research assessment procedures. the data collection visit lasted about 1.5 hrs. a brief introduction to the protocol was provided, first showing parents the room where data would be collected and where the target child would remain for child care (during survey data collection). informed consent was read to participants if they desired; otherwise, participants were given time to read through the informed consent and ask any questions. special emphasis was made to assure participants that sensitive information would be kept confidential. information regarding legal status was not obtained to avoid any data collection activities that might cause a distressing environment. we know anecdotally, however, that most of the families were undocumented. families were paid for their participation, $25 per parent and a small gift ($5 or under) for the child. this amount equals about $10 per hour for participation, which is consistent with payment in similar studies. measures socioeconomic variables. socioeconomic and demographic information were obtained from a self-report questionnaire. the inventory assessed age, household annual income, marital status, postal code, educational status, and number of persons and children currently living in the household. acculturation. level of acculturation was assessed using cuellar, arnold, and maldonado’s (1995) acculturation rating scale for mexican americans-ii (arsma-ii). this 30 item, self-report, 5-point likert scale assesses for level of acculturation status with scores indicating two orientation scores, mexican and anglo, which are then used to determine acculturation status: integrated, separated, assimilated, and marginalized. the spanish version of the arsma-ii was administered. the arsma-ii in spanish has good internal reliabilities for both the mexican orientation scale (cronbach alpha = .88) and the anglo orientation scale (cronbach alpha = .86). the arsma-ii in spanish also shows good test-retest reliability (.96) and good concurrent validity with the original arsma in spanish (.89; cuellar et al., 1995). the arasma-ii in spanish is appropriate for use with other latino populations (schwartz, zamboanga, & jarvis, 2007). consistent with schwartz et al.’s research, participants were instructed to substitute the name of their country of origin where the form indicated mexico. alabama parenting questionnaire (apq). the apq is a self-report measure assessing the five core parenting processes of sil theory that are conceptualized to be important parental practices related to child outcomes: involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, and corporal punishment. this measure was developed using the oregon social learning center (oslc) parent management training system and sil theory, and includes questions on discipline practices (shelton, frick, & wooton, 1996). the apq has 42 items, which are answered on a likert scale ranging from 1 (never) to 5 (always). the apq demonstrated good psychometric properties in the original scale development (shelton et al., 1996). internal consistency reliability alphas for the involvement scale (.80) and the positive parenting (.80) scales were strongest. poor supervision/monitoring (.67) and inconsistent discipline (.67) had marginally acceptable reliabilities. the corporal punishment (.46) did not yield an acceptable reliability. the reliability coefficients of the normative sample suggest that the apq’s most reliable subscales are the involvement and positive parenting sub scales. the normative sample did not respond consistently to the poor supervision/monitoring and inconsistent discipline subscales, and the corporal punishment scale did not reach adequate levels of internal consistency reliability. the low reliability coefficient of the corporal punishment scale is most likely due to the limited number of items included in the scale (n = 3), and the normative sample demonstrated limited range of responses (shelton, frick, & wooton, 1996). the normative sample was based on a clinically referred and community sample in the united states, and we predicted that given that our sample consists of a community sample, we may find similar reliability coefficients. the apq was well suited for research in the current study because the apq has previously shown good psychometric properties both within the u.s. and internationally with parents of children between the ages of 4-10 (dadds, maujean, & fraser, 2003; dhaule, bhagat, & thakkar, 2005; hawes & dadds, 2006). the apq was not available in spanish. the measure was translated using back translation and a bilingual committee (marin & marin, 1991). measures were first translated into spanish, then back-translated into english by an independent translator unfamiliar with the measure. finally, differences were resolved through a bilingual committee. equivalence and conceptual understanding was examined and resolved. a complete list of the translated items is found in the appendix at the end of this article. the items are rated on a five point scale from never to always. in spanish, the anchors are nunca (never), no mucho (not so much), algunas veces (sometimes), frecuentemente (frequently), and siempre (always). child behavior checklist (cbcl). childhood behavioral problems were assessed using achenbach and rescorla’s (2000) child behavior checklist. the cbcl has two forms, one for children ages 1.5 to 5 years old, and another for children ages 6 to18 years old. this is a selfreport measure that is completed by parents or caregivers to assess behavioral, emotional, and social functioning (for children 1.5 to 18 years old) and competence (for children donovick & domenech rodríguez 56 6 to 18 years old). the cbcl is available in english and spanish. the spanish version was administered to participants. the cbcl generates scores representing two broad groupings of symptoms. one grouping is the internalizing domain, which consists of symptoms of anxiety and depression, somatic complaints, and withdrawal. for children 1.5 to 5, emotional reactivity is also assessed in the internalizing domain. the second grouping is the externalizing domain, which consists of attention problems and aggressive behavior. a total problem score can also be derived, and is an indication of the total sum of scores on the 99 specific problem behavior items of the cbcl. scores can range from 0 to 200. the cbcl for ages 1.5 to 5 years old shows excellent test-retest alpha reliabilities for the internalizing scale (.90) externalizing (.87) and total problems (.90). the cbcl for children ages 6-18 years old also has good psychometric properties, with excellent test-retest alpha reliabilities for the internalizing (.91), externalizing (.92) and total problems (.94) scales. the cbcl has been standardized and normed utilizing a sample that included latino children. the cbcl also possesses adequate construct, content, and criterion-related validity (achenbach & rescorla, 2000). the cbcl in spanish also demonstrated excellent test-retest alpha reliabilities for the internalizing scale (.90) externalizing scale (.94) and total problems (.97) (gallo, muñoz, vargas, cardenas, perez, & villanueva, 2005). results the purpose of this study was to describe common parenting practices of first generation spanish-speaking latino families with a child between the ages of 4 and 9 years old, and report basic reliability data for the spanish version of the apq. additionally, we examined the relationship between self-reported parenting practices and child outcomes. an analysis of frequencies was used to determine common parenting practices. alpha coefficient estimates were calculated to determine basic apq reliability data. regression analyses were preformed to examine the relationship between self-reported parenting practices and child outcomes. common parenting practices common parenting practices were calculated by examining the response pattern to each apq individual item. those items that participants endorsed as occurring “always” and “frequently” – and on the reversed scored items, those that participants endorsed as “never” and not “so much” – by 80% of the sample were considered common parenting practices. the current examination of common parenting practices is modeled after research carried out by calzada and eyberg (2002), who examined parenting practices of dominican and puerto rican mothers with a child between the ages of 2 and 6 years old. of the apq’s 42 items, 12 seemed to tap common parenting practices for the current sample. when analyzed by parent gender, the common parenting practices stay fairly stable with the exception of three items. positive parenting. two items were highly endorsed by both fathers and mothers. over 80% of fathers and mothers reported letting their child “know when he or she is doing a good job with something” and hugging or kissing their child “when he or she has done something well,” either “always” or “most of the time.” fathers reported high endorsement (over 80% of the time reporting “frequently” or “always”) for two additional items: “you praise your child if he or she behaves well,” and “you tell your child that you like it when he or she helps around the house.” mothers endorsed these items 73.5% and 77.1% of the time, respectively. involvement. only one item in this 10-item subscale was highly endorsed by parents. most mothers (87.5%) reported “frequently” or “always” to the item “you ask your child about his or her day at school.” fathers endorsed the item frequently as well, but did not reach the 80% cutoff to be considered highly endorsed. poor monitoring. the monitoring scale had the highest number of common parenting practices. in other words, latino families reported monitoring their children very closely. of the 12 items, 7 tapped common parenting practices for the current sample. eighty percent of parents reported “not so much” or “never” to the following parental monitoring items: “your child stays out in the evening past the time he/she is supposed to be home,” “your child is out with friends you don’t know,” “your child goes out without a set time to be home,” “your child is out after dark without an adult with him/her,” “you get so busy you forget where your child is and what he/she is doing,” “your child comes home from school more than an hour past the time you expect him/her home,” and “your child is at home without supervision.” other discipline practices. eighty percent of parents responded “not so much” or “never” to the following discipline items: “you use time-out (make him/her sit or stand in a corner) as punishment,” and “you ignore your child when he or she is misbehaving.” corporal punishment. over 80% of parents in the current sample responded “not so much” or “never” to the following apq items: “you hit your child with a belt, switch, or other object when he/she has done something wrong,” and “you slap your child when he or she has done something wrong.” child behavior checklist (cbcl) results of child mental health among latino families in the current study did not reveal clinically significant levels of internalizing or externalizing disorders. based on the criteria set forth in the cbcl manual, t scores above 67 indicate a clinically significant child behavioral problem (achenbach & rescorla, 2000). both mothers’ and fathers’ latino parenting 57 responses on the internalizing subscale (e.g., withdrawn, depressed) yielded t-scores below this cutoff (m = 58.04, sd = 8.94, and m = 55.17, s d = 10.10, respectively). likewise, mothers’ and fathers’ responses on the externalizing subscale (e.g., acting out, aggression) did not yield clinically significant t-scores (m = 54.63, sd = 9.80, and m = 53.64, sd = 9.43, respectively). finally, mothers’ and fathers’ responses on the total behavior problems subscale, again yielded t-scores below the clinical cutoff (m = 56.33, sd = 9.52, and m = 54.38, sd = 9.25, respectively). while these results suggest that latino parents did not report clinically significant symptoms of child emotional and behavioral problems, an informal trend is worth noting. both mothers and fathers reported slightly more internalizing problems, compared to externalizing and total behavior problems. apq reliabilities the original apq contains 42 items and five parental constructs, plus a group of discipline questions. the entire scale was administered to each parent in the study. of the five scales, two scales worked well with our sample in their original form: positive parenting and involvement. a third scale, poor monitoring, showed good reliability in a revised form. findings for each of the scales follow. positive parenting scale. six items contained in this scale reflect the use of positive reinforcement. sample items are: “you compliment your child when he or she has done something well,” and “you reward or give something extra to your child for obeying you or behaving well.” cronbach’s alpha for parents’ scores on the apq scale for positive parenting was .72 (m = 24.91; sd = 3.22). the possible range for the positive parenting scale was 6-30. involvement scale. ten items included in this scale reflected parental involvement. sample items are: “you ask your child about his/her day at school,” and “you play games with your child or do other fun things with your child.” cronbach’s alpha for parents’ score on the involvement scale was .77 (m = 35.99; sd = 6.11). the possible range for the involvement scale was 10-50. poor monitoring scale, revised. items in this scale reflect the lack of monitoring and supervision of the child. the original apq monitoring scale has 10 items. the original version of the poor monitoring scale showed poor reliability with the current sample, with a cronbach’s alpha of .55. upon further examination of common parenting practices it became evident that 7 of the 10 items represented common parenting practices for parents in our sample. as such, the items did not provide enough variability to be viable for inclusion in this scale. when the highly endorsed parenting practices items were removed, only three items remained: “your child fails to leave a note or to let you know where he or she is going,” “you don’t check that your child comes home from school when he or she is supposed to,” and “you don’t tell your child where you are going.” despite the sparse number of items, cronbach’s alpha for parents’ score on the modified scale was .73 (m = 9.33, sd = 4.10). the possible range of scores for the apq revised poor monitoring scale was 3-15. inconsistent discipline scale. this scale contains six items that reflect lack of consistency in applying discipline. sample items include: “you threaten to punish your child and then do not actually punish him/her,” and “your child is not punished when he or she has done something wrong.” cronbach’s alpha for the inconsistent discipline scale was .58 (m = 13.72, sd = 3.45). the inconsistent discipline scale yielded a rather low alpha due to lack of variability of responses and the wide range of severity of the items. the range for the inconsistent discipline scale was 6-30. corporal punishment scale. this scale contains three items that assess for the use of corporal punishment. sample items include: “you slap your child when he or she has done something wrong,” and “you hit your child with a belt, switch, or other object when he or she has done something wrong.” the cronbach’s alpha of parents’ reported scores on the corporal punishment scale was .41 (m = 4.57, sd = 1.46). the corporal punishment scale yielded a low alpha due to the limited number of items included in the subscale, the lack of variability of responses, and the wide range of severity of the items. the range of items on the corporal punishment scale was 3-15. concurrent validation parenting practices such as ineffective discipline and poor monitoring have been shown to be correlated with children’s externalizing behavior problems among white families (bank, forgatch, patterson, & fetro, 1993). parent interventions that encourage and develop parents’ monitoring and discipline skills have been effective in reducing antisocial child behavior (e.g., bank, marlowe, reid, patterson, & weinrott, 1991; chamberlain & reid, 1991; forgatch, 1991; patterson, chamberlain, & reid, 1982). in another study, elevations on the apq parenting scales showed correlations with disruptive behavioral disorders among children (shelton, frick, & wootton, 1996). based on previous literature findings, it was expected that apq parental practices would correlate with cbcl scores, and thus provide a concurrent validity check. correlations were calculated for mothers and fathers in order to examine the relationship between self-reported parenting practices and child outcomes. correlations of self-reported parental practices and internalizing behavior problems were in the expected directions (see table 1). fathers’ parental involvement (r = -.43, p < .01) and positive parenting (r = -.40, p < .01) were significantly related to externalizing behavior problems, wherein increased endorsement of involvement and positive parenting was associated with fewer externalizing behavior problems. based on a previous study, williams (2003) found that white fathers’ self-reported parental involvement was correlated with child externalizing behavioral disorders. mothers’ donovick & domenech rodríguez 58 poor monitoring was significantly correlated with externalizing problems (r = .37, p < .05). mothers’ scores on the original version of the poor monitoring scale were used in the analysis. thus, mothers who endorsed higher levels of poor monitoring were more likely to report increased child externalizing behavioral problems. when examining total behavior problems, fathers’ (r = -.42, p < .01) and mothers’ (r = -.36, p < .05) involvement, and fathers’ positive parenting (r = -.46, p < .01) emerged as statistically significant correlations. the correlations indicate a significant relationship between increased involvement and positive parenting, and decreased total behavioral problems. caution must be taken regarding clinical significance given the small correlation coefficients. based on the basic reliability data and concurrent validity checks, it seems likely that the spanish apq is a promising scale that can be used with first generation spanish-speaking latino families of primarily mexican origin. however, continued research is needed to further demonstrate reliability and validity with other latino populations. in an effort to further examine the relationship between self-reported parenting practices and internalizing, externalizing, and total behavior problem scores on the cbcl, regression analyses were conducted. given the complexity of using parents’ ratings on the same child, mothers’ and fathers’ scores were analyzed separately. regression analyses included mothers’ and fathers’ scores on the following apq scales: involvement, positive parenting, and the original poor monitoring scale. only these three scales were used as predictors because the others did not have acceptable levels of internal consistency. although the original poor monitoring scale yielded low reliability, it was included in the analysis due to the strong response pattern indicating common parenting practices around monitoring. table 1 correlations among parenting practices and child internalizing, externalizing, and total problems for mothers and fathers parenting practice int ext tot mother involvement -.28 -.29 -.36* positive parenting -.14 .12 .01 poor monitoring -.10 .37* .03 father involvement -.25 -.43** -.42** positive parenting -.29 -.40** -.46** poor monitoring -.08 -.08 -.12 ** p < .01, * p < .05 therefore, including the full scale (original poor monitoring scale) in the analysis could provide conceptually meaningful data regarding common parenting practices and their relationship with child mental health. the outcome variables were mother and father reported scores on the internalizing, externalizing, and total problem subscales of the cbcl. preliminary analyses were conducted to determine if background factors were associated with primary study variables. socioeconomic status among spanish-speaking latino families of primarily mexican origin was examined by analyzing frequencies for income and educational attainment. for the current sample, 96% (n = 92) of latino parents reported earning less than $35,000 per year, and 4% (n = 4) reported earning more than $35,000. given the lack of variability in socioeconomic status, these variables were dropped from further analyses. educational attainment was generally low with 83% (n = 80) of participants having a high school diploma or less, 7% (n = 7) having some college education, and 6% (n = 6) having a college degree. since the majority of parents fell into one category, the educational status variable was dropped from further analyses. acculturation status was examined by analyzing the frequencies of categorical constructs. for the current sample, 80% (n = 77) of parents were categorized as traditional/separated, 18% (n = 17) were classified as bicultural, 1% (n = 1) was classified as assimilated, and 1% (n = 1) was categorized as marginalized. given that the assimilated and marginalized categories only included one parent, the acculturation variable was dropped from further analyses. mothers’ scores of positive parenting, parental involvement, and the original version of poor monitoring together significantly predicted externalizing child behavioral problems, f (3, 33) = 4.4, p = .01, and the model accounted for 28% of the variance. all predictors made a significant contribution to the model (see table 2). the model for fathers’ scores of positive parenting, parental involvement, and poor monitoring (original) predicted externalizing child behavioral problems, f (3, 37) = 2.9, p = .05, accounting for 19% of the variance. however, none of the individual predictors had significant independent contribution. the fathers’ model predicting total behavioral problems was also significant, f (3, 37) = 3.6, p = .02, accounting for 22% of the variance. however, none of the individual predictors had significant independent contribution (see table 3). none of the self-reported parenting practices significantly predicted internalizing behavior problems. discussion one of the primary goals of this research was to examine the applicability of the spanish version of the apq with a sample of first generation spanish-speaking latino families. based on the current study’s reliability and concurrent validity findings, the spanish version of the latino parenting 59 table 2 simultaneous multiple regression of mother’s positive parenting, parental involvement, and poor monitoring predicting externalizing behavioral problems on the cbcl b se t p intercept 36.13 11.39 4.05 .00 positive parenting .90 .46 1.96 .06 parental involvement -.58 .23 -2.50 .02 poor monitoring .78 .35 2.24 .03 r_ = .28 table 3 simultaneous multiple regression of father’s positive parenting, parental involvement, and poor monitoring predicting externalizing behavioral problems and total behavioral problems on the cbcl b se t p externalizing behavior problems intercept 82.80 12.59 6.57 .00 positive parenting -.69 .54 -1.28 .20 parental involvement -.48 .35 -1.37 .18 poor monitoring .32 .34 .96 .34 total behavioral problems intercept 89.10 12.15 7.33 .00 positive parenting -1.00 .52 -1.92 .06 parental involvement -.35 .34 -1.04 .30 poor monitoring .15 .33 0.47 .64 r_ = .19 for externalizing behavioral problems, and r_ = .22 for total behavioral problems apq appears acceptable for use with first generation spanish-speaking latino families. results indicate acceptable levels of internal consistency and reliability for the positive parenting and involvement scales of the apq in spanish. although the poor monitoring scale demonstrated low reliability in its original form, a revised poor monitoring scale demonstrated acceptable reliability with the current sample. future studies with older children may want to include the full scale, as these findings may be developmentally bound. the inconsistent discipline scale and corporal punishment scale revealed low reliability alphas in the current sample. this finding is most likely due to the limited amount of items included in the scales and the wide range of severity of the items. the second goal of this research was to examine the common parenting practices among spanish-speaking latino families utilizing a parenting questionnaire. results indicate a number of parenting practices that could be considered common parenting practices among spanishspeaking latino parents of young children (4-9 years of age) primarily of mexican origin. over 80% of the sample’s parents endorsed “frequently” or “always” to hug or kiss their child when he or she has done something well and to ask their child about their day at school. interestingly, a previous study (calzada & eyberg, 2002) found similar results with a different latino sample consisting of puerto rican and dominican mothers. calzada and eyberg found that over 85% of first generation puerto rican and dominican mothers in their sample endorsed “always” for the item “i express affection by hugging, and kissing my child.” both studies highlight a similar common positive parenting practice; both latino samples reported frequently expressing physical warmth with their children. it may be that positive parenting practices such as parental warmth may be related to latino cultural values common among first generation puerto rican, dominican, and mexican parents. more than 80% of parents reported “not so much” or “never” using time-out as a punishment when their children misbehave. additionally, 80% of parents reported “not so much” or “never” hitting their children with a belt or switch or other object when they have done something wrong. these findings are consistent with previous research carried out by calzada and eyberg (2002), who found that over 80% of their latino sample of mothers reported “seldom” or “never” using physical punishment, criticism, or argument as discipline. thus, both studies found that parents tended to not use physical punishment as a discipline method despite both samples representing heterogeneous latino countries, again suggesting that this might not be common parenting practice among parents across various latino countries. interestingly, these results differ from previous research, which found that latina mothers did not tend to use positive parenting techniques (garcia coll, 1990; laosa, 1980), and rather tended to use physical punishment as discipline (fracasso, buschrossnagel, & fisher, 1994; knight, virdin, & roosa, 1994). thus, it seems that there might be heterogeneous methods of discipline common among latino families. alternately, there may be other important factors such as acculturation that play a significant role in common parenting practices. the current study utilized a sample of first generation latino families, while other studies utilized second generation or more acculturated samples (garcia coll, 1990; laosa, 1980; fracasso et al., 1994; & knight et al., 1994), and some studies failed to mention acculturation status of latino parents. donovick & domenech rodríguez 60 in terms of discipline practices, over 80% of the spanish-speaking latino families of primarily mexican origin included in the sample reported that they do not ignore their children’s misbehavior. this finding is also consistent with calzada and eyberg (2002), who found that 92% of puerto rican and dominican mothers denied ignoring their children’s misbehavior. in addition, spanish-speaking latino parents of primarily mexican origin in the current study reported consistently following through with discipline and consequences when their children misbehave. this finding is in line with calzada and eyberg (2002), who describe puerto rican and dominican mothers as highly consistent with discipline following children’s misbehavior. in cross-cultural studies, evidence suggests that consistent follow-through with discipline is congruent with raising a child who is well-behaved or bien educado; being well-behaved (e.g., proper behavior, interdependence) has been documented as important to latino parents (carlson & harwood, 2003). this suggests that latino parents socialize their children in ways that may be consistent with their cultural values. the corporal punishment and inconsistent discipline scales did not reach conventional standards of reliability. domenech rodríguez and villatoro (2004) used the spanish-language apq presented herein with a sample of mexican parents living in mexico city, and the discipline scales reliably assessed parenting practices. it may be possible that parents living in the united states are reluctant to report their discipline practices. for example, based on focus group data, domenech rodríguez (2004) found that firstgeneration parents reported fear of child protective services involvement as a result of differences in parenting practices between latinos and “americans.” related to this, it may be that parents’ responses reflect a social desirability bias. the original validity studies on the apq did not include social desirability measures. or, it may be that given the scale’s limited number of items, it is difficult to consistently reach acceptable high alphas across different samples, particularly for the corporal punishment scale, which only contained three items. the current sample of spanish-speaking latino families primarily of mexican origin reported common parenting practices that are mainly consistent with previous studies with other latino families. the sil model conceptualizes latino culture as part of the context that surrounds the parent and child relationship. sil hypothesizes that contextual factors such as culture impact parenting practices. this study provided evidence that the use of the apq with theoretical underpinnings of the sil model can be applied to latino families to further understand latino child socialization. the investigation of self-reported parenting practices on the apq and their relationship with child outcomes on the cbcl revealed that none of the self-reported parenting practices for mothers and/or fathers predicted internalizing behavior problems. it is possible that this finding is related to a measurement issue, wherein the apq is based on a theoretical model of observed parenting practices related to externalizing behavioral problems. on the other hand, mothers’ and fathers’ parental involvement, positive parenting, and poor monitoring predicted externalizing behavioral problems. these findings are consistent with the literature on white majority families (bank, marlowe, reid, patterson, & weinrott, 1991; chamberlain & reid, 1991; forgatch, 1991; patterson, chamberlain, & reid, 1982). fathers’ parental involvement, positive parenting, and poor supervision predicted total child behavioral problems. in summary, these findings have important implications for prevention and intervention efforts with latino families. it seems likely that the sil model and the use of self-reported parenting practices on the apq can be applied to the understanding of parenting among latino parents of primarily mexican origin. thus, clinical interventions that incorporate and encourage parental involvement, positive parenting skills, and monitoring may be beneficial and useful in decreasing overall behavioral problems among latino children. exploring preferred discipline methods among firstgeneration latino families may be beneficial to researchers and clinicians. time-out and selectively ignoring misbehavior have been found to be effective methods of discipline among majority white families (patterson, dishion, & bank, 1984; wells & rankin, 1988); yet, over 80% of the current sample reported to not use time-out as a method of discipline. this finding may represent a potential opportunity for a new tool in intervention and prevention efforts. it may be possible that parents have not learned how to use time-out, have never tried using time-out, or may have learned an incorrect way. further exploration is needed to clarify if there is a cultural misalignment between latino parenting and the use of time-out. then again, it may be that the use of time-out is a parenting construct adapted from white western culture and may not be an appropriate form of discipline for latino parents. limitations to the current study should be noted. first, the data included in the current study are based on selfreport surveys. even though this method is useful and feasible, it may be subject to social desirability bias and may not provide an accurate picture of parenting practices (varela, vernberg, sanchez-sosa, riveros, mitchell, & mashunkashey, 2004). secondly, since the data was analyzed for each parent separately, limitations may exist. for example, it may be possible that weaknesses in one parent’s parenting practices were strengths in the other’s, together leading to positive child outcomes. thus analyzing data from parents separately would not capture this dynamic parenting process. thirdly, caution must be taken when evaluating the study’s findings, given that the apq was based on parenting constructs originally developed with majority western culture notions of parenting. it may be possible that the apq did not include important aspects of latino parenting. it would be beneficial for future studies to examine latino parenting behaviors at multiple levels latino parenting 61 of specificity (e.g., styles, dimensions, practices) and their relation to child outcomes. qualitative and observational methods may be fruitful in increasing scientific knowledge regarding the socialization processes of latino parenting and their relation to child outcomes. longitudinal and experimental studies are needed to clarify the developmental trajectory of latino parenting and its implications for child development. overall, basic reliability results suggest that the spanish version of the apq is acceptable for use with first generation spanish-speaking latino parents. in the current sample of spanish-speaking, first generation, latino families of primarily mexican origin several themes emerge concerning common parenting practices. the first theme highlights positive parenting practices. over 80% of parents reported to endorse positive parenting practices such as parental involvement and positive reinforcement for appropriate behavior. the second theme points out that latino parents do not report using harsh discipline parenting practices. over 80% of the current sample endorsed not using corporal punishment. the third theme reveals that latino parents tend to be protective. over 80% of the current sample reported engaging in high levels of monitoring and supervision with their children. in addition, our findings indicate that mothers’ and fathers’ scores on the apq (parental involvement, positive parenting, and monitoring) predicted child behavior problems, a finding that is consistent with the sil model of parenting. therefore, it seems likely that the sil model which incorporates core parenting practices such as positive parenting practices, involvement, monitoring/supervision, and limit setting would be applicable to latino families. in sum, the current study’s sample of fist generation spanish-speaking latino parents of primarily mexican origin reported common parenting practices including engaging in high levels of parental involvement, positive parenting skills, and monitoring. parents’ self-report of child behavioral problems were below the clinical range, perhaps indicating that latino common parenting practices may be a protective factor for prevention of future child behavioral problems. references achenbach, t. m. & rescorla, l. a. 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(1992). childrearing, social stress and child abuse: clinical considerations with hispanic families. journal of social distress & the homeless, 1, 291-309. appendix alabama parenting questionnaire spanish version item 1 tiene una plática (conversación) amigable con su hijo. 2 le dice a su hijo cuando él o ella está haciendo un buen trabajo con algo. 3 amenaza a su hijo con que lo va a castigar, pero no lo castiga. 4 se presta de voluntario para ayudar con actividades en las que su hijo está involucrado (como deportes, niños escucha, grupos de niños de la iglesia). 5 premia o le da cosas extras a su hijo por obedecerlo o por portarse bien. 6 su hijo no le deja recado o no le deja saber a donde va. 7 juega juegos divertidos o hace otras cosas divertidas con su hijo. 8 su hijo le convence de que no lo castigue después de que ha hecho algo malo o incorrecto. 9 le pregunta a su hijo acerca de como estuvo su día en la escuela. 10 su hijo se queda fuera de la casa en las noches pasada la hora de regresar a casa. 11 ayuda a su hijo con sus tareas escolares. 12 se siente que el lograr que su hijo le obedezca es más problema del que desea enfrentar. 13 halaga a su hijo cuando hace algo bien. 14 le pregunta a su hijo cuales son sus planes para el próximo día. 15 lleva a su niño en auto a una actividad especial. 16 halaga a su hijo si se porta bien. 17 su hijo sale con amigos que usted no conoce. 18 le da abrazos o besos a su hijo cuando hace algo bien hecho. 19 su hijo sale sin tener hora fija para regresar. 20 habla con su hijo acerca de sus amigos. 21 su hijo está fuera de la casa al llegar la noche, sin compañía de un adulto. 22 le quita castigos a su hijo antes de tiempo (o sea, lo deja salir más temprano de lo que originalmente dijo). 23 su hijo ayuda a planear actividades familiares. 24 usted se pone tan ocupado que se le olvida donde está su hijo o qué está haciendo. 25 su hijo no recibe castigo cuando hace algo malo o incorrecto. 26 asiste a reuniones de la asociación de padres y maestros (pta), conferencias de padres, u otras reuniones en la escuela de su hijo. 27 usted le dice a su hijo que le gusta cuando él o ella ayuda en la casa. 28 usted no chequea que su hijo haya llegado a casa cuando se supone que llegue. 29 usted no le dice a su hijo a donde va. 30 su hijo llega a casa de la escuela más de una hora después de lo que usted espera. 31 el castigo que le da a su hijo depende de su estado de ánimo. 32 su hijo está en la casa sin supervisión de un adulto. 33 le da nalgadas con la mano a su hijo cuando ha hecho algo malo o incorrecto. 34 ignora a su hijo cuando se está portando mal. 35 le da cachetadas a su hijo cuando ha hecho algo malo o incorrecto. 36 le quita privilegios o dinero a su hijo como castigo. 37 manda a su hijo a su cuarto como castigo. 38 le pega a su hijo con un cinto (cinturón, correa), u otro objeto cuando él o ella ha hecho algo malo o incorrecto. 39 le grita a su hijo cuando él o ella ha hecho algo malo o incorrecto. 40 calmadamente le explica a su hijo por que su comportamiento está mal cuando él o ella se porta mal. 41 usa el “tiempo fuera” (se sienta o para en la esquina) como un castigo. 42 le da a su hijo quehaceres adicionales como castigo. running head: violent media and age graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university the role of self-views in college adjustment alanna joy raines teachers college, columbia university gary lewandowski, jr. monmouth university the transition to college presents a host of stressors for students to navigate in the novel environment. previous research has shown that the transition to college and adaptation to new demands can be highly distressing for students. college adjustment has been shown to predict retention rates and uptake of risk behaviors such as alcohol use. it is likely that some students may be at greater risk for maladjustment based on their ability to adapt to the college environment. thus, the current study examined how individual differences in self-views relate to college adjustment. ninety-one participants (75 females and 16 males) completed measures of self-concept clarity, self-esteem, selfacceptance, and college adjustment. college adjustment was significantly correlated with self-concept clarity (r = .29, p = .01), self-esteem (r = .39, p = .00) and self-acceptance (r = .36, p = .00). these results have important implications for university programs that focus on facilitating the transition to college, espousing the need for interventions that address promotion of acceptance of self and life events. there is a long research tradition that has endeavored to address the question: “what helps college students successfully adapt to their new environment?” during this shift to a novel environment, some individuals more readily orientate to the wealth of new experiences and adjust to life away from familiarity. however, it has been shown that others are not as able to identify with and feel comfort in their new environment (cassidy & trew, 2001). research has shown that it is appropriate to look at the transition to college as a disturbing event in the lives of young adults (choi, 2002; naz & weber, 2003; paul & brier, 2001). for many reasons, shifting from high school to a university setting can cause students to invoke self-views to help inform and guide academic and social behaviors in the new environment. the novel demands posed by autonomous living and the management of social freedom are daunting obstacles to be encountered in college. yet, successfully overcoming the challenges can yield valuable and lasting benefits for those who navigate the transition. it has been shown that adjustment is closely related to academic success in terms of grade point average and retention rates (gerdes & mallinckrodt, 1994). in a recent meta-analysis conducted by crede and kunkel (2008), study skill inventories were found to be largely unrelated to college grades, but were moderately related to personality constructs (i.e., motivation to succeed). furthermore, anxiety regarding academic performance was a strong negative predictor of grade point average. these results suggest that there are individual differences in personality that affect academic performance. thus, it is likely that these factors also affect the college adjustment process as a whole. 1 the current study attempts to determine novel correlates that relate to successful college adjustment in order to facilitate intervention programs that focus on retention and correspondence: alanna joy raines, ajr2153@columbia.edu risk behavior prevention. for the purposes of this paper, selfviews in evaluative and cognitive dimensions will be referred to as self-understanding, which is the compilation of three constructs: self-esteem (rosenberg, 1965), self-concept clarity (campbell et al., 1996), and self-acceptance (ryff, 1989). as such, the combination of both evaluative and cognitive components of self-knowledge provides a broad conceptualization of traits, thoughts, and behaviors across situations. the transition to college students commonly question their new identity as autonomous adults, shedding familial dependencies upon entering college (cassidy & trew, 2001; choi, 2002). stemming from their newly-found independence, individuals must also properly manage their social freedom and find a personal balance between social interaction and personal space (naz & weber, 2003). without the immediate presence of parents, the autonomous individual must develop self-soothing behaviors that can be enlisted in times of anxiety to quell fears and frustrations. the paucity of familiar others and the doubt that can arise from acquiring new affiliations and behaviors is compounded by “friendsickness.” paul and brier (2001) describe this feeling as a longing for friends previously held in secondary school and the personal identity once held among them. reestablishing the former identity among new others is a task that can bring forth great anxiety when socially adjusting to a new environment. the duress placed on students during this time can jeopardize an individual’s physical and emotional health. for example, anxiety can manifest itself in a variety of ways, such as psychological and somatic distress, low self-esteem, and even depression (giddan, 1988). elevated levels of anxiety may also lead students to use alcohol and other substances to ease the tension and discomfort they 46 college adjustment 47 experience in their unfamiliar environment. the use of addictive and illegal drugs can further compound the stress an individual feels, placing the student at higher risk for physical health and legal problems (naz & weber, 2003). separation-individuation erikson (1968) postulated that the most crucial developmental task an individual must face is separation from familial dependencies and achievement of selfsufficiency as an autonomous adult. a refined notion of this developmental issue is separation-individuation (mattanah, hancock, & brand, 2004). healthy separation-individuation involves developing and maintaining an identity that conforms to one’s own personality, rather than that of the individual’s parents. furthermore, early research in this area sought to determine if the successful independence from parents and other close relatives was related to college adjustment. rice (1992) espoused this notion, demonstrating that freshmen experience significant increases in individuation during each subsequent grade until graduation. although necessary for independence of the self, this sense of autonomy requires individuals to separate themselves from immediate familial social supports (choi, 2002). as a result, students must learn new coping methods to deal with stress, and must seek out new sources of social support. self-differentiation similar to separation-individuation, self-differentiation refers to the establishment of a self separate from the identity of an individual’s parents (skowron, wester, & azen, 2004). this concept broadens the definition of separationindividuation to include both internal and external factors of successful independence from parents. emotion regulation (i.e., coping with emotional experiences), examination of consequences and outcomes, and thoughtful deliberation of behavior make up the intrapsychic components of selfdifferentiation. these are crucial issues to navigate, as young adults make decisions for themselves in the absence of parents. in the social context, one must establish working and supportive friendship networks that aid in emotional support. these close relationships, if successfully established, should be fulfilling and ultimately mirror the relationship with close family members (wintre & yaffe, 2000). these resources aid in the establishment of social support, resembling the closeness of a family. identity commitment cassidy and trew (2001) investigated students’ commitment to maintaining their identity from secondary school to their first year at college. the researchers made a distinction between short and long-term identity change, positing that long-term personality change is difficult to evoke. short-term change is characterized by the characteristics that are exhibited as individuals move in and out of social roles. a distinct relationship exists between environmental context and individuals’ self-views. this is similar to the conceptualization of the working self-concept proposed by markus and wurf (1987) which states that the multiple identities can overlap and be present at different times throughout social situations. long-term change in identity, however, refers to a major life transition in which an individual experiences an enduring change in their identity patterns. thus, cassidy and trew (2001) proposed that long-term change due to relocation and social environment for college students would elicit such change. however, results showed that the psychological centrality of identities participants cited in secondary school did not change one year after the college transition. this gives support to the notion that individuals seek to retain their precollege identity. it also shows commitment to establishing social networks in college that parallel their previous relationships with friends and family, while maintaining the identity that they exhibited in those relationships. big five personality traits wintre and sugar (2000) examined personality characteristics and their relationship to college adjustment. specifically, they examined the big five personality traits outlined by mccrae and costa (1992). the first component, neuroticism, is characteristic of those with high selfconsciousness and negative affect. extraversion largely deals with social competence and warmth toward others. receptivity to new ideas and activities is characterized by openness to experience. those who are empathetic and generous are considered agreeable using this taxonomy. lastly, conscientiousness describes those who strive for excellence and achievement, as well as display neatness and orderliness. wintre and sugar (2000) hypothesized that conscientiousness would predict academic and institutional college adjustment. agreeableness and extraversion were hypothesized to predict social and institutional adjustment. lastly, it was also hypothesized that neuroticism would be negatively correlated with institutional, social, personal, and emotional college adjustment. results showed that conscientiousness was related to males’ academic and institutional college adjustment, yet the same pattern did not materialize for females. agreeableness and extraversion predicted both genders’ social adjustment, yet only females’ institutional adjustment. lastly, females who reported high neuroticism also reported lower institutional, social, personal, and emotional college adjustment. this study delineates the predictive power of personality characteristics and gender in determining college adjustment, as well as individual differences predictive of college adjustment in various dimensions. self-views and college adjustment self-esteem. self-concept is a cognitive schema comprised of an individual’s traits, values, and personal raines & lewandowski 48 goals (pelham & swann, 1989). self-esteem (campbell et al., 1996) is the evaluative component of self-concept. selfesteem is an individual’s positive, neutral, or negative view of his or her own personality characteristics. when mentally aggregated, it results in a general satisfaction or dissatisfaction with the self. it is likely that a global positive or negative view of the self will similarly influence the global view of the college experience. self-acceptance. self-acceptance is an evaluative measure of one’s attitude toward the self within the context of past life events and accomplishments. ryff (1989) describes self-acceptance as a measurement of healthy psychological functioning. high measures of self-acceptance relate to acceptance and comfort with previous positive or negative experiences. further, self-acceptance yields a satisfaction or dissatisfaction with a person’s past selves and life events, rather than a positive or negative view of the contents of the self-concept, measured by self-esteem (campbell, 1990; campbell et al., 1996). self-concept clarity. self-concept clarity is defined as the stability and consistency of the traits in the self-concept (campbell et al., 1996). this is a cognitive component of self-knowledge which assembles personality traits into an organized structure. it works to incorporate new information into the existing organization. individuals with high selfconcept clarity have a well-defined view of who they are, and derive high self-esteem from the strength and consistency of self-beliefs (campbell & lavallee, 1993). previous work examining individual differences in the clarity of the self-concept have pointed to its relation to college adjustment. crede and kunkel (2008) propose that those with a clear knowledge of personal abilities and motivating factors tend to have greater academic success in college. although previous studies have focused on personality characteristics’ relation to college adjustment, research has failed to properly address the role of self-views. given the prominent role that self-concept and self-esteem play in everyday functioning, they are likely to affect how students acclimate to a novel environment such as college. those who have high self-esteem possess a positive evaluation of the self (rosenberg, 1965), which might lead to positive evaluations of their college experience. in addition, it is possible that those who have high self-concept clarity, which is characterized by a clear, stable, and defined view of their personal expectations, traits, and abilities (campbell, 1990), will have better adjustment as they choose academic endeavors, goals, and affiliations in college that complement the existing self-concept. lastly, it is plausible that those with high self-acceptance, characterized by having an accepting and approving view of personal accomplishments and life events (ryff, 1989), will also have a favorable impression of their academic and social experience in college. thus, it is hypothesized that those who report high self-esteem, self-concept clarity, self-acceptance, and selfunderstanding, will also report higher overall college adjustment (hypothesis 1). it is also hypothesized that the self-variables (i.e., self-esteem, self-acceptance, and selfconcept clarity) will be independently related to the four specific dimensions of college adjustment (i.e., social, academic, institutional, and personal). method participants participants in this study were 91 undergraduate students (75 females and 16 males) enrolled at a private university in the northeast. participants’ ages ranged from 18 to 28, with a mean age of 19.75. the sample was comprised of 82 participants of eastern-european decent, 3 african-americans, 3 hispanic-americans, 2 asianamericans, and 1 participant who identified their ethnicity as “other.” the sample included 39 freshmen, 15 sophomores, 12 juniors, and 25 seniors. all participants were treated ethically throughout the course of the study according to american psychological association guidelines (apa, 2002). materials materials used in the current study included a questionnaire packet that consisted of a measure of college adjustment (naz & weber, 2003), a self-acceptance scale (ryff, 1989), a self-esteem measure (rosenberg, 1965), a measure of self-concept clarity (campbell et al., 1996), as well as a demographics sheet. the internal consistency (chronbach’s alpha) for all measures ranged from .70 to .91, with exception of the personal adjustment scale which was .62. college adjustment. this measure is a 28-item scale that is designed to measure participants’ social, academic, institutional, and personal adjustment to college. participants were asked to respond on a 7-point scale (1 = strongly disagree; 7 = strongly agree). social adjustment. this subset of questions in naz and weber’s (2003) college adjustment scale determined participants’ level of social adjustment at the university. this was measured in terms of their development of meaningful and satisfying relationships with other students, as well as their likelihood to attend cultural events with friends at the university. a sample item includes: “since coming to this university, i have developed close personal relationships with other students.” academic adjustment. these questions measured participants’ level of academic adjustment in terms of their satisfaction with their intellectual development upon coming to the university, as well as their courses and grades. a sample item includes: “my academic experience has had a positive influence on my intellectual growth and interest in ideas.” institutional adjustment. this subset of questions was designed to measure participants’ level of comfort with their current university and confidence in their decision to attend college adjustment 49 the school. a sample item includes: “the likelihood that i will finish the present school year is almost certain.” personal adjustment. the last subset of questions measured participants’ feelings that their current university fits their personality and the extent to which their university feels like home to them. a sample item includes: “sometimes i get homesick.” self-esteem. this measure assesses the degree to which participants take a positive attitude toward themselves (rosenberg, 1965). participants were asked to respond on a 4-point scale (1 = strongly disagree; 4 = strongly agree). sample items include: “on the whole i am satisfied with myself” and “i feel i’m a person of worth, at least on an equal plane with others.” self-acceptance. this measure of well-being assesses participants’ acceptance and comfort with their selves, accomplishments, and life events (ryff, 1989). participants were asked to respond on a 6-point scale (1 = strongly disagree; 6 = strongly agree). sample items include: “in general, i feel confident and positive about myself” and “i like most aspects of my personality.” self-concept clarity. this measure assesses the stability and coherence of participants’ perception of their personality characteristics (campbell et al., 1996). participants were asked to respond on a 5-point scale (1 = strongly disagree; 5 = strongly agree). sample items include: “i seldom experience conflict between different aspects of my personality” and “in general, i have a clear sense of who i am and what i am.” demographics. the demographics sheet asked participants to indicate their gender, ethnic background, age, and year in college. procedure participants signed up in advance for a time slot of 30 minutes using a web-based participant pool. after arriving at the laboratory, participants were met by an experimenter who confirmed their attendance. they were then given an informed consent sheet and its contents were read aloud as participants followed along. upon written consent, a questionnaire packet was distributed to participants, along with a demographics sheet. the completion of the two materials took approximately 15 minutes. when participants finished, they were orally debriefed and any remaining questions were answered by an experimenter. after they were asked to keep the details of the current study confidential, participants were released. results correlation between overall college adjustment and self variables means and standard deviations for the key variables are shown in table 1. correlations between college adjustment and the various components of self-understanding are shown in table 2. as predicted, self-esteem, self-concept clarity, and self-acceptance were all significantly positively related to overall college adjustment. this indicates that those who have generally positive self-views tend to display higher college adjustment. table 1. means and standard deviations variable m sd n self-esteem 3.43 .47 91 self-concept clarity 3.67 .65 91 self-acceptance 4.82 .74 91 overall college adjustment 5.34 .72 91 academic college adjustment 5.38 .77 91 personal college adjustment 5.23 .86 91 institutional college adjustment 5.95 .97 91 social college adjustment 4.82 1.11 91 correlations between college adjustment subscales and self variables (hypothesis 2). correlations between the college adjustment subscales and self-understanding (and its components) for all participants are also shown in table 2. self-esteem and selfacceptance were positively correlated with academic college adjustment (r = .29, p < .01; r = .30, p < .01, respectively), whereas self-concept clarity approached significance (r = .20, p = .054). self-acceptance was positively correlated with institutional college adjustment, whereas self-concept clarity (r = .18, p = .09) and self-esteem (r = .20, p = .06) approached significance. table 2. correlations between self variables, overall college adjustment, and college adjustment subscales scale 1 2 3 4 5 6 7 8 1. self-esteem .68** .87** .39** .29** .44** .20 .27** 2. self-concept clarity .72** .29** .20 .31** .18 .21* 3. self-acceptance .36** .30** .34** .22* .25* 4. overall college adjustment .78** .77** .74* .80** 5. academic college adjustment .42** .59** .52** 6. personal college adjustment .37** .55** 7. institutional college adjustment .35** 8. social college adjustment note. *p < .05. **p < .01. raines & lewandowski 50 discussion previous research has shown that the transition to college is distressing for students (paul & brier, 2001). it has also been shown that personality traits are more closely linked to academic performance than a range of academic factors (e.g., study skills) (crede & kunkel, 2008). research in this area has pointed to, yet not fully determined the role of self-views in terms of college adjustment. the current study sought to isolate novel correlates of college adjustment, specifically self-esteem, self-concept clarity, and self-acceptance. results demonstrated that overall college adjustment was significantly positively correlated with self-concept clarity, self-esteem, and self-acceptance. this illustrates that individuals who positively evaluate themselves, characterized by high self esteem (rosenberg, 1965), are more likely to rate their college experience more positively. it also suggests that those who have high self-concept clarity (campbell, 1990) are better adjusted due to an ability to choose academic endeavors that complement the existing self-concept. in addition, it is demonstrated that those with high self-acceptance, characterized by an accepting and approving view of personal accomplishments and life events (ryff, 1989), are more likely to have a favorable impression of their academic and social experience in college. results suggest that students with positive self-views are more comfortable with themselves, have a better idea of their strengths and weaknesses, possess the personal resources necessary to be successful, and ultimately have better overall college adjustment. as predicted, self-esteem, self-concept clarity, and selfacceptance were positively significantly correlated with social and personal college adjustment. these findings indicate that those who have a greater awareness of who they are may be more likely to seek social support that adequately fulfills their emotional needs. they also appear more likely to be well-adjusted due to a better perceived “match” between their goals and the resources afforded to them at their university. self-esteem and self-acceptance were positively correlated with academic college adjustment, whereas self-concept clarity only approached significance. this suggests that those who hold a positive evaluation of their personal characteristics and life achievements are more likely to be satisfied with their academic performance and intellectual growth when compared against their peers. selfacceptance was positively correlated with institutional college adjustment, whereas self-concept clarity and selfesteem only approached significance. this shows that those who have a forgiving and tolerant view of past decisions are more likely to accept their choice to attend the college. previous research has pointed to individual differences in college adjustment (crede & kunkel, 2008; wintre & sugar, 2000). however, this study was the first to assess the value of positive self-views with respect to college adjustment. strengths of the present study include an analysis of different aspects of college adjustment. with use of naz and weber’s (2003) college adjustment scale, participants’ academic, social, institutional, and personal adjustment were measured. each subscale was designed to measure a specific component of adjustment, yielding a more informative analysis of the sample. a limitation of the current study was that a majority of its sample were freshmen. since their transition to college was fairly recent, the disturbances caused by being uprooting from their home and daily familial interaction were still very new. compared to sophomores, juniors and seniors, freshmen’s issues related to separation-individuation were in the early stages of negotiation. it might have been too early for the freshmen to determine their comfort with their university and academic performance. another limitation of this study is the inclusion of items on both the institutional and personal sections of the college adjustment scale (naz & weber, 2003) that did not apply to non-residents. many participants commuted to school, and were unable to answer residential life questions on the subscales, such as “i like living in the residence hall” and “i feel like the residence hall is home now.” this resulted in the relatively low-reliability of the institutional (α = .70) and personal (α = .62) college adjustment subscales, yielding inconclusive results for self-concept clarity and self-esteem’s relationship to institutional adjustment for all participants. lastly, participants in this study were largely female. previous research has shown that there are distinct gender differences in the adjustment patterns of males and females (wintre & sugar, 2000). this study was unable to address this issue due to a paucity of male participants. future research should determine differences in college adjustment and self-views based on gender. based on the results of this study, future research examining the benefit of increasing positive self-views in college students is warranted. this study shows that those who have high self-esteem, self-concept clarity, and selfacceptance, report higher college adjustment. as such, these results have important implications for university programs that focus on facilitating the transition to college. possible university intervention programs could focus on inciting positive increases in students’ self-views. it is likely that this will allow students to learn about their traits and abilities and to better use them to adapt to their new environment. techniques, such as writing about personal characteristics to identify and clarify them, could possibly aid in this process. perhaps inciting such an increase will yield college adjustment benefits, such as improved academic grades and retention. in addition, future studies should address the question of whether positive self-views yield the same benefits in the workplace. this study demonstrated that college students with positive self-view were surer of their goals and viewed their personal endeavors more positively. similarly, it is plausible that the same individuals would be happier and more satisfied with their jobs. this relationship might stem from the choice of work environment complimenting an college adjustment 51 individual’s goals and personal characteristics, resulting in an easier transition to a new job. previous research has shown that the transition to college can be distressing for students (choi, 2002; paul & brier, 2001). college adjustment has also been shown to predict retention rates (gerdes & mallinckrodt, 1994). wintre and sugar (2000) have pointed to individual differences in college students’ ability to adjust to their new environment. the current study addressed the role of possible individual differences in personality by examining self-variables and their relationship to college adjustment. self-esteem, self-concept clarity, and self-acceptance were examined within the context of college adjustment. results showed that those who reported high self-esteem, selfacceptance, and self-concept clarity also reported high overall college adjustment. thus, novel correlates of college adjustment have been isolated by this study. perhaps the employment of methods that assist in fostering positive selfviews might ease the transition to college, benefiting adjustment and, ultimately, retention. references american psychological association. 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(2000). first-year students’ adjustment to university life as a function of relationships with parents. journal of adolescent research, 15, 9-37. 5 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university prevalence, comfort with, and characteristics of sex toy use in a us convenience sample using reddit.com emily fippen1 & george gaither2 1 teachers college, columbia university; department of clinical & counseling psychology 2 ball state university, department of psychological science in 2020, the global sex toy market was valued at $33.64 billion, more than double compared to the 2009 value of $15 billion (grandview research, 2021). with the sex toy industry growing at an exponential rate, more people throughout the world are having differential experiences with sexually-enhancing technology. sex toys are now sold in several commercial grocery stores, such as walmart and target, and can also be found within sex shops, various stores at shopping malls, and on countless websites. the proposed study aims to identify participants’ comfort levels and experiences with sex toys, as well as to identify levels of comfortability among participants who reported previous experiences with sexual assault, sexual dysfunction, and/or post-traumatic stress disorder (ptsd). understanding how and why american adults use sex toys and sexual “aids” can allow for a better analysis of why sex remains a taboo topic within the united states, and can inform clinicians on how to best incorporate sex toys and sexual “aids” into therapeutic practice. sex toys, as defined by döring and poeschl (2020), are sexual enhancement products with the intent of improving the nature and quality of sexual experiences. sex toys are material objects that are used directly on the body and include “sexual aids” such as lubrication, bondage, and lingerie. this operationalization of sex toys emphasizes pleasure and the enhancement of sexual experiences as it pertains to overall sexual health and satisfaction. throughout this study, the terms “sex toys” and “sexual aids” may be used interchangeably, as the term “sexual aids” refers to “an object or device that is primarily used to facilitate human sexual pleasure” (miranda et al., 2019,). in the diagnostic and statistical manual of mental disorders (dsm-v), a sexual dysfunction can be defined as “a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (american psychiatric association, p. 423). in the united states, sexual dysfunctions affect approximately 43% of women and 31% of men (rosen, 2000), some of which include hypoactive sexual desire disorder, erectile dysfunction, orgasmic disorder, and female sexual arousal disorder. it is noteworthy to mention that the diagnosis of hypoactive sexual desire disorder has changed with the newest edition of the dsm (dsm-v) and is now enveloped underneath an umbrella diagnosis titled ‘female sexual interest/arousal disorder’. currently, little is known about comfortability with toys, especially among individuals with sexual assault or sexual dysfunction-related issues. the present study aims to explore participants’ levels of comfortability with and use of various types of sex toys and sexual aids. further, this study aims to identify although döring and poeschl (2020) have presented findings on the use of a broader range of sex toys from a german national sample, little is known about the prevalence and characteristics of users of a broad range of sex toys in the united states. the present study aims to examine the prevalence, characteristics of, and comfort with sex toys among a sample of american adults (n = 231). within this study, the term “sex toy” refers to any object used directly on the body (e.g., vibrator, dildo, handheld masturbator), while “sexual aids” refers to items that may enhance sexual pleasure or libido (e.g., lubrication, aphrodisiacs). we used survey data that was previously collected in 2020 using reddit.com/r/samplesize and ball state university’s communications center to solicit participation. using data from döring & poeschl (2020) to assess sex toy use, we added questions regarding participant comfortability using sex toys in the past. if the participant had never previously used sex toys but would be willing to do so in the future, we asked about the perceived comfort of using a sex toy. we also asked about the perceived positive and negative effects of toy use, as well as a number of possible predictors of use including personality, sexuality, mental health, and trauma-related experiences (sexual assault, sex problems/dysfunctions, being diagnosed with ptsd). our findings revealed that a significant portion of americans have previously used sex toys. among our participants who have never used a sex toy, a significant portion said they would be willing to try doing so in the future. future research could examine prevalence, comfort with, and characteristics of sex toy use among a more sexually and racially diverse sample. implications for sexual health will be discussed in terms of the positive sexuality and positive technology frameworks. keywords: sex toys, sexual aids, sexual dysfunction, sexual assault, convenience sampling 6 fippen & gaither levels of comfortability with sexual aids among participants who report having ever experienced a sexual assault, sexual dysfunction, and/or ptsd. in addition to past and present sex toy usage, we asked participants about past experiences with sexual assault, ptsd, and religiosity, as well as perceived positive and negative effects of and comfortability with sex toys. literature review sex toys trends a plethora of research regarding sex toys and their users is not currently available, due to a lack of empirical studies. this lack of research may be informed by the consideration of many americans that sex toys, and discussions of sex in general, are taboo. many discussions about sexual behavior and sexual health are clouded by discomfort, awkwardness, and a negative stigma (schwallie, 2020). however, a select few studies have been conducted, such as the research by reece and his colleagues (2010), as well as by döring and poeschl (2020). these studies aimed to examine rates of sex toy and sexual aid use among singles and couples, what individual demographics influence people to consume these toys, and exactly what kinds of toys these groups are using. further, these studies were conducted using nationally representative samples, which implies that there is a high level of confidence that the data can be generalized to the larger population. throughout the existing literature, it has been repeatedly found that women are the largest consumers of sex toys, especially vibrators, with queer women having the highest rates of use. it has been found in one sample that around 90% of women reported ever having used sex toys during partnered sex, masturbation, or both (fahs & swank, 2013). approximately 37.3% of women reported ever having used a vibrator during partnered sexual intercourse, while 46.3% reported ever having used a vibrator during foreplay (herbenick et al., 2009). 85% of women (n = 889) reported feeling comfortable using a vibrator alone while 69.6% reported that they feel comfortable using a vibrator with a partner (herbenick et al., 2010). however, rates of sex toy use during solo masturbation vary by study, with reece and his colleagues (2010) finding that 46.3% of women have ever used a vibrator alone during masturbation. comparatively, in döring and poeschl’s (2020) research, they found that 72% (n = 366) of women – almost three-fourths, reported ever having used a toy designed to stimulate the vagina or vulva during solo sex. rates of reporting may vary due to fear of judgment, social stigma, or sampling methods, as was reported by participants in fahs and swank’s (2013) study. these studies indicate that many women, if not comfortable enough to incorporate sex toys into their solo and/or partnered activities, are at least familiar with different types of sex toys and their uses. an important note to make regarding women’s sex toy use is that attitudes and perceptions tend to vary based on sexual orientation, as demonstrated by the work of fahs and swank (2013). their study examined rates of sex toy use by sexual orientation and found that nonheterosexual women reported less shame and expressed more desire to use toys with a partner, as these women tended not to place such an emphasis on phallocentrism and heteronormativity. most of the heterosexual women, however, were more concerned about their partner’s attitudes and opinions on their use of sex toys, and feared that their partner would feel sexually inadequate, despite many of these participants reporting that their partner had never expressed these concerns. because nonheterosexual women tend to not place as much, if any, emphasis on sexual phallocentrism and heteronormativity, these women were better able to adopt a more playful connotation surrounding sex toys, both during solo and partnered sex. both groups of women were found to vary in their expression of agency in reference to their relationship with and feelings about sex toys, particularly penetrative toys, as heterosexual women were more likely to believe that masturbating without penetrative toys was abnormal and a cause for concern, while nonheterosexual women did not hold this belief. the work of fahs and swank (2013) effectively distinguishes rates of sex toy use among american heterosexual and nonheterosexual women, as well as discusses how sex toys often carry a negatative connotation when discussed within the confines of a heterosexual relationship. contrary to the popular belief that women use sex toys and sexual aids at higher rates, it has been found that rates of sex toy usage among men and women are similar, with 43.8% of men (n = 423) reporting that they had ever used a vibrator, either during solo or partnered sex (reece et al., 2010). comparatively, it was found by döring and poeschl (2020) that 34% of men (n = 295) reported ever having used sexu7 sex toy use in the us al aids designed for the stimulation of the penis and testicles, while 44% had ever used aids designed for the stimulation of the vulva and vagina. interestingly, sex toy usage varies by partnership among men, as has been found in reece’s and his colleagues’ (2010) research. reece et al. (2010) found that men in partnerships were much more likely to report ever having used a vibrator during partnered sexual intercourse, with 43% of men in romantic partnerships and 38% of married men displaying this trend. comparatively, only 21.3% of single men reported ever having used a vibrator during sexual intercourse with a partner. approximately one-third of the sample (n = 985) reported ever having used a vibrator during masturbation alone. the work of döring and poeschl (2020) and reece et al. (2010) indicate that sex toy use, particularly vibrator use, is common among heterosexual men, and is a phenomenon that should be studied further. similar to “sexual aid” research as a whole, there exists a lack of current research examining the rates and types of sex toy use among gay and bisexually identifying men. it has been found that, among gay and bisexual men (n = 25,294), nearly 80% report ever having used at least one type of sex toy (rosenberger et al., 2011), including dildos (62.1%), vibrators (49.6%), butt plugs (34.0%), masturbation sleeves (27.9%), and anal balls or beads (19.3%). a commonly reported phenomenon among gay and bisexual men is inserting a toy, such as a butt plug or dildo, into one’s own anus during masturbation (95.7%) or into their partner’s anus (72.0%). types of toys few existing studies have examined exactly what types of toys are being used by the overall population. in a study that aimed to examine the most used sex toys, as well as hygienic behaviors following their use, it was found that the most popular sexual aid is the vibrator, with 54.53% of people (n = 1,435) with a vulva and vagina reporting that they had ever used any sort of store-bought or homemade vibrator (wood et al., 2017). similarly, 21.26% of these people reported ever having used a dildo, and 9.26% reported using sexual toys related to bdsm (bondage, dominance, sadism, masochism), such as whips, anal beads, or devices used for restraint. among heterosexual men, 52% (n = 295) have reported using sex toys designed for the stimulation of the penis and testicles, such as cock rings or handheld masturbators, within the past year during solo sex (döring & poeschl, 2020). comparatively, 31% of men from the same sample reported using toys designed for the vagina and/or vulva, such as a vibrator, during solo sex within the past year. 26% of men reported ever having used toys for bondage or s&m (sadism and masochism), such as whips or cuffs, and 46% reported ever having used arousal-enhancing remedies, such as ingesting food or substances that elicit sexual desire (i.e., aphrodisiacs), during solo sex within the past year (döring & poeschl, 2020). sexual aids as treatment sexual aids are increasing in popularity as clinician recommended treatments for sexual dysfunctions, as well as for anxiety and fear following a sexual assault. nearly all the existing literature on sexual aid recommendation focuses on cancer-related sexual dysfunctions, which result from radiation targeted at the pelvis and surrounding areas. when radiation targets the pelvic area, it may damage nerves and arteries necessary for sexual functioning (american cancer society, 2020). sexual aids have recently been utilized for rehabilitation, as they may serve to increase sensitivity, functioning, and pleasure among cancer patients. however, as discovered by bober and his colleagues (2019), the majority of cancer survivors do not receive adequate support or education about sexual health. while exact statistics vary regarding sexual dysfunction as a side effect of cancer treatment, it has been found by andersen (1985) that 20 to 90 percent of adult cancer patients suffer from significant sexual dissatisfaction or dysfunction. however, among these various cancer-treatment centers, only 27% offer sexual aids and rehabilitation for women, while even fewer (13%) offer the same aids for men (bober et al., 2019). sexual aids, while serving to increase pleasure and intimacy among couples, can also serve as a form of rehabilitation for individuals suffering from sexual dysfunctions resulting from sexual assault, ptsd, and cancer-related treatments. further, physicians and clinics should make sexual rehabilitation in these instances more accessible to increase sensitivity and functioning among those with sexual dysfunctions. sexual dysfunction it has been found that sexual dysfunctions are common within the united states, affecting approximately 43% of women and 31% of men (rosen, 2000). among these sexual dysfunctions, hypoactive sexual desire is most common among women, with about 30% of the female population meet8 fippen & gaither ing the diagnostic criteria. erectile dysfunction is the most common sexual dysfunction among men, and rates vary due to the prevalence of this dysfunction growing exponentially with age (rosen, 2000). sexual dysfunctions have a variety of causes and may only arise during certain situations or circumstances. common psychological causes for sexual dysfunction include stress, anxiety, and depression (beaumont health, 2023). it has been found that when performance-related demands were placed on both sexually functioning and sexually dysfunctional men, the sexually dysfunctional men had lower levels of sexual arousal due to becoming distracted by the demand and the accompanying performance-related concerns (barlow, 1986). sexually dysfunctional men from the same study also reported that they perceived themselves as having less control over their sexual arousal than sexually functional men, even when levels of erectile response were the same. current literature outlines how sexual dysfunctions can have a strong influence on sexual confidence, anxiety, and the sense of control one feels over their sexuality. further, some common physiological causes for sexual dysfunction include neurological disorders, various prescription medications, alcohol and drug abuse, cancer and related treatments, and sexual assault (beaumont health, 2023). selective serotonin reuptake inhibitors (ssris), a medication commonly prescribed for depression, are commonly known as having adverse side effects, particularly in that they can contribute to the development of sexual dysfunction (jing & straw-wilson, 2016). while the exact cause of sexual dysfunction as a side effect of ssris is not known, researchers have identified that it is the reuptake process of particular neurotransmitters, such as serotonin or norepinephrine, that influence the emergence of sexual dysfunctions (prabhakar & balon, 2017). the effects of ssris on sexual functioning have been researched, and it has been found that around 40 to 50 percent of both men and women experience reduced levels of sexual arousal when taking an ssri (balon, 2006). in relation to cancer, sexual dysfunctions arise when radiation targets areas surrounding the pelvis, such as the prostate, rectum, colon, or ovaries. further, the psychological implications that may arise from enduring cancer treatments may contribute to lasting sexual dysfunctions, such as body dysmorphia resulting from hair loss or a change in weight (archangelo et al., 2019). the treatment of sexual dysfunctions today originates largely from the work of masters and johnson, who became pioneers of sex therapy after the creation and effective execution of sensate focus exercises in 1980 (auteri, 2014). sensate focus is a technique used to improve communication between partners regarding sex, reduce sexual performance anxiety, and shift away from goal-oriented expectations toward a more intimate and partner-focused experience (smsna, 2023). these sessions of non-demanding, sensual touching can increase comfortability with receiving touch from a partner. when exercised alone, this self-exploration can help an individual reclaim their sensuality and confidence. sensate focus is commonly used for dysfunctional problems such as female sexual interest/ arousal disorder, erectile dysfunctions, and male hypoactive sexual desire disorder. other commonly used treatments involve hormone therapy, cognitive-behavioral therapy (cbt), medications, and mechanical aids such as penile implants (cleveland clinic, 2020). one increasingly common treatment recommendation by sex therapists involves the incorporation of sexual aids or sex toys into masturbatory and partnered sexual activities. sex toys may increase sensitivity and pleasure, and may also help to alleviate anxiety and fear among individuals who have been sexually assaulted (rullo et al., 2020). however, individuals with dysfunction and/or sexual assault-related histories may be less inclined to use a sexual aid, either alone or with a partner, due to anxiety and fear surrounding sexual behaviors and sensual intimacy (kaplan, 1974). appropriate discussions between a client and their clinician are necessary to help determine what aids would be the most beneficial, as well as to determine how and when to use these particular aids. an increasing amount of literature is being made available to help guide the public in their sexual-aid endeavors, especially regarding dysfunction and sexual assault. for example, rullo et al. (2020) posit that “there is no wrong way to use a vibrator. patients should be encouraged to explore vibrator use all over the body, not just the genitals, and be reminded that vibrator use is for both men and women” (p. 7). these guidelines, and others like them, may help to increase comfortability with the use of sex toys and sexual aids. sexual assault according to the rape, abuse, and incest national network (rainn, n.d.), sexual assault can be 9 sex toy use in the us defined as: sexual contact or behavior that occurs without explicit consent of the victim. some forms of sexual assault include: attempted rape, fondling or unwanted sexual touching, forcing a victim to perform sexual acts, such as oral sex or penetrating the perpetrator’s body, [and] penetration of the victim’s body, also known as rape. rates of sexual assault among women is a topic that has been highly researched, with previous findings indicating that upwards of 20 to 30 percent of women have experienced rape or attempted rape at least once during their lifetime (koss, 1993, as cited in ullman & brecklin, 2002). sexual assault is the least reported violent crime, with less than one-third of sexual assaults being reported to law enforcement (rainn, n.d.). reasons for not reporting an assault may include fear of retaliation by the perpetrator, a belief that law enforcement won’t succor the situation, or a belief that the incident wasn’t severe enough to report. the reporting of a sexual assault is less frequent among male victims, as men may be reluctant to report instances of sexual assault due to a widespread societal belief that men are perpetrators, not victims, or due to the belief by the victim that the incident was not actually assault (ullman & brecklin, 2002). further, a common physiological response to anxiety or fear is sexual arousal, and many instances of sexual assault are discounted legally because the victim retained an erection and/or experienced ejaculation during the assault (bullock & beckson, 2011). regardless of reporting status, experiencing a sexual assault has been found to be highly correlated with a decline in mental health (ullman & brecklin, 2002), as well as the development of post-traumatic stress disorder (ptsd). sexual assault may lead to serious mental and physical health complications and can contribute to the development of a sexual dysfunction. further, various assault-related factors, such as the severity of the assault or perceived level of social support, can influence the severity and duration of implications following the assault. according to the cdc (2021), nearly one in five american women are victims of attempted or completed rape, and one in three female rape victims first experienced an assault between the ages of 11 and 17. additionally, it is estimated that around 30% of current ptsd diagnoses were a direct result of sexual assault or sexual violence (texas a&m health, 2019). following an assault, common responses among women include panic attacks, flashbacks, depression, sexual dysfunctions, anxiety, and phobias, as well as an increase in overall anger, fear, guilt, and alcohol and drug abuse (us department of veterans affairs, n.d.). currently, cognitive-behavioral therapy (cbt) is the most common form of psychotherapy used to treat individuals dealing with psychological problems, such as dissociation or ptsd, following a sexual assault. many treatments have been empirically proven to improve individual symptoms dependent from ptsd, such as anxiety and depression, these treatments are often incorporated into a multifaceted treatment plan. recently, treatment plans began recommending the use of sexual aids, as “vibratory stimulation of the genitals is an evidence-based treatment” (rullo et al., 2020, p. 2) for many sexual dysfunctions, including hypoactive sexual desire in men and female sexual interest/arousal disorder. through the process of psychotherapy, victims of sexual assault are helped to recognize and target their feelings about the assault, and to increase their levels of self-confidence and comfortability. experiencing a sexual assault may result in sexual dysfunction or related issues, such as post-traumatic stress disorder (ptsd). current treatments for individuals suffering from psychological afflictions following a sexual assault include cognitive-behavioral therapy (cbt), sensate focus exercises, the prescription of ssris, and individual and/or couples’ therapy (falsetti & bernat, 2000). it has been determined by previous research that psychotherapy is necessary to restore declining mental health following a sexual assault (kaplan, 1974). additionally, research suggests that using sex toys or aids is beneficial in overcoming physiological implications following an assault, such as dysfunction issues and their accompanying psychological implications. the present study previous literature has briefly examined sex toy and sexual aid use, as well as explored demographic trends for each. however, the literature fails to examine levels of comfortability among individuals, as well as potential willingness regarding sex toy use. the present study aims to expand on the conversation held by herbenick and her colleagues (2010) regarding participant comfortability with sexual aids in solo 10 fippen & gaither and partnered sexual behaviors. further, no current research exists on the correlations among sexual assault, sexual dysfunction, ptsd, and sex toy and sexual aid use. the present study aims to fill these gaps by asking participants about their previous experiences using and researching sex toys, their levels of comfortability or willingness regarding these toys, and how levels of comfortability may be influenced by a previous history of sexual assault, dysfunction, and/or ptsd. understanding american adults’ comfortability and willingness to use sex toys can potentially provide insight into why sex remains a taboo topic within the united states, how to best introduce sex toys into one’s sexual practices, and how to incorporate sex toys and sexual aids most comfortably into sexual assault and dysfunction related treatments. the present study was influenced by the work of döring and poeschl (2020), as their study introduced an important aspect of participants’ sexual ideology by asking participants about their self-perceived positive and negative effects, giving valuable insight into rates and trends regarding sex toy usage. data provided by the participants of this study will be analyzed in accordance with the positive sexuality and positive technology frameworks. the positive sexuality framework views sexuality through a pragmatic yet multidisciplinary lens while addressing the full range of positive and negative implications that arise from engaging in sexual behavior. by analyzing sexuality through a positive framework, socially negative sexual stigmas can be avoided, and sexuality can be understood as a means of individuality, interrelationship strengthening, pleasure, and peacemaking (williams, 2015). further, this framework acknowledges the risks and negative consequences that can accompany sexuality and sexual behavior. to combat these negative implications, the positive sexuality framework emphasizes education and communication as a means of understanding. the positive technology framework views technology as a means of “fostering personal growth and individual integration in the sociocultural environment, by promoting satisfaction, opportunities for action, and self-expression” (riva et al., 2012, p. 69) technology, in some capacity, can influence and enhance nearly every constituent of human experiences and overall functioning. further, this framework considers sexual aids to be not only devices used for pleasure, but also therapeutic aids that can help to reduce sexual anxieties, physical pain, sexual dysfunctions, and the accompanying implications that these factors may have on sexual functioning. in combination with the positive sexuality framework, sex toys and sexual aids can be viewed as a technological innovation that could potentially help millions of people become more comfortable with their bodies and sexualities. purpose and hypotheses the purpose of this study is to better understand the prevalence of americans’ sex toy and “sexual aid” use through the lenses of the positive sexuality and positive technology frameworks. the following hypotheses were generated: hypothesis 1: women will report higher rates of sex toy and sexual aid usage than men, as found by döring & poeschl (2020). hypothesis 2: compared to men, women will report higher usage of sex toys designed to stimulate the vulva and vagina, and lower usage of sex toys designed to stimulate the penis and testicles, during only masturbatory behavior, as found by döring & poeschl (2020). hypothesis 3: among participants who report that they have never used a sex toy but would be willing to, there will be no significant difference between men and women in levels of willingness to use sex toys. hypothesis 4: women will report more comfort using and researching sex toys than men. hypothesis 5: among women, the most used sex toys will be toys designed for stimulation of the vagina and vulva, as found by wood et al. (2017). hypothesis 6: among men, the most used “sexual aid” will be toys designed to stimulate the penis and testicles. hypothesis 7: participants with a history of sexual assault will be less likely to report using sex toys and sexual aids for both solo and partnered sexual activity. hypothesis 8: regarding sexual assault and sex toy use, there will be a gender effect such that women who report having experienced a sexual assault will be significantly less likely to have used toys than those who haven’t. however, there will be no difference in sex toy usage between men who have and have not been sexually assaulted. hypothesis 9: regarding sexual dysfunction and sex toy use, there will be a gender effect such that men who report having experienced a sexual dysfunction will be significantly more likely to have used toys than those who haven’t. however, there will be 11 sex toy use in the us no difference in sex toy usage among women who have and have not experienced a sexual dysfunction. method participants the data collected by dr. gaither and his students was obtained largely through reddit, using convenience sampling. a total of 311 participants entered the survey, while 231 fully completed the survey, as some participants exited the survey early. the only exclusion criterion for this study included being under the age of 18. participants of this study (n = 231) were between the ages of 18 and 71 (m = 24.89, sd = 8.59). slightly over two-thirds of participants were women (68.3%, n = 224), compared to 26.5% of the participants being male (n = 87). for racial demographics, 82.9% of participants were caucasian (n = 272), 3.4% were hispanic (n = 11), 3.0% were asian (n = 10), 2.4% were african american (n = 8), 1.4% were latinx (n = 4), 0.3% were pacific islander or native hawaiian (n = 1) and 4.9% reported being of another race not listed (n = 16). most participants identified as heterosexual (63.7%, n = 209), while 18.0% identified as bisexual (n = 59), 3.7% identified as gay (n = 12), 4.0% identified as lesbian (n = 13), 3.7% identified as pansexual (n = 12), 2.4% identified as asexual (n = 8), and 2.4% identified as another sexual orientation not listed (n = 8). when asked about levels of religiosity, 48.5% of participants reported that they were not at all religious (n = 159). similarly, 25.0% reported that they were slightly religious (n = 82), 15.9% reported that they were moderately religious (n = 52), 7.3% reported that they were very religious (n = 24), and 1.2% reported that they were extremely religious (n = 4). when asked, “have you ever been sexually assaulted?” 34.5% of participants responded with yes (n = 113). when participants were asked “have you ever been diagnosed with posttraumatic stress disorder (ptsd)?”, 9.5% of participants responded with yes (n = 31). when asked, “have you ever had problems functioning sexually?”, 32.0% of participants responded with yes, i have had some problems with functioning sexually, but have never been officially diagnosed with a sexual dysfunction (n = 105), while 2.4% responded with yes, i have been diagnosed with at least 1 sexual dysfunction in my life (n = 8). there was no incentive provided to participants for completing the survey. measures/materials participants completed a survey that contained several subscales within it. as part of a larger study, participants completed several items that included demographics, comfort, use of toys, experiences with assault and dysfunction, and measures of personality. questions regarding specific variables (e.g., previous experiences using sex toys, sexual assault, sexual dysfunction, etc.) were concise and straightforward to make sure participants fully understood each item. this study will not explain all variables utilized in the survey and will only explain relevant variables. variables excluded from the analysis and discussion include satisfaction and personality. self-perceived positive and negative effects, while not part of the initial analysis, will be explored more in the discussion section. sociodemographic characteristics the first set of items were demographic items including age, race, gender, sexual orientation, birth country, and levels of religiosity. experience with sexual assault was assessed with single item (“have you ever been sexually assaulted?”), with response options of yes and no. use & comfort with use of sex toys the next section of the survey asked participants about their previous experience with sex toys and sexual aids. items asked participants about their previous experience with sex toys, if they had ever researched a sex toy, what sex toys they had previously used, levels of comfortability with using and researching sex toys, comfortability with attending a sex toy party, and perceived positive and negative effects of using a sex toy. examples of survey items include “have you ever looked into, or researched sex toys?” and “have you ever used a sex toy for masturbation?” with response options of yes, no but i would be willing to do so in the future, and no and i cannot see myself ever doing so. if respondents answered yes, they were taken to a follow-up question that asked, “how comfortable were you when you researched sex toys (or when you used a sex toy for masturbation)?”. response options for comfortability items utilized a 7-point likert scale, which ranged from extremely comfortable (1) to extremely uncomfortable (7). if respondents answered no but i would be willing to do so in the future, they were taken to a follow-up question that asked, “how comfortable do you think you would be if you were to research sex toys (or if you were to use a sex toy for masturbation)?” response options 12 fippen & gaither for expected comfortability ranged from extremely comfortable (1) to extremely uncomfortable (7). if respondents answered no and i cannot see myself ever doing so, no item regarding comfortability was presented. for comfort items, higher numbers within the data indicate lower levels of comfortability. sexual dysfunction the next section of the survey, which had three items, asked about participants’ previous history with sexual dysfunction. present survey items were based on items from the 1992 national health and social life survey, which aimed to better understand americans’ various sexual practices, as well as the surrounding life circumstances and social contexts in which these practices occur. an example of one of the survey items includes “have you ever had problems functioning sexually or been diagnosed with a sexual dysfunction?” with response options including no i have never had any problems functioning sexually, yes i have had some problems with functioning sexually, but never been officially diagnosed with a sexual dysfunction, and yes, i have been diagnosed with at least 1 sexual dysfunction in my life. if respondents answered this item with anything other than no i have never had any problems functioning sexually, they were taken to a follow-up question, also modeled from the nhsls, that asked about the specific sexual dysfunction that the respondent has experienced. respondents were asked to report on whether they have experienced lacking desire for sex, arousal difficulties, inability achieving climax or ejaculation, anxiety about sexual performance, climaxing or ejaculating too rapidly, physical pain during intercourse, and not finding sex pleasurable. for each of these dysfunctions, respondents were presented with response options of yes and no. procedure recruitment ads for the study (i.e., convenience sampling) were posted on reddit.com/samplesize and on the ball state university communications center during the fall of 2020. people who were interested in participating clicked on a link to the anonymous survey which began with a study information and consent page. those who did not click “i agree” were skipped to the end of the survey; otherwise, they entered the survey. the first question asked for age; anyone who typed in a number less than 18 was skipped to the end of the survey. those who remained in the survey answered questions about demographics, experiences and comfort with sex toys from a variety of perspectives (e.g., ever researched toys, used them, bought them, attended a party, etc.). participants also completed items regarding whether they had ever been sexually assaulted, diagnosed with ptsd, experienced problems in sexual functioning, or been diagnosed with a sexual dysfunction. they completed short forms of the openness and extraversion subscales of the big five inventory, the behavioral subscale of the sociosexual orientation inventory, and the sexual esteem subscale of the sexuality scale. finally, participants completed items regarding their relationship and sexual satisfaction, as well as their perceived effects of sex toy use. once participants reached the end of the survey, they were thanked for their participation. the data was analyzed using spss software. a series of frequency tests, chi-square, one-way anovas (cross tabulations), and independent samples t-tests were conducted to examine the data and to compare with the generated hypotheses. frequency tests were used to analyze demographic information and to obtain the frequencies of the number of participants for individual items. the chi-square crosstabs were used to better uncover the correlation between specific variables, such as sex toy use and previous experiences with sexual assault. crosstabs were used to analyze means between various groups of conditions, such as between male and female sex toy users who either have or have not been sexually assaulted. t-tests were used to measure the means between two groups regarding various items, such as measuring the mean comfort level when using a sex toy during masturbation among individuals who report that they have or have not dealt with sexual functioning issues. significance levels were adjusted using the bonferroni correction method to attribute for running multiple analyses results acquisition of sex toys both male and female participants of this sample (n = 231) were overall well acquainted with sex toys and sexual aids. a series of frequency tests were run, split by gender, to better understand the prevalence of participants’ acquisition on each item. 84.2% of all participants reported that they had ever researched or looked into sex toys, and 80.4% said that they had looked at sex toys in an online shop. 41.8% of participants had ever spoken to someone else about sex 13 sex toy use in the us toys, and 17.7% had ever received a sex toy as a gift. a majority of the sample (69.8%) had ever bought a sex toy themselves. a series of crosstabs were also run to determine statistical significance regarding the acquisition of sex toys between the genders. overall, there was no significant difference between men and women on measures of acquisition of sex toys, except for items that asked about sex toy parties. there were no men within the sample that reported ever being invited to a sex toy party or ever hosting a sex toy party. because none of the men reported that they had ever been invited to attend a sex toy party, they were not shown the follow-up question “have you ever attended a sex toy party that someone else hosted?” however, 13.8% of male participants who reported that they had never hosted a sex toy party also reported that they would be willing to host a party in the future (p = .002, see table 1). among female participants (n = 224), 63.7% reported that they had ever attended a sex toy party, and 5.5% reported that they had hosted a sex toy party. sex toy use, comfort, & willingness in solo sex sex toy use was analyzed by running a series of crosstabs to determine statistical significance during masturbation between the genders. all percentages regarding sex toy use, comfort, and willingness in solo sex can be found within table 1. most participants (70.4%) reported that they had ever used a sex toy during solo sex, while 19% reported that they had not yet, but would be willing to do so in the future. women reported using sex toys more than men during masturbation, with 76.1% of women reporting ever having used a sex toy during solo sex, compared to 63.1% of men (p = .04, see table 1). this finding provides support for the first hypothesis. among women, the most used sex toys and sexual aids during masturbation included toys designed for the stimulation of the vagina and vulva (69.2%), lubricants (42.9%), and erotic lingerie (22.8%). among men, the most used sex toys and sexual aids during masturbation included lubricants (47.1%), toys designed for the stimulation of the penis and testicles (42.5%, p < .001, see table 2), and toys designed for the stimulation of the vagina and vulva (26.4%). although a notable number of men reported having used toys designed for the stimulation of the vagina and vulva, women were significantly more likely to use these same toys during masturbation (p < .001, see table 2), and this provides support for the second hypothesis. percentages regarding specific sex toys can be found in table 2. an independent samples t-test, split by gender, was run to determine the means of comfortability regarding sex toy use during solo sex for each item, with lower means representing higher levels of comfortability. women largely reported being slightly more uncomfortable (m = 1.70, sd = 1.17, d = -.05) when having used a sex toy during masturbation compared to men (m = 1.64, sd = 1.19; see table 3). overall, there were no significant differences between men and women on items of comfort, except that men reported feeling significantly more comfortable, t (153) = -2.32, when researching a sex toy (m = 2.09, d = -.29, p = .022) compared to women (m = 2.51, see table 3). these findings are directly contradictory to the fourth hypothesis. overall, men reported higher comfort with all items relating to acquisition (e.g., research, talking to others, purchasing, receiving a toy as a gift), as well as use during masturbation and partnered sexual activity. these data could be skewed by the disproportionate number of women to men, but the women within this sample consistently reported slightly higher levels of discomfort than the men on all measures. a series of crosstabulations were run to determine statistical significance among participants who have never used a sex toy during masturbation but would be willing to do so in the future. among individuals who have never used a sex toy but would be willing to, there were no significant differences between men and women on willingness to use sex toys during masturbation, except that men reported significantly more willingness, x2(1) = 28.56, to try toys designed for the stimulation of the penis and testicles than women (p < .001; see table 1). this finding is directly contradictory to hypothesis three, which predicted no difference in levels of willingness between the genders. trends reflect that men within this sample are more willing to try lubricants, remedies for enhancing arousal, and toys designed for the stimulation of the penis and testicles, whereas women are more willing to try erotic lingerie, toys designed for the stimulation of the vagina and vulva, and toys for bondage and s&m. sex toy use, comfort, & willingness in partnered sex all percentages regarding sex toy use, comfort, and willingness in partnered sex can be found within table 1. 46% of men and 55.4% of women reported ever having used a sex toy during partnered sexual ac14 fippen & gaither tivity, which was analyzed through a series of crosstabulations. although there was no statistically significant difference among men and women for types of toys used during partnered sex, trends indicate that women are more likely to have used erotic lingerie (33.5%) and toys for stimulation of the vagina and vulva (46.9%) during partnered sexual activity within the past 12 months. men and women were about equally likely to have used lubricants (35.6% of men vs. 40.6% of women), remedies for enhancing arousal (4.6% vs. 5.8%), toys designed for the stimulation of the penis and testicles (19.5% vs. 15.2%), and toys for bondage and s&m during partnered sexual activity (21.8% vs. 23.2%) within the same time frame. percentages regarding specific sex toys can be found in table 2. interestingly, trends indicate that men reported being more willing to try every sex toy listed during intercourse with a partner than women, as analyzed through a series of crosstabulations. there was a statistically significant difference in that men reported being more willing to try toys designed for the penis and testicles during partnered intercourse than women (p < .001). this data reflects that men and women are about equally as likely to try various sexual aids and sex toys during masturbation, other than toys designed for the penis and testicles, but that men are more willing than women to incorporate toys into partnered sexual activity. this finding challenges the dominant heteronormative belief that most men are against bringing sex toys into partnered sexual activities. sex toy use & comfort among victims of sexual assault all factors relating to the use and comfort of sex toys among victims of sexual assault were analyzed through a series of crosstabulations and independent samples t-tests. 13.8% of men within the sample reported ever having experienced a sexual assault, compared to 41.7% of women, as shown through a frequency analysis. among men who reported ever having experienced a sexual assault, 81.8% reported ever having used a sex toy during masturbation, while 9.1% reported that they had not but would be willing to do so in the future. among women who experienced an assault, 81.5% had ever used a sex toy during masturbation, while 15.2% reported that they had not but that they would be willing to do so in the future. it is noteworthy to emphasize that nearly an identical percentage of men and women who have been sexually assaulted reported using a sex toy during masturbation (81.8% vs. 81.5%), and that men reported slightly higher rates of toy use during masturbation compared to women. among men who have been sexually assaulted, 63.6% reported ever having used a sex toy during partnered sex, while 36.4% reported that they had not but that they would be willing to do so in the future. none of the men who reported having been sexually assaulted reported that they would never be willing to try sex toys during partnered sex. among women who have been sexually assaulted, 68.9% reported that they had ever used a sex toy during partnered sex, while 21.1% reported that they had not but that they would be willing to do so in the future. although not statistically significant, it is noteworthy to mention that trends indicate that both men and women who have been sexually assaulted are more likely to have used toys than those who have never been sexually assaulted, both during masturbation and sex with a partner. this finding directly contradicts the seventh hypothesis and slightly contradicts the eighth hypothesis in that there was no gender effect for sex toy use among those who have been sexually assaulted. however, both men and women who have been sexually assaulted also reported lower levels of comfortability during their previous experiences using sex toys. among participants who have never been sexually assaulted, men reported more comfortability on all items. the reverse effect was found among participants who reported ever having experienced a sexual assault in that men reported much lower levels of comfortability than women who have been sexually assaulted. among men who have ever used toys during masturbation, those who have been sexually assaulted reported much lower levels of comfortability (m = 2.33) than those who have never been assaulted (m = 1.64). among women who have ever used sex toys during masturbation, those who have been assaulted reported only slightly lower levels of comfortability (m = 1.76) than those who have never been assaulted (m = 1.70). among men who have ever used sex toys during partnered sex, those who reported ever having experienced a sexual assault reported much lower levels of comfortability (m = 2.71) than those who have never been assaulted (m = 1.75). among women who have ever used a sex toy during partnered sex, those who reported ever having experienced a sexual assault reported only slightly lower levels of comfortability (m = 1.95) than 15 sex toy use in the us those who have never experienced a sexual assault (m = 1.90). the potential factors contributing to this phenomenon will be discussed in the discussion section. sex toy use & comfort among those with sexual dysfunctions toy use and comfort among participants who have at least one sexual dysfunction were analyzed through a series of crosstabulations. 32.2% of men and 35.7% of women reported ever having experienced problems with sexual functioning, either with or without a formal diagnosis. among men who reported ever having experienced a sexual dysfunction, 17% reported that they had ever used a sex toy during masturbation, while 5.0% reported that they had not but that they would be willing to do so in the future. similarly, 17.5% of men in the same subsample reported that they had ever used a sex toy during partnered sex, while 11.8% reported that they had not but that they would be willing to do so in the future. among women who reported ever having experienced a sexual dysfunction, 45.2% reported that they had ever used a toy during masturbation, while 35.9% reported that they had not but that they would be willing to do so in the future. similarly, half of the women who reported ever having experienced a sexual dysfunction (50.0%) also reported that they had ever used a sex toy during partnered sex, while 27.9% reported that they had not but that they would be willing to do so in the future. although not statistically significant, both men and women who reported having experienced a sexual dysfunction also reported using sex toys during both masturbation and partnered sexual behavior at lower rates than those who have never experienced a sexual dysfunction. this finding refutes hypothesis nine, seeing as both men and women who have a sexual dysfunction reported lower rates of sex toy use than those without a sexual dysfunction. regarding comfortability using sex toys among those with sexual dysfunctions, women reported lower levels of comfortability on both items of masturbation (m = 1.84) and partnered sex (m = 2.02) than those who have never experienced a sexual dysfunction. among men, those who reported ever having experienced a sexual dysfunction reported feeling more comfortable when using a sex toy during masturbation (m = 1.37) compared to those who have never had a sexual dysfunction (m = 1.79). however, the reverse effect was found during partnered sex, in that men who reported having experienced a sexual dysfunction reported less comfortability when using a sex toy with a partner (m = 1.81) compared to those who have never had a sexual dysfunction (m = 1.71). discussion sex toys and sexual “aids” have existed throughout history and all over the world to help promote sexual stimulation and physiological responses. since the rise of modern technology, the sex toy market has blossomed into a multi-billion-dollar industry, primarily emphasizing sexual pleasure. however, sex toys can also harbor a therapeutic function, eliciting sexual responsiveness among those with sexual dysfunctions. further, sex toys can be a means of regaining comfortability with sexuality and sexual intimacy among individuals who have experienced a sexual assault (rullo et al., 2020). the findings of this study correlate with the positive sexuality framework, seeing as participants acknowledged both the positive and negative effects of sex toy use, but also reported a significant level of willingness to learn about and use sex toys in the future. the empirically proven benefits of sex toys and sexual aids for dysfunction and assault-related implications align with the positive technology framework in that sex toys and sexual aids, through means of increasing sensitivity and overall pleasure, serve to increase sexual functioning as well as the overall quality of life for users. american participants within this sample have reported considerate sex toy use, both during solo and partnered sex. men and women reported similar rates of sex toy use, both during solo and partnered sex, although women consistently reported higher usage of sex toys overall. similarly, among those who reported that they have never used sex toys, a decent percentage reported that they would be willing to try incorporating them into their masturbatory or partnered sexual behavior. this data indicates that most american adults who have not experienced using sex toys would be willing to try one in the future. the sex toy industry should consider this group of willing individuals as an entirely separate group of consumers and should market to this group accordingly. sex toy shops and websites are often hypersexualized and intimidating environments. further, sex toy shops can be very overstimulating, expensive, and confusing for first-time buyers, and perhaps a different approach to sex toy con 16 fippen & gaither sumerism would benefit those who are willing to try sex toys but have not yet been able to have that experience. this approach could include a less overtly sexual environment, as well as an emphasis on education and pleasure for all participating individuals, as opposed to some typical sex shops that advocate for the infantilization, domination, and hypersexualization of women. when compared to the results of döring & poeschl’s (2020) study, participants in the present study reported higher rates of sex toy use during masturbation when compared to partnered sex. however, rates of sex toy use were similar between german and american participants among items of partnered sexual activity. the only item in which germans scored higher than american participants was on measures of sex toy use during partnered sex, in which german men reported higher usage of sex toys than american male participants. this finding indicates that perhaps germany, and europe at large, has a more relaxed and sex-positive stance on sex toys, and thus are used more during partnered sex. among participants of the present study, women reported higher rates of sex toy use during both masturbation and partnered sexual activity. women reported higher usage of sex toys designed to stimulate the vagina and vulva overall, while men reported higher usage of toys designed to stimulate the penis and testicles which provides support for hypotheses five and six. trends indicate that men are more willing to try all toys listed in the survey during partnered sex, with the only statistically significant finding being that men were significantly more willing to introduce toys designed for the penis and testicles into partnered sexual activity than women were?. this finding directly counters the assumption by many women that men are unwilling or uncomfortable with incorporating sex toys into partnered sexual activities (fahs & swank, 2013). open communication between sexual partners is necessary to establish willingness and comfortability with incorporating sex toys into partnered sexual behaviors. there exists a toxic, heteronormative belief that most men are against the incorporation of sex toys into partnered sexual activity due to the accompanying belief that men should be able to completely satisfy their partner on their own, with their own bodies. however, the present data is directly contradictory to this harmful belief, as it was found that many men are willing to incorporate sex toys into partnered sexual activity. accompanying this willingness should be education. sex toy parties are one safe environment to learn more about different kinds of sexual “aids”. among the men in our sample, 13.8% reported that they would be willing to host a sex toy party if given the opportunity, this was found to be statistically significant. because various state laws (alabama anti-obscenity enforcement act, 1998; texas public indecency act, 1973) consider the sale of sex toys to be a form of solicitation, men are often not allowed at sex toy parties. further, many sex toy companies, such as pure romance, claim that “having some men in attendance would make some women uncomfortable” (sex toys, 2021). due to these hindrances in male attendance to toy parties, male participants within this study were not asked if they have ever been invited to attend a party, and were therefore not asked if they’ve ever attended one nor about their levels of willingness regarding attending a party. this data reveals that a decent portion of men want or are willing to attend a sex toy party to learn more about and potentially purchase toys for themselves and their partners. male sex toy parties could be an effective way for more men to learn about and purchase sex toys within an educational environment. further, all individuals should feel comfortable expressing their desires with their sexual partner and be receptive to their partner’s desires, because open communication may reveal that they are more willing to try new sexual experiences than previously thought. one of the most prevalent findings of this study is that, among participants who report ever having experienced a sexual assault, both men and women report higher rates of sex toy and sexual aid usage during masturbation and partnered sexual activity, but also report lower levels of comfortability doing so. this finding is directly contrary to hypotheses seven and eight, as it was expected that the trauma of sexual assault would provoke fear of sexual behavior among victims and would deter them from using sex toys. however, participants that have been sexually assaulted reported the highest rates of sex toy usage of all participants, this could be due to several factors. victims of sexual assault have experienced a violation of bodily autonomy that may take a substantial amount of time to gain back, and sex toys may be one way for victims to reclaim their sexuality. rather than placing sexual pleasure and other sexual expectations on another person, sex toys are an efficient way to gradually increase the intensity or fre17 sex toy use in the us quency of physiological sexual responses and can help to increase desire. sexual aids, such as lubricants or vaginal dilators, could prove useful in increasing comfortability or eliciting a sexual response among individuals who may or may not suffer from negative implications, such as trauma or a sexual dysfunction, following a sexual assault (kaplan, 1974; petrak & hedge, 2002). however, the finding that those who have ever experienced a sexual assault, despite using toys at higher rates, also reported lower levels of comfortability during these experiences with toys was unexpected. lower comfortability with sexual activity or material following a sexual assault is common and can be expected due to the high prevalence of trauma and ptsd development after an assault (texas a&m health, 2019). similarly, a common reaction to sexual assault is a change in sexual desire or activity, such as an increase in the amount of sexual or masturbatory behavior the victim engages in. within this sample, a higher rate of sex toy usage and lower levels of comfortability were reported among those who have ever been sexually assaulted when compared to those who have never been sexually assaulted. higher levels of toy use, despite lower levels of comfortability using these toys, may be reflective of an attempt to regain comfortability with sexual activities through the use of sex toys. similarly, if the sexual assault resulted in a sexual dysfunction, the use of sex toys could be a means of sexual rehabilitation, despite conflicting levels of comfort. for example, vibrators that are smooth and shorter in length and circumference may be beneficial for patients who deal with genital, anal, or pelvic pain, or pain during sexual activity (rullo et al., 2018). regardless of why these rates of toy use and comfort persist among those who have ever been sexually assaulted, clinicians should recommend sex toys to clients with caution and guidance to help provide them with the necessary resources to regain sexual comfortability and confidence. both men and women who suffer from at least one sexual dysfunction reported lower rates of sex toy usage during masturbation and partnered sexual behavior than those who do not suffer from a sexual dysfunction. lower levels of comfortability were also reported by the same group of participants, this could be due to various factors. individuals who suffer from sexual dysfunctions may feel a sense of embarrassment or incompetency due to not wanting or not being able to perform sexually, and this may contribute to lower levels of comfortability using toys. participants who reported ever experiencing a sexual dysfunction may feel as though sex toys won’t work to increase their sexual desire or functioning, and some of these participants may choose to abstain from any sexual behavior at all. sensate focus and related treatments for sexual dysfunctions have been empirically proven to alleviate anxiety surrounding sexual activity and performance (auteri, 2014; masters & johnson, 1980), which could prove useful among individuals who suffer from sexual dysfunctions that worsen with heightened anxiety. further, the incorporation of sex toys into sensate focus exercises could elicit a stronger sexual response or sexual arousal than normally experienced due to increased physiological sensitivity (rullo et al., 2020). sensate focus allows an individual to focus purely on the physiological sensations that make them feel good, by ridding sexual behavior of expectations of orgasm, ejaculation, and pressure to please a partner. further, it can help those with sexual dysfunctions become more comfortable with their sexual identity and to better understand what types of sensations they enjoy the most. although not part of our initial analysis, we did examine the self-perceived positive and negative effects of sex toy use among participants. there were substantially more positive effects reported compared to negative effects. examples of some positive effects of sex toy use reported by participants include: “allowing me to be kinky and really bond with my partner,” “butt plug helped me come out to my friends,” “rabbit vibrator allowed for my partner to climax multiple times after i climaxed,” and “couples vibrator (like wevibe), or bullet vibrator during intercourse, helped my partner to relax, and to climax, enhancing overall enjoyment.” there were several repeated trends among self-perceived positive effects of sex toy use. several men reported that the use of penetrative sex toys, such as butt plugs or dildos, helped them to become more comfortable with their sexuality. both men and women reported that the use of couples’ toys, such as a joint vibrator, has helped to increase the desirability and frequency of orgasms and strengthened the bond between partners. many women reported that the use of vibrators and/or dildos has helped them to become more familiar with their bodies and has improved their sex life by allowing them to better learn which types of touch they prefer where. sex toy use can have great effects on sexual functioning and the strengthening 18 fippen & gaither aspects of education, sexuality, consent, individual and interpersonal identity, and learning which techniques can help a client maximize comfortability and pleasure. this form of sex therapy may involve sex toys, which can be utilized at the client’s request to better understand how these sexual aids can increase arousal, pleasure, and intimacy alone or between partners. “most practitioners will say their client sessions are around 30% touch and 70% non-touch such as establishing boundaries, breathwork, nervous system regulation, embodiment techniques, and movement” (rowett, 2020). although met with significant resistance, sexological bodywork is increasing in popularity among individuals who suffer from sexual dysfunction, trauma, or assault-related issues, and shows significant promise for the future of sex therapy. however, the ability for a clinician to touch a client’s body and manipulate their genitals for purposes of tension redistribution and sexual education is currently illegal in all states except california, where only a select few individuals are licensed to practice sexological bodywork (rowett, 2020). this is a recent modality of sex therapy and education, thus accounting for the lack of empirical research on its benefits. however, numerous female clients have been taking to the internet to blog about their positive experiences with the practice (magner, 2017; dubofsky, 2018). just as vibration techniques were used as a clinical means of treating hysteria among 20th-century women (horowitz, 2020), sex toy use in sex therapy or sexological bodywork shows promise for the treatment of sexual dysfunctions or issues surrounding sex following a sexual assault. limitations this study had several limitations. because data was collected in the form of an anonymous survey, the data relies on self-report measures of sexuality and sexual behavior. the survey link was posted on reddit.com/samplesize, and thus relied on convenience sampling. actual rates of comfortability may vary from those that the participants self-reported, potentially due to a desire to provide socially desirable data or because those who use reddit may have different inclinations to use toys. further, there were many more women in the sample than men, and thus the data received from male participants may not be as representative of the general population. most men within the sample (61%) reported ever having used a sex toy during masturbation, and this refutes of interpersonal relationships which is reflective of the positive sexuality and positive technology frameworks. sex toys have only increased in popularity and functionality since they became technologically innovative. these toys have shown promise to increase various aspects of sexuality, such as sensitivity and overall pleasure, and can help to restructure an individual’s perception of their sexuality and sexual functioning. however, there were also a considerable amount of negative self-perceived effects of sex toy use reported among participants. examples of negative effects reported include “i feel that i may be more comfortable with toys [than] the real thing sometimes,” “when i’m with a partner that traditionally doesn’t use toys, i can feel judged a bit when suggesting them,” and “felt guilty about masturbating with a toy larger than my husband’s penis.” negative experiences, however slight, with sex toys during an intimate and vulnerable sexual encounter can significantly hinder one’s perception of and potential future use of sex toys and sexual behavior overall. several women within this study reported that they felt judged or ashamed of their sex toy use, during masturbation or partnered sex, for various reasons including their partner’s perception of toy use, and embarrassment of requiring toys to increase sensitivity or feeling like they depend on toys for pleasure during sexual activity. thoughtful discussion is necessary between partners for the proper acquisition and incorporation of sex toys into their individual or joint sex lives. sex toys are not the main attraction of sexual activity, but are merely a means of increasing pleasure and sensitivity, and can even bring a sense of newness or excitement into partnered sex. the introduction of sex toys and sexual aids into sex therapy is both a controversial and ethical issue. an increasing number of clinicians are recommending sex toys and sexual aids for individuals who suffer from sexual dysfunctions relating to sexual assault or cancer-related treatments (bober et al., 2019), as these tools can increase sensitivity and physiological response to sexual stimulation. aside from merely recommending clients to use sex toys and sexual aids at their own discretion, many clinicians are advocating for the advancement of sex therapy to include sexological bodywork, which is a form of educational sex therapy that potentially allows for one-way sensual touch between the clinician and the client, although not always (rowett, 2020). sexological bodywork involves 19 sex toy use in the us the assumed belief that men are more hesitant to use sex toys. however, due to the limited number of men within the sample, actual statistics may vary. the present study was forced to exclude participants from the analysis who identified as anything other than a man or woman. 3.7% of the sample (n = 12) self-identified as an “other” gender, but because this sample was so small they were excluded from the study. future research could focus on other-gendered participants to better understand the prevalence and characteristics of their sex toy use. as discussed by fahs and swank (2013), nonheterosexual and other-gendered individuals may not emphasize phallocentrism and male dominance during sexual activity with a partner, and may feel more inclined to use sex toys as a means of campy and subversive pleasure. because this survey and individual items were created by the researchers, as well as borrowed from the work of döring and poeschl (2020), there are no psychometric properties to report. however, using standardized measures to assess prevalence, comfortability, and willingness regarding sex toys could have provided stronger research support for this study. finally, the participants of this study were largely young white college students. older individuals or individuals without technological access may not have been able to access the survey link because it was posted to reddit and ball state university’s communication page. our study’s lack of diversity could be expanded upon in future research, emphasizing minority or older cohort sex toy use. implications for future research this study could be expanded to include a larger minority sample, including sexual, gendered, and racial minorities, to better understand their sex toy use and how they became socialized to utilize these toys. further, future research could focus on an older cohort sample, as the rate of sexual dysfunctions tends to increase exponentially with age. sex toys could elicit heightened sensitivity or arousal from individuals who suffer from age-related sexual dysfunctions and could further help connect partners. with respect to sexual dysfunctions, future research could examine how sex toys and sexual aids can be incorporated into sex therapy to help increase physiological responses following a sexual assault. sex toys could be incorporated into sensate focus exercises to increase sensitivity and pleasure for the individual, allowing them to focus solely on the pleasurable sensations. to combat the physiological complications of sexual dysfunction, clinical psychologists may recommend or prescribe various sexual aids to use either alone or with a partner. these sexual aids may include vibrators, dilators, kegel balls, and dildos, and successive approximations may be utilized until the client gradually becomes more comfortable with sensual touching, and eventually, sexual intercourse. however, the introduction of sex toys into sex therapy recommendations for victims of sexual assault should be predated with caution and a thoughtful discussion between the client and the clinician, as some of these individuals may suffer from ptsd (yu yip & yuen, 2010). conclusion the findings of this study indicate that a substantial number of american adults have ever used a sex toy during solo or partnered sex. among women, the most used sex toys during masturbation included toys designed for the stimulation of the vagina and vulva, lubricants, and erotic lingerie. among men, the most used sex toys and sexual aids during masturbation included lubricants, toys designed for the stimulation of the penis and testicles (see table 2), and toys designed for the stimulation of the vagina and vulva. men and women were about equally likely to have used lubricants, remedies for enhancing arousal, toys designed for the stimulation of the penis and testicles, and toys for bondage and s&m during partnered sexual activity. similarly, among participants who have never used a sex toy, a significant portion of this subsample would be willing to incorporate sexual aids into solo or partnered sexual 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(2017). a cross-sectional survey of sex toy use, characteristics of sex toy use hygiene behaviours, and vulvovaginal health outcomes in canada. the canadian journal of human sexuality 26(3), 196-204. https://www.muse.jhu.edu/ article/680831 woollaston, v. (2015, january 13). the sex toys dating back 28,000 years: ancient phalluses made from stone and dried camel dung started trend for sex aids. daily mail. retrieved from https://www. dailymail.co.uk/sciencetech/article-2908415/ the-sex-toys-dating-28000-years-ancient-phalluses-stone-dried-camel-dung-started-trend-sexaids.html yu yip, y. & yuen, m. (2010). rape trauma syndrome. cornell university law school. retrieved from https://courses2.cit.cornell.edu/sociallaw/student_projects/rapetraumasyndrome.html 23 sex toy use in the us table 1 frequencies among men and women that have or are willing to use sex toys note. bolded are significant at p = .002; dashes represent data that was not obtained or is not relevant to this study. 24 fippen & gaither table 2 percentage of participants who reported using each type of toy by gender note. bolded are significant at p < .001 25 sex toy use in the us table 3 means and standard deviations for comfort items among men and women note. bolded are significant at p < .001; lower means represent higher levels of comfortability. microsoft word vol10_tracistein_avk#2af73e.doc 23 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 dialectical behavior therapy: an effective treatment for individuals with comorbid borderline personality and eating disorders? traci r. stein teachers college, columbia university patients with either or both borderline personality disorder (bpd) and an eating disorder face a number of intrapsychic and interpersonal difficulties that have been historically treatment resistant. dialectical behavior therapy, which combines elements of cognitive behavioral therapy and zen practices, has shown some promise as a potential treatment for patients with comorbid personality and eating disorders. criticisms of dbt include the limited number of randomized, controlled trials examining the efficacy of the treatment, small sample sizes, and as of yet no clear understanding of the specific mechanisms of action. these limitations aside, dbt is the only treatment considered empirically supported for use with patients who have bpd. the focus on acceptance in the present moment may be particularly beneficial for patients with eating disorders, especially in light of their characteristic lack of acceptance of their bodies. given the promising results in reducing self-harming behaviors among patients with bpd, further study of this therapy for those with both personality and eating disorders is warranted. borderline personality disorder (bpd) is characterized by a pervasive pattern of emotional and interpersonal instability, impulsivity, and fears of abandonment (american psychiatric association, 2000). borderline individuals tend to engage in behaviors that are potentially self-damaging, which can include binge eating, substance abuse, reckless driving or unsafe sex, as well as self-mutilating or suicidal behavior. most (75%) of patients with bpd are female, and the prevalence of the disorder is estimated to be about 2% of the general population, 10% of psychiatric outpatients, and up to 20% of psychiatric inpatients. between 30 and 60% of patients with personality disorders meet criteria for bpd (american psychiatric association, 2000). linehan (2000) describes bpd as a persistent and severe mental disorder with poor outcomes following the use of traditional treatments, and hypothesizes that the disorder arises from a tendency toward emotionality that is shaped by an invalidating environment (linehan, 1993a). bpd is characterized by high rates of psychiatric hospitalization and serious risk of suicide. between 60 and 80% of patients with bpd engage in parasuicidal or self-injurious behavior at some point in their lives and there is often little change in level of functioning or rates of psychiatric hospitalization up to 5 years after treatment (linehan & heard, 1999). patients with bpd present unique challenges to therapists. these include high rates of noncompliance with treatment, the tendency to misuse medications, poor correspondence concerning this article should be addressed to traci r. stein, email ts2007@columbia.edu. outcomes with even intensive psychotherapy, high rates of parasuicidal behavior, high rates of psychological comorbidity, and tendencies to engage in hostile behaviors toward their therapists (linehan, 2000). bpd is considered substantially comorbid with both axis ii (e.g., histrionic personality disorder), and axis i disorders (e.g., mood disorders, substance related disorders), including eating disorders, and is less responsive to pharmacotherapy than many other psychological illnesses (american psychiatric association, 2000; clarkin, levy, lenzenweger, & kernberg, 2004). for those borderline patients who have comorbid eating disorders, treatment is often more difficult and prognosis poorer than for those patients with bpd or an eating disorder alone (palmer, birchall, damani, gatward, mcgrain, & parker, 2003). thus, it is essential to find a treatment that will address adequately the specific needs and challenges of these patients. this paper will review and summarize the research findings and limitations related to a dialectical behavior therapy (dbt) as a potential treatment for those with this comorbid bpd and eating disorders. comorbidity of eating disorders and bpd both clinical observations and empirical research suggest that personality disorders (pd) are more common among patients who have eating disorders than those who do not have an eating disorder diagnosis (livesley, jang, & thordarson, 2005; sansone, levitt, & sansone, 2005). conversely, eating disorders also appear to be more prevalent in patients with personality disorders, and are more common in patients with bpd than in patients diagnosed with other personality disorders. reported prevalence rates stein 24 of co-occurrence vary widely, ranging from 27 to 93%, with bulimia and the binge-eating/purging subtype of anorexia being the eating disorders most commonly comorbid with bpd (livesley et al., 2005; sansone et al., 2005). related to the above, bpd is the most frequent axis ii disorder diagnosed in patients with bulimia nervosa, with a prevalence rate of over 28%, and it is also the most frequent personality disorder diagnosed among those with the bingeeating/purging subtype of anorexia at a rate of 25% (sansone et al., 2005). in these two types of eating disorders, impulsivity is expressed via the behaviors of binge eating and purging. in addition, though obsessive-compulsive personality disorder is the most common axis ii diagnosis in individuals with binge eating disorder, bpd makes up approximately 12% of the axis ii diagnoses in those with this type of eating disorder (sansone et al., 2005). outcomes in patients with dual diagnoses patients who have both an eating disorder and a comorbid personality disorder tend to have poorer overall psychotherapy treatment outcomes and prognoses (palmer et al., 2003), though it is unclear whether this relates to eating disorder symptomatology or other psychiatric symptoms found in individuals with both diagnoses (sansone et al., 2005). in addition, the variety of self-defeating and self-damaging behaviors exhibited by those with bpd and comorbid eating disorders, including impulsivity and engaging in self-harming behaviors, can reduce the likelihood of patients benefiting from most therapies (palmer et al., 2003). etiology and common mechanisms – bpd and eating disorders although several studies have described eating disorders as being more prevalent among patients with personality disorders, this finding was contradicted in one fairly recent, large-scale trial. in this study, researchers examined the prevalence of eating disorders among 668 patients who were diagnosed with schizotypal, borderline, obsessivecompulsive, or avoidant personality disorder, or major depressive disorder (mdd). the results indicated that personality disordered patients were not significantly more likely to have an eating disorder than those patients with mdd (grilo, sanislow, skodol, gunderson, stout, & shea et al., 2003). it is unclear whether this is due to a common mechanism or mechanisms shared by patients with major depression, eating disorders, and personality disorders (livesley et al., 2005). it is possible that factors common to bpd, eating disorders, and major depression may include genetic and environmental influences on the development of these disorders; however, the trial was not designed to explore this hypothesis. in another trial, however, researchers sought to elucidate etiological factors that may be common to the development of pds and eating disorders. in their recent study of 221 pairs of monozygotic (121 pairs) and dizygotic (100 pairs) twins, livesley and colleagues (2005) explored the relationship between axis ii symptoms and a measure of eating disorder symptoms. they estimated the extent to which genetic and environmental influences on symptoms were shared with specific personality characteristics by exploring correlations between scales assessing personality disorder and eating disorder traits. genetic correlations between variables were estimated using a method similar to estimating the heritability (proportion of the total variance) of a single variable. heritability was estimated by comparing the similarity (in terms of endorsement of symptoms) of monozygotic and dizygotic twins. a higher within-pair correlation for monozygotic than dizygotic twins was indicative of genetic influence. the team’s findings suggested that, while there were genetic influences in the development of the disorders, the relationship between personality disorder traits and eating disorders was relatively modest, and there were small but significant phenotypic relationships. specifically, the investigators found dimensions of “concern with overeating” to share a genetic etiology with the construct of “emotion dysregulation.” affective lability was phenotypically and etiologically related to purging, and the strongest association was between purging and the tendency to self-harm. these findings suggest that personality characteristics are related to eating disorders, but that the degree to which they are expressed may vary according to environmental experiences. the authors postulated that purging may be related to the spectrum of self-harming behaviors in bpd, and this may account, at least in part, for the relationship between bulimia and bpd. though this study was comprised of individuals from a general population sample, rather than those with a diagnosable eating disorder, it suggests hypotheses linking bpd and eating disorders are worthy of further study. dialectical behavior therapy for bpd there are few randomized controlled trials of specific treatments for personality disorders (see bateman & fonagy, 2000, for a review). however, psychotherapy is the most commonly applied treatment for personality disorders, and, despite linehan’s (2000) observation of poor outcomes associated with patients with a personality disorder, psychotherapy has been associated with an up to seven-fold faster rate of recovery as compared to no treatment at all (clarkin et al., 2004). dialectical behavior therapy (dbt; linehan, 1993a) is a treatment that blends cognitive-behavioral and zeninspired practices, and was specifically developed to address the problems of affect dysregulation that are at the core of bpd. dbt, which combines individual psychotherapy with group skills training, was the first psychotherapy intervention that was shown via controlled trials to be effective for the treatment of bpd (linehan, armstrong, suarez, allmon, & heard, 1991; linehan, heard, & armdialectical behavior therapy for bpd and ed 25 strong, 1993). dialectical philosophy, which stresses the importance of understanding and incorporating the natural tensions between acceptance of one’s emotions at the present moment and the simultaneous need for change, is at the heart of dbt. dbt is highly structured, particularly during the initial stage of treatment. prior to the initial stage, the therapist must secure the client’s agreement to the requirements of dbt. these include a year-long commitment to treatment and up to 4 hours per week for the individual, group, and consultation sessions. during the first stage, the therapist facilitates decreasing both the patient’s life-threatening and therapyinterfering behaviors (e.g., missing appointments without calling, hostility toward the therapist), and targets those behaviors that interfere with the patient’s quality of life. at this stage, dbt focuses on four concurrent modes of treatment: weekly individual psychotherapy; group skills training sessions, which emphasize acquiring and strengthening interpersonal and coping skills; telephone consultation with the therapist (as needed); and weekly consultation team meetings for therapists. the manualized skills training sessions are structured and include the assignment of homework (linehan, 1993a; linehan, 1993b). the team meetings are aimed at helping therapists process and receive feedback regarding treatment concerns and enhance their capability for effectively working with patients (mcmain, korman, & dimeff, 2001). during stage two, the emphasis is on using a cognitivebehavioral therapy approach to reduce the symptoms of posttraumatic stress that are common to most patients with bpd (smith & peck, 2004). for example, key techniques include keeping a thought diary, behavioral analyses, exposure techniques, flooding, and contingency management (although these can be applied during any stage of treatment). during stage three, the client with bpd begins to apply the newly acquired skills to every area of life. this includes planning for the future, asking the therapist for help in an appropriate way, focusing on reducing shame and self-hate, accepting reality as it is, and integrating the self with the past, present, and future (linehan, 1993a). studies of dbt for patients with bpd while an exhaustive review of the literature on dbt is not within the scope of this paper, a brief overview of the support for dbt for bpd is presented below. several studies have examined the use of dbt compared to standard care, or treatment as usual (tau), for patients with bpd, usually for those with a history of self-harm or parasuicidal behavior (smith & peck, 2004). in their 1991 study, linehan and colleagues conducted a randomized clinical trial to evaluate the effectiveness of dbt for the treatment of chronically parasuicidal women who met criteria for bpd. the treatment lasted 1 year, with assessments every 4 months. the control condition was tau. prior to randomization, subjects were matched regarding the number of past parasuicidal events, psychiatric hospitalizations, age, and prognosis. however, almost one third of potential subjects across both groups either dropped out or were excluded from the sample because they did not meet inclusion criteria. twenty-two subjects were left in the dbt group, 20 of whom remained in dbt for the required year. the control subjects (n = 20) received referrals for therapy in the community. tau subjects reported significantly fewer hours of individual or group therapy, but reported more day treatment than the dbt group. at most assessment time points, subjects who received dbt had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. there were no between-group differences on measures of depression, hopelessness, suicidal ideation, or reasons for living, and scores on all four measures decreased throughout the year. there were several limitations associated with this study. among them were the high pretreatment attrition rate and the somewhat sparse information regarding the specifics of the treatment received by those in the tau group. in addition, the dbt subjects received treatment for free, whereas the tau subjects were charged for services obtained in the community, resulting in their seeking treatment in low-fee settings. this last limitation likely accounted to some extent for the fact that subjects in the dbt condition were significantly more likely to begin and remain in therapy than the tau subjects (scheel, 2000). in another trial by barley, buie, peterson, and hollingsworth (1993), dbt was adapted for use with 130 bpd patients (almost 80% of whom were women) who were discharged from an inpatient psychiatric unit after an approximately 100-day length of stay. the patients received individual therapy, group skills training and other activities, including dbt homework. average rates of parasuicidal behavior were compared for the 19 months prior to the introduction of dbt, the 10 months of the initial phase of the program, and the subsequent 14 months of dbt. this approach resulted in a significant reduction in parasuicide under the full dbt program as compared to the pre-dbt and phase i dbt periods. rates were also significantly lower than the average rates of parasuicide within a general psychiatric unit offering treatment as usual (scheel, 2000). the primary strength of this study may be its reasonably large sample size (n = 130) as compared to other trials of dbt. however, without a true control group or random assignment to either dbt or another therapeutic intervention, definitive conclusions cannot be made attributing observed benefits to dbt alone. yet, reduction of parasuicidal behaviors seems to be a consistent finding across dbt studies (see scheel, 2000, for a review). in addition, barley and colleagues (1993) reported that dbt was readily accepted and understood by both patients and hospital staff alike, presumably adding to the observed effectiveness of this approach. stein 26 dbt for binge eating disorder although most studies of dbt have been with patients who have an axis ii diagnosis, a 2001 study by telch, argas, and linehan evaluated dbt for patients with binge eating disorder (bed). the investigators adapted dbt for use with this population in a randomized, controlled trial. this study followed an uncontrolled pilot study during which 11 women with bed received the group skills training portion of dbt, which was adapted from linehan’s (1993b) treatment manual but was not accompanied by the other aspects of standard dbt. the original pilot skills training program took place over 20 sessions. in the rct, however, the treatment was adapted from the dbt manual as follows: participants were taught mindfulness, distress tolerance, and the emotion regulation skills that are normally part of dbt, but the interpersonal effectiveness components of dbt were not included. furthermore, standard dbt includes both weekly group therapy skills training and weekly individual therapy. the adaptation of dbt in this study combined skills training and skills-to-daily-life components in a weekly group therapy format. the intervention was structured in this way both to decrease the amount of time spent in therapy, and to allow for comparisons of this affect regulation treatment with other interpersonally focused therapies for eating dysfunction. there were no dropouts in the pilot, and 82% of women were abstinent from binge eating at the end of treatment as well as at 3 and 6 months post-treatment (telch, agras, & linehan, 2000; wise & telch, 1999). thus, despite the elimination of portions of the dbt protocol, these patients experienced reduction in a key symptom that was maintained after the cessation of the intervention. dbt for bpd patients with comorbid eating disorders a review of the literature revealed only one published study on the use of dbt for patients diagnosed with both bpd and a comorbid eating disorder (palmer et al., 2003). the trial adapted a full program of dbt for use with patients in a specialized eating disorder service who met dsm-iv (american psychiatric association, 2000) criteria for both bpd and an eating disorder (binge eating disorder, n = 1; bulimia, n = 5; eating disorder nos, n = 1; two of the subjects also met criteria for anorexia nervosa prior to, but not at the time of enrollment in the study). the team was comprised of experienced clinicians who had undergone intensive training in dbt prior to the study. subjects received weekly individual therapy sessions, weekly skills training in a group format, and phone contact with therapists outside of the formal sessions. in addition, the therapeutic team met for a weekly consultation group as per standard dbt. the adaptation consisted of the addition of a skills training module that focused on problems of weight and eating. the all-female study sample was small, however (n = 7), and began with three patients, with three more being enrolled at 6 months into the intervention, and a seventh being enrolled at 1 year. the length of time patients were enrolled in the program thus varied from a minimum of 6 months to 18 months, rather than adhering to the normal minimum requirement of remaining in dbt for 1 year. all of the women in the sample had engaged in prior acts of self-harm and most had been patients on the service for some time prior to the intervention, though this range was not specified in the article. five of the patients had received inpatient treatment prior to the study. as several of the patients were “uncooperative” (p. 283) with respect to filling out questionnaires during the study, data for pre-post comparisons were limited, leaving only two variables available for all patients. these were the total number of days spent in the hospital and the number of acts of self-harm that either did receive, or should have received medical attention. acts such as self-cutting not requiring stitches were not counted. self-harm episodes were obtained via documentation by the clinical staff and from diary cards patients filled out during the program. these endpoints were also available for the 18 months prior to and the 18 months after the completion of the program, as well as for the duration of the program. due to the small sample size and variability of the data available for each patient, the research team deemed it inappropriate to attempt to perform statistical analyses and instead provided results descriptively. all patients survived and remained in treatment throughout the duration of the program. there was a reduction in both inpatient days and self-harm requiring medical attention for the group as a whole. however, one patient was assaulted during the finalthird of her treatment, and this was followed by a major relapse necessitating prolonged hospital admission. the investigators reported marked reduction in minor self-harm (that not requiring medical attention) in all patients, and eating disorder symptoms also decreased in the group such that by the end of follow-up, none of the patients still had a full syndrome eating disorder, although four had partial syndromes diagnosable as eating disorder nos. all participants retained some concerns regarding weight and eating behaviors; however, in the post-treatment months all were described as making “significant progress in their lives” (p. 284), including marriages, having a baby, a graduation, and progress in employment (palmer et al., 2003). also, none continued to present the behavioral/interpersonal difficulties in therapy that had been characteristic prior to the dbt program. the limitations to this study are many. first, the small sample size, lack of a control group or randomization, great variation in total time subjects spent in the study, and incomplete baseline and other data make it impossible to conclude that the dbt program was effective above and beyond the effects of internal validity confounds. however, the results of this program are promising and suggestive of significant benefits for patients who are at high-risk, tend to be difficult and demanding, and who remain treatmentresistant even after extensive therapy. additional trials of dialectical behavior therapy for bpd and ed 27 dbt for patients diagnosed with bpd and comorbid eating disorders are warranted to further explore the utility of this approach with this challenging population. in a follow up to the aforementioned study of patients with bed by telch and colleagues (2001), the team conducted a controlled trial of 44 women meeting diagnostic criteria for bed, (27% of whom had a current, but unspecified, personality disorder) that were randomized to either dbt skills training (n = 22) or a wait-list control condition (n = 22). following randomization, 10 participants dropped out of the study (four in the treatment group and six in the waitlist control). participants were assessed at baseline and after completing 20 weeks of treatment using the scid i and ii, the binge eating scale, the emotional eating scale (ees), the beck depression inventory, the positive and negative affect schedule (panas), and the negative mood regulation scale. those in the treatment group also completed abbreviated assessments of binge frequency and skills usage at 3 and 6 months post-intervention. assessments were performed via structured clinical interview by trained interviewers. though the original design specified having interviewers unaware of group assignment, the blind was often broken by the patient. there was a great deal of psychiatric comorbidity in the sample, and over 75% of participants had received psychiatric treatment in the past, though they did not receive other types of psychotherapy during the trial. analyses were limited to those who completed treatment (n = 34). there were no significant differences between groups on any of the baseline measures, but significant effects were found at the end of the treatment for binge days and episodes. eighty-nine percent of the treatment group were considered abstinent (no binges in the previous 4 weeks) compared with 12.5% of the control group. those in the treatment group also had significantly lower scores on measures of weight concerns, shape concerns, and eating concerns, though there were no significant differences in dietary restraint. patients in the treatment group reported significantly lower scores on a scale measuring the urge to eat when experiencing anger. changes were maintained among many of the women in the post-treatment months, with 67% and 56% being abstinent at 3 and 6 months, respectively. the majority of participants (89%) continued to practice skills taught during treatment. of those in the waitlist control group, 14 women accepted the invitation to participate in treatment. for those who completed the intervention, 90% were abstinent at the end of treatment and 80% and 67% were abstinent at the 3and 6-month follow ups, respectively. the study was limited by its small sample size and relatively high dropout rate. the authors were also unable to conclude how dbt worked to reduce binge eating, and the results of the study offered no support for the hypothesis that the treatment worked by reducing negative affect or by improving expectancies for mood regulation (telch et al., 2001). however, treated women reported significantly lower scores on the anger subscale, but not the anxiety and depression subscales, of the ees at posttest. these findings suggest, but do not conclusively demonstrate, that the modified dbt program used in this study may work by reducing the urge to eat when experiencing negative emotions rather than by changing affect directly. summary and future directions personality disorders and eating disorders appear to be frequently comorbid, and patients with either or both borderline personality disorder and an eating disorder face a number of difficulties that have been historically treatment resistant. dialectical behavior therapy, which combines elements of cognitive behavioral therapy and zen practices, addresses many of the specific challenges of bpd via individual psychotherapy and group skills training, as well as a focus on self-acceptance. at present, dbt is the only treatment that is considered empirically supported for patients with bpd, and has been shown to reduce selfharming behaviors and improve interpersonal functioning in this population. as bpd and eating disorders appear to share some common features, including the tendency to engage in self-harming behaviors, it has been hypothesized that dbt may be a useful treatment option for those with this type of comorbidity. dbt has shown some initial promise as a potential treatment for patients with binge eating disorder, and preliminary research suggests it may be of benefit to those with bpd and comorbid eating disorders. criticisms of dbt include the limited number of randomized, controlled trials examining the efficacy of the treatment, small sample sizes, and as of yet no clear understanding of the specific mechanisms of action. also, attrition rates are high in many studies of bpd due to the impulsivity and instability of patients with this disorder. furthermore, dbt frequently does not result in significant reductions in the depression or hopelessness characteristic of bpd. outcomes of interest vary from study to study, as do the measures used to assess them. both of these issues make it difficult to compare the results of trials even when conducted with comparable patient populations. in a related vein, dbt is often adapted for use in different settings and for patients who meet different diagnostic criteria, resulting in treatments that are similar but not quite the same. this too makes comparison across trials difficult. comorbidity presents additional and significant challenges to treating and conducting rigorous research with those who have personality disorders. many individuals are diagnosed with more than one axis ii disorder, and the interaction between axis ii and axis i disorders may obscure treatment effects. studies may also confound personality change with improvement in symptoms. additionally, since most patients with either bpd or an eating disorder are women, it is unclear whether and to what extent dbt would have similar effects for men with either or both disorders. last, dbt is a time-intensive and thus, potentially costly treatment. this presents probable barriers to those with limited incomes or whose work schedules would not stein 28 allow for the up to 4 hours per week required for standard dbt. nevertheless, these limitations aside, dbt is the only treatment considered empirically supported for use with patients who have bpd. the focus on acceptance in the present moment may be particularly beneficial for patients with eating disorders, especially in light of their characteristic lack of acceptance of their bodies. given the promising results in reducing self-harming behaviors among patients with bpd, the preliminary results showing similar benefits for those with both bpd and a comorbid eating disorder, and benefits, including decreased weight and eating concerns for those with binge eating disorder, further study of this therapy for those with both disorders is warranted. references american psychiatric association. 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(1999). dialectical behavior therapy for binge eating disorder. journal of clinical psychology, 55, 755-768. interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 17 naturalistic examination of a training clinic: is there a relationship between therapist perception and client self-report of treatment outcomes? scott h. waltman, katherine h. rex, and alyson williams pacific university numerous psychometrically sound measures of psychotherapy outcome have been developed; however, few clinicians administer such tools, and when they do so, they rarely utilize these results to inform treatment. moreover, studies have reported a discrepancy between therapists’ judgment and clients’ self-report of treatment outcome. the current study aimed to further investigate the relationship between therapists’ judgment and clients’ self-report of treatment outcome in a psychological training clinic, using the criteria of reliable change (rc) and clinically significant change (csc). one hundred and forty-four clients receiving therapy at a psychological training clinic in the pacific northwest were administered the outcome questionnaire 45.2 (oq) at the beginning and end of treatment. study participants were primarily caucasian (88%) and female (56%), with a mean age of 32 years. changes in outcome scores were compared to therapist judgments regarding treatment effectiveness. results indicated a significant relationship between therapists’ judgment of treatment outcome and whether clients achieved rc or csc. a large effect size (φ = .56) was found between csc and therapist judgment whereas a medium effect size (φ = .32) was found between rc and therapist judgment. these results suggest that there is lack of agreement between the rc and csc criteria, and that outcome measure alone cannot account for therapist judgment about treatment outcomes. suggestions are made for maximizing the accuracy and practicality of client outcome assessment. a number of psychometrically sound instruments assessing psychotherapy outcome exist; however, the majority of clinicians do not use such tools (lambert & hawkins, 2004). moreover, even when clinicians do administer measures that track therapeutic outcomes, many do not utilize the results to inform treatment (garland, kruse, & aarons, 2003).  research findings show discrepancies between therapists’ judgment and clients’ self-report of treatment outcomes (swift, callahan, & levine, 2009); it appears that many clinicians evaluate treatment outcomes based on their own perceptions, rather than based on standardized measures intended to accurately assess clients’ clinical symptoms and functioning. this raises important clinical questions, given that the accurate evaluation of treatment outcomes informs whether treatment was effective and is a critical component of improving treatment (american psychological association [apa], 2006). in a recent study of a psychological training clinic, swift and colleagues (2009) compared two methods of evaluating treatment outcome: therapists’ judgment of treatment outcome and clients’ scores on standardized outcome tracking measures. the authors reported a low level of agreement scott h. waltman, m.s., katherine h. rex, m.s., and alyson williams, ph.d., school of professional psychology, pacific university. scott waltman would like to thank dr. alyson williams for her patience, guidance, and assistance in that endeavor. correspondence concerning this article should be addressed to scott waltman, school of professional psychology, pacific university, 190 se 8th ave. hillsboro, or 97123. email: walt2155@pacificu.edu. between these two methods, suggesting that therapists who rely on their judgment alone are more likely to describe treatment as being successful compared to those using collateral information from objective outcome measures. drawing on these research findings by swift and colleagues (2009), the current study aims to investigate whether there is a lack of agreement between therapists’ judgment of treatment outcomes and clients’ self-reported changes in other psychological training clinics. the present study uses a naturalistic design (i.e., absence of experimental manipulations) that provides a realistic evaluation of how a training clinic functions. clinicians’ use of outcome measurements given that therapists are subject to the same judgment errors as all other humans (ruscio, 2007), numerous treatment outcome measures have been developed to help clinicians assess the effectiveness and quality of psychosocial interventions (garland et al., 2003; hatfield & ogles, 2004; mours, campbell, gathercoal, & peterson, 2009). usually, these are client self-report measures that assess on a weekly timeframe the impact of presenting problems on functioning. however, it is estimated that less than one-third of all clinicians use outcome tracking measures in their clinical practice (lambert & hawkins, 2004). underuse of outcome measures was reported by garland and colleagues (2003) in a survey of clinicians who participated in a state program that mandated the use of outcome measures. the authors found that as many as 92% of the clinicians had never referenced standardized outcome measures in their practice (garland et waltman, rex, & williams 18 al., 2003). in a different survey of a national sample of licensed psychologists, only 37% of respondents reported using some sort of standardized assessment in their practice (hatfield & ogles, 2004). it is necessary to examine therapist attitudes about outcome measures, as this may illuminate why these measures are so infrequently utilized. in the study by garland and colleagues (2003), clinicians reported that outcome measures are cumbersome or intrusive, can be expensive to practitioners, are burdensome to clients, and do not provide new information (garland et al., 2003). rather than using outcome measures that have been shown to lead to improvements in treatment outcomes (reese, norsworthy, & rowlands, 2009) and increased cost-effectiveness (slade et al., 2006), many of these clinicians reported using “real world functional indicators” (e.g., school grades), clinical intuition, and client-reported satisfaction in order to evaluate treatment effectiveness (garland et al., 2003). it is clear that some therapists may view their clinical judgment as being more accurate or useful than the information obtained from outcome measures. it is unclear, however, whether this trend also exists in a training clinic setting, as there is limited research on the relationship between student clinician and licensed professional judgment. understanding the relationship between therapist judgment about treatment outcomes and client changes in scores on outcome measures will be informative as to whether some student therapists view their developing clinical judgment as being more accurate and useful than the information generated from standardized outcome measures. measurement of reliable change and clinically significant change the regular use of standardized outcome measures is a recommended routine practice for tracking client progress (hatfield & ogles, 2004). advantages of using these measures include their established reliability and validity and their sensitivity in determining clinically meaningful changes in client functioning. the concepts of reliable change (rc) and clinically significant change (csc) were introduced as a statistical approach of determining when meaningful change has occurred (jacobson, follette, & revenstorf, 1984). rc indicates that a change in scores on a measure is sufficiently larger than the standard error of the difference between the two scores, and thus is not due to chance (jacobson & truax, 1991). csc is more a more stringent criterion for determining treatment outcome than rc, as csc requires that rc has occurred and that a client’s score on an outcome measure has moved from the dysfunctional to the functional range (jacobson & truax, 1991). in order for clients to obtain csc, they must begin treatment in the clinical range of functioning and move into the nonclinical range of functioning (wise, 2004). the use of the criteria of rc and csc has advantages over other statistical methods. a traditional statistical method of comparing different groups is comparing group means (e.g., analysis of variance; anova), which has two major limitations (jacobson, roberts, berns, & mcglinchey, 1999). first, comparing group means provides little information about the variability within those groups (i.e., the proportion of group members who improved or recovered). second, a large effect size does not mean that the effect was clinically meaningful (jacobson et al., 1999). the criteria of rc and csc have been used to evaluate the effectiveness of treatment in psychological training clinics. callahan and hynan (2005), for example, examined the treatment outcomes of 61 clients who were treated in a psychological training clinic by comparing clients’ changes in scores on a routinely administered measure, the outcome questionnaire 45.2 (oq; lambert et al., 2004), from the beginning to the end of treatment. they determined that over the course of treatment, 18% of participants achieved csc, 33% demonstrated rc, and 67% showed no rc (callahan & hynan, 2005). this study illustrated that fewer clients achieve csc than rc, which is to be expected as csc is a more stringent criterion to meet. in another study of a training clinic, swift and colleagues (2009) found a csc rate of 23% and a rc rate of 37%. the authors concluded that therapists often labeled treatment as successful when csc had not occurred, and sometimes therapists labeled treatment as unsuccessful when csc had happened (swift et al., 2009). therapist judgment of treatment outcome borrowing from the premature termination literature, it has been suggested that therapist judgment may be the best method of determining when a client has prematurely terminated (wierzbicki & pekarik, 1993); however, a problem with using therapist judgment to determine outcome is the issue of reliability (wierzbicki & pekarik, 1993). not all therapists may decide a client has prematurely terminated from therapy based on the same criteria (hatchett & park, 2003; swift et al., 2009), and research has found that therapists are likely to use self-serving attributions when explaining why a client prematurely terminated from treatment (murdock, edwards, & murdock, 2010). additionally, therapists’ and client’s descriptions of treatment termination may differ (hunsley, aubry, verstervelt, & vito 1999). in fact, it has been proposed that therapist perception of progress and client self-report of satisfaction have a low level of agreement (mours et al., 2009). several studies have failed to find a significant relationship between client satisfaction and symptomatic improvement (lambert, okiishi, finch, & johnson, 1998; lunnen & olges, 1998; lunnen, ogle, & pappas, 2008; pekarik & wolff, 1996), and yet, multiple surveys of practicing clinicians have found that many clinicians are likely to rely on their own intuition and the client’s self-report to determine if treatment has been successful (garland et al., 2003; mours et al., 2009). given potential discrepancies between therapists’ and clients’ reports, treatment evaluation based on therapists’ judgment alone may be insufficient. research has demonstrated that therapists’ judgments about treatment outcome are more likely to be accurate only when it is positive (hunsley et al., 1999). this may be due to biases in training clinic examination 19 the judgment of the clinicians. specifically, therapists may be more likely to attend to positive information about treatment outcomes than to negative information (ruscio, 2007). these biases in therapist judgment are problematic, especially since it is likely that they decrease therapists’ ability to recognize the occurrence of a negative treatment outcome. the current study is an investigation of the relationship between clients’ changes in outcome questionnaire-45.2 scores (oq; lambert et al., 2004) and student therapist judgment about treatment success. this study is particularly relevant because the student clinicians had access to the oq data as they rated the successfulness of treatment. thus, the level of agreement between therapist judgment and outcome scores may be interpreted as an indicator of how influential outcome measurement is to student therapist judgment. the following research questions guided the present examination (a) how often do clients achieve rc and csc?; and (b) what is the relationship between therapist judgment of treatment outcome and client changes in oq scores? it was hypothesized that therapist judgment about treatment outcomes would be related to whether rc and csc occur on client oq scores. method participants clients. archival data were used from 144 clients receiving therapy during the 2007-2008 academic year at a university-based psychological training clinic located on a small campus in a downtown urban area of the pacific northwest. this training clinic provides outpatient services to the general public. the clinic operates on a sliding fee scale, with session fees ranging from $20 to $85 depending on client income level. the clinic additionally offers a discounted rate of $20 per session for college students. although data concerning socioeconomic status were not collected as a part of this study, the clients receiving therapy from this clinic are often unemployed or working poor (i.e., underemployed) (brooks, 2007). clients may receive individual or couples therapy, and may present with a variety of presenting concerns. typical presenting problems include depressive symptoms, anxiety symptoms, and relationship concerns. individuals interested in treatment participate in a standardized screening procedure. those who endorse particular risk factors, such as active suicidal ideation or excessive substance use concerns, are referred out to treatment settings that may provide higher levels of care. of the 144 clients, 31% (n = 45) were excluded from analysis due to either missing oq test score data or the client having only attended an intake session. clients who were identified as only attending an intake session were not included in this evaluation, as it has been suggested that clients who did not return for therapy after the intake did not start treatment (hatchett & park, 2003). furthermore, at least two administrations of an outcome measure are required to calculate rc and csc. of the remaining clients, demographic data was available for 67% (n = 66). this sample of 66 clients had more women (56.1%) than men (43.9%), had an average age of 32 years (sd = 8.87), with a range of 17 to 57 years. in regards to ethnicity, 87.9% of clients were caucasian, 4.5% were of asian descent, 1.5% were african-american, 4.5% were multi-ethnic, and 1.5% were unknown. inclusion in the current study depended upon the presence of both a therapist rating of the successfulness of treatment and test scores from the first and last administrations of the oq. a pearson’s chi-square (χ 2 ) was utilized to determine if there was a relationship between therapist description of treatment outcome and whether or not demographic data were available. additionally, an anova was used to evaluate whether group differences existed in the average amount of change in oq scores depending on the availability of demographic data. no significant differences were found in these analyses, which suggest that it was appropriate to include clients with missing demographic information in further analyses. therapists. clients received therapy from doctoral students who were enrolled in a clinical psychology program and supervised by licensed clinical or counseling psychologists. these clinicians were trained in treatment for presenting problems ranging from anxiety and depression to relationship problems. supervisors were licensed psychologists who were either faculty members or psychologists from the community with private practices. this training program follows a practitioner-scholar model, and student therapists were either in their second, third, or fourth year in the program. three of these therapists were pre-doctoral interns who were either in their fifth or sixth year of training. in total, approximately 45 therapists recorded data for this study. at the time this data were collected, information about individual therapists was not collected due to concerns about student privacy and confidentiality. this will be discussed later as a limitation of the study. measures outcome questionnaire. the oq is a 45-item selfreport measure that assesses general psychological distress (lambert et al., 2004). an overall score may be calculated after administration, along with subscale scores related to symptom distress, interpersonal functioning, and social role. the oq is typically administered to every adult client at every session in this training clinic. for this study, only the first and last administrations of the oq were analyzed. the average number of sessions completed by clients was 13. other studies have used the oq to measure rc and csc, and to identify when individual treatment has been successful (callahan & hynan, 2005; callahan, swift, & hynan, 2006). on the oq, an overall score above 63 is indicative of symptoms in the clinical range (anderson & lambert, 2001). the oq manual states that no gender differences exist between male and female scores. the manual also specifies that no significant differences have been found between the total scores of caucasians, hispanics, and africanamericans. the oq has adequate psychometric properties, waltman, rex, & williams 20 with a test-rest reliability of .87 and internal consistency of .93 (lambert et al., 2004). the internal consistency for this sample could not be calculated, as only the total oq scores from the first and last administration were analyzed in this study. closing file outcome tracking form. the closing file outcome tracking form (interested readers may contact the corresponding author for a copy; brown, williams, waltman, & sutton, 2010) was created for use in this particular training clinic. it is a brief form that is completed by the client’s assigned therapist as a part of the regular file closing procedure. this form contains information about diagnosis, client scores on the oq, therapist description of therapy outcome, therapy duration, and demographic information. for this study, only a subset of information from the form was analyzed: data related to oq scores from the first and last administration of the measure, therapist description of the outcome of therapy, and demographic information. procedure clients were informed that their demographic and treatment related information may be used for research purposes during the informed consent process at the beginning of therapy. approval for the study was obtained from pacific university’s institutional review board (irb). data obtained from the closing file outcome tracking form were de-identified and coded into a database. data were coded into the following three variables: therapist judgment, reliable change, and clinically significant change. pearson’s chi-square (χ 2 ) was utilized to determine if there was a relationship between therapist description of treatment outcome and client changes in oq scores. a phi correlation (φ) was conducted to measure the relationship between changes in oq scores and therapist rating of treatment successes. therapist judgment. the information about therapist judgment of the treatment outcome was recorded on the closing file outcome tracking form by each student therapist. therapist judgment was coded as it was recorded on the form: “successful completion of treatment,” “substantial progress without successful completion of treatment,” “incomplete or moderate progress,” or “no progress.” reliable change and clinically significant change. based on the recommendations of the test publisher (lambert et al., 2004), a decrease in total oq scores of 14 or more was coded as “reliable change.” a change in total oq scores of 13 or less was coded as “no reliable change.” clinically significant change requires that rc has occurred and that a predetermined cut-off point has been crossed. a drop in total oq score of 14 or more, and a decrease from a total score of above 64, to a total score below 63, was coded as “clinically significant change.” a failure to attain a drop in oq scores of at least 14 points or a failure to cross the cutoff point of 63 was coded as “no clinically significant change.” the 47 clients who began treatment with oq scores below 64 were unable to achieve csc and were thus excluded from the examination of the relationship between therapist judgment and csc. results descriptive statistics descriptive statistics were used to compute the frequency of rc, csc, and therapist description of treatment outcomes. overall, from the beginning to the end of treatment, the mean change in total oq score for the entire sample was a 9.67 point decrease. only 35.4% of clients achieved rc. in determining csc, it was found that only 18.2% of the clients had achieved csc. it is worth noting that 47.5% of the clients began treatment with an oq score in the nonclinical range, so they could not achieve csc; of the clients who began treatment in the clinical range of functioning, 34.6% achieved csc. it was found that therapists described 10.1% of treatment outcomes as “no progress,” 33.3% of treatment outcomes as “incomplete or moderate progress,” 21.2% of treatment outcomes as “substantial progress without successful completion of treatment,” and 35.4% of treatment outcomes as “successful completion of treatment.” table 1 provides the percentages of treatment outcomes that achieved rc or csc and the percentage of treatment outcomes according to therapist description. table 1 comparison of methods for determining client treatment outcome therapist judgment of treatment outcome total a (%) reliable change clinically significant change b yes (%) no (%) yes (%) no (%) successful completion 35.4 18.2 17.2 8.1 27.3 substantial progress 21.2 9.1 12.1 6.1 15.2 incomplete or moderate progress 33.3 7.1 26.3 4.0 29.3 no progress 10.1 1.0 9.1 0 10.1 total 35.4 64.6 18.2 81.8 an = 99. b47.5% of clients began treatment with oq scores in the nonclinical range, and subsequently could not achieve clinically significant change. training clinic examination 21 therapist judgment, reliable change, and clinically significant change in order to evaluate if therapist judgment was related to rc, a two-way contingency table analysis was conducted. the two variables were therapist judgment with four levels (i.e., “successful completion of treatment,” “substantial progress without successful completion of treatment, “incomplete or moderate progress,” or “no progress”) and rc with two levels (i.e., rc and no rc). the two variables, therapist judgment and reliable change were found to be significantly related, χ 2 (3, n = 99) = 10.18, p =.017, φ = .321, consistent with a medium effect size (cohen, 1988). these results support the conclusion that therapist judgment of treatment outcome is related to whether rc occurs. in order to determine if therapist judgment was related to whether csc occurred, a second two-way contingency table analysis was completed. the two variables were therapist judgment with four levels (i.e., “successful completion of treatment,” “substantial progress without successful completion of treatment,” “incomplete or moderate progress,” or “no progress”) and csc with two levels (i.e., csc and no csc). the two variables of therapist judgment and csc were found to be significantly related, pearson χ 2 (3, n = 52) = 16.20, p =.001, φ = .558, consistent with a large effect size (cohen, 1988). these results support the conclusion that a relationship exists between therapist judgment of treatment outcome and whether csc occurs. post-hoc analysis after it was found that a sizeable portion of the sample was not capable of achieving csc, the researchers decided to conduct an additional post-hoc analysis, a one-way analysis of variance (anova), to evaluate the relationship between therapist judgment of treatment outcomes and the change in oq scores from the first to last administration of the measure. it was hypothesized that significant differences would be found between the average amount of change in total oq scores and therapists’ judgment of treatment outcomes. the independent variable was therapist judgment and the dependent variable was the change in oq scores from first to last administration of the measure. the results of the anova were significant, f(3, 95) = 4.41, p = .001. the strength of the relationship between therapist judgment and the change in oq scores, assessed by η 2 , was moderate, with the therapist judgment accounting for 12% of the variance in the dependent variable. follow up tests were conducted to evaluate pairwise differences among the means. based on levene’s test of the homogeneity of variance, it can be assumed that the variances were homogenous among the three groups. post hoc comparisons were therefore conducted using tukey’s hsd there was a significant difference in the means between the group that was judged to have successfully completed treatment (m = -18.80, sd = 23.13) and the group that was judged to have made no progress (m = 1.50, sd = 10.64), as well as between the group that was judged to have successfully completed treatment and the group that was judged to have incomplete or moderate progress (m = -2.55, sd = 21.12). no significant difference was found between the substantial progress without completion of treatment group (m = -10.95, sd = 20.87), and the no progress group. there was not a significant difference found between the other pairwise comparisons. discussion the current study investigated the relationship between therapists’ judgment and clients’ self-report of treatment outcome; the latter was operationalized as changes in outcome scores using both rc and csc criteria. the study is of particular relevance to those interested in understanding how the use of outcome measures affects therapist judgment, as the therapists had access to the oq data when they were rating the overall successfulness of treatment. the results of this study demonstrate that a relationship exists between therapists’ judgment of treatment outcome and whether a client achieves rc or csc on an outcome measure. additionally, a large effect size was found between csc and therapist judgment, indicating a strong relationship between these two variables. these findings suggest that training therapists often labeled treatment as successful when csc did occur, which is commensurate with findings from a prior study by swift and colleagues (2009). although these results denote that therapist judgment and rc are related, the results also suggest that there is a low level of agreement between these two methods of determining treatment outcomes as 17% of therapists labeled treatment as successful when rc had not occurred, and 8% labeled treatment as unsuccessful when rc had occurred. further research is needed to explore why this low level of agreement exists. it is possible that this low level of agreement is due to clinicians trusting their own judgment more than the outcome tracking measure. the post hoc analysis revealed that changes in oq scores significantly differed between the different client groups depending on whether the therapist judged treatment to be table 2 mean change in total oq score by therapist judgment of treatment outcome therapist judgment total score m (sd) 95% ci a successful completion 35 -18.80 (23.13) -25.87, -11.73 substantial progress 21 -10.95 (20.87) -20.08, -1.82 incomplete or moderate progress 33 -2.55 (21.12) -9.83, 4.73 no progress 10 1.50 (10.64) -11.7, 14.73 total 99 -9.67 (22.15) aci = confidence interval. waltman, rex, & williams 22 successful or incomplete (see table 2). there were no significant differences between the successful completion and substantial progress groups, suggesting that the distinction between these different groups may not be meaningful. within the subset of clients who were judged to have successfully completed treatment, the mean change in oq score was a decrease of 18.8 points. this supports the conclusion that a client who has been judged to have successfully completed treatment will, on average, have had a decrease in oq score by 18.8 points, which is a larger score decrease than the one necessary for obtaining rc. however, this analysis does not provide information about the level of agreement between therapist judgment and rc as it applies to individual cases. the rates of rc and csc found in this study seem to be commensurate with those reported in other psychological training clinics. in this study, it was found that 35.4% of clients achieved rc. prior reported rates of rc in other training clinics include 37% (swift et al., 2009) and 33% (callahan & hynan, 2005). in this study, it was established that 18.2% of clients achieved csc; it is worth noting, however, that 47.5% of the clients included in this study could not achieve csc because they started treatment with a score in the nonclinical range. prior reported rates of csc in other training clinics include 23% (swift et al., 2009) and 18% (callahan & hynan, 2005). as such, the rates of rc and csc found in this study appear consistent with the rates reported by other training clinics. rates of reliable and clinically significant change it has been suggested that therapist perception of treatment progress and client self-report of treatment satisfaction are not accurate indicators of treatment effectiveness (mours et al., 2009). by contrast, this study showed that therapist perception of treatment outcome was significantly related to the criteria of rc and csc on a standardized measure. in this study, therapists judged that 56.6% of clients achieved successful completion of treatment or made substantial progress, whereas 35.4% of clients were found to have met the criteria for rc. when comparing treatment success rates, there was a discrepancy of over 20%, which was potentially due to errors in therapists’ perception (ruscio, 2007). it is also possible that in some cases, treatment was successful despite the client not achieving rc on the total oq score. for this particular subgroup, the mean change in total oq scores was a decrease by 9.67 points. this decrease in overall score could indicate rc on one of the subscales of the oq, but this could not be further investigated since subscale data were not collected for the database. the oq has three subscales: symptom distress, interpersonal relations, and social role. on these subscales, a respective decrease in score of 10, 8, and 7 points is considered rc (lambert et al., 2004). it is possible that if subscale data were collected, then individuals who did not demonstrate rc on the oq may demonstrate rc on one of these subscales. the therapists who rated the successfulness of treatment were cognizant of this subscale data, and that knowledge may, in part, account for the disparity between therapist judgment and rc rates. as previously stated, oq scores were the only client outcome data collected in this study. it is therefore possible that if these clients were administered a standardized measure specific to their presenting difficulties, then perhaps rc may have been found. in many instances in this clinic, additional standardized measures were utilized. for example, clients being treated for an anxiety disorder are often administered an inventory specific to anxiety, such as the beck anxiety inventory (bai; beck & steer, 1990). if a client were repeatedly administered an additional measure, then scores from that measure may have influenced the therapists’ description of the outcome of therapy; however, data from any additional measures were not collected as a part of this investigation. the knowledge gained from additional assessments may account for some of the disparity in treatment success rates. implications for the relationship between therapist judgment and outcome measures the study’s findings of the low level of agreement between changes in scores on the oq and therapist judgment have important implications for clinical training and practice. student therapists should be trained to recognize that their perception of client progress may not accurately reflect the client’s self report. psychologists in training may, in some cases, be selectively attending to that information which confirms their beliefs that the client is making progress, thereby ignoring any conflicting information (ruscio, 2007). for example, if a therapist feels that a client is making progress, then he or she may focus on how the client consistently attends sessions and ignore the client’s selfreport of increasing symptomatology on an outcome measure. clinicians would benefit from seeking information that is both confirmatory and disconfirmatory to their perceptions (ridley, 2005). student clinicians’ supervisors may play a role in helping students learn how to obtain such information and to navigate the process of developing a comprehensive view of clients’ progress in treatment. the use of standardized outcome measures can and should be a preferred method to evaluate the accuracy of a clinician’s intuition, and to inform practice by tracking client progress. psychologists in training are forming the habits which will guide their future practice, and it is imperative that they form habits consistent with best and ethical practice guidelines (apa, 2006). such habits would include regularly using outcome tracking measures to track client progress, evaluating if changes in course of treatment are necessary, and determining if therapy was successful. this study utilized a measure of general distress, but other outcome tracking measures which quantify symptom distress, life satisfaction, and personality functioning are also valuable sources of information. in addition to seeking guidance from supervisors, student clinicians may benefit from participation in trainings designed to introduce the concept of using training clinic examination 23 multiple sources of information to evaluate treatment progress. limitations the present study used archival data, which therefore limited the type of data available for analysis. the information about therapist judgment of outcome was categorical, limiting the types of analyses which could be conducted. also, this study utilized nonparametric statistics, and it can therefore be difficult to estimate how the findings of this study relate to the general population. this study took place in the pacific northwest with a sample of clients that may not represent the cultural or ethnic diversity of other regions. of the 99 clients whose information was included for analysis, demographic data was only available for 66 of those clients; this limits generalizability of the findings. additionally, no demographic data about the therapists was collected, and it is possible that some therapist characteristics (e.g., years of training) could reveal interesting information. for example, a recent study found that particular student therapist variables, such as the number of client contact hours and days in doctoral training, were predictors of treatment outcome (powell, hunter, beasely, & vernberg, 2010). future directions the results of this study were mixed regarding the agreement between different ways for measuring outcomes. rc sometimes occurred when the therapist did not describe treatment as being successful. in other instances, rc did not occur, but the therapist did describe treatment as being successful. it remains unclear what a clinician should do when these two methods produce different descriptions for the same outcome. should clinicians disregard their own judgment? or should clinicians trust their judgment and intuition? the answer to these questions is beyond the scope of this study, but it may be important to recognize the discrepancies in the reports regarding therapy outcome. to account for the low level of agreement between the two methods, it is recommended that therapists draw information about the disposition of treatment from a number of sources, such as the client’s self-report, scores on a routinely administered outcome measure, verbal report from a collateral source (e.g., a client’s spouse), clinical observation, and progress towards treatment goals. additionally, a multitrait multimethod type approach (mtmm; campbell & fiske, 1959) may be appropriate in determining whether treatment was successful. gathering information about the outcome of treatment from multiple sources may provide a more comprehensive and therefore clearer description of the outcome of therapy. one method of determining treatment outcomes that could incorporate both therapist perception and standardized measures is the use of the client’s treatment plan as the standard for evaluating the successfulness of treatment. an appropriate treatment plan includes realistic and measurable goals (leahy & holland, 2000). it should also include goals reflecting what the client expects to gain from treatment. if clients meet their treatment goals, then treatment has been successful. if clients do not meet their treatment goals, then treatment has not yet been successful. research has found that many clinicians prefer using “real world functional indicators” instead of standardized measures in the evaluation of the effectiveness of treatment (garland et al., 2003). using the client’s treatment plan to evaluate the successfulness of treatment may be a valuable addition to the use of therapist judgment and standardized outcome measures. it is possible to construct treatment plans that measure progress based on real world functional indicators (e.g., improvements in school or work attendance), scores on outcome measures, and client reported improvement (e.g., subjective units of distress scales). research on the use of treatment plans to evaluate when treatment has been successful will demonstrate whether a client’s treatment plan is an appropriate method for determining the outcome of treatment. it is possible that research may find the essential components needed for a treatment plan to be an appropriate means of determining when treatment is successful. another future direction for research would be to study the attitudes of student clinicians in regards to outcome measures and assessment, as it is unknown how their attitudes correspond to the previously studied attitudes of practicing professionals. references american psychological association. 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(2004). methods for analyzing psychotherapy outcomes: a review of clinical significance, reliable change, and recommendations for future directions. journal of personality assessment, 82, 50-59. doi: 10.1207/s15327752jpa8201_10 127 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university the impact of a brief humanizing intervention on prejudice towards transgender individuals aya touma sawaya and megan k. mccarty simmons university, boston, massachusetts transgender is an umbrella term used to describe people’s experiences with gender identity. transgender individuals are people whose sex assigned at birth does not align with their true gender identity. transgender men are men who were assigned female at birth and transgender women are women who were assigned male at birth (national center for transgender equality, 2016). the limited body of literature surrounding people in this community and their experiences has been growing over recent years. this literature consistently demonstrates that transgender individuals face an abundance of stigma and prejudice from society, making them vulnerable to discrimination and violence (pellicane & ciesla, 2022). prejudice is defined as a negative attitude or negative behavior towards a person or a group of people based on their belonging to a certain social group (allport & lindzey, 1954). transgender people are twice as likely to be unemployed compared to the larger population because of laws and policies that allow employment discrimination (national lgbtq task force, 2022). the 2022 national survey by the trevor project showed that 71% of transgender and non-binary youth reported having been discriminated against based on their gender identity. in addition, transgender folk are four times more likely to be sexually assaulted, raped, or assaulted in comparison to their cisgender counterparts (williams institute, 2021). thirty-seven percent of transgender and non-binary youth have reported being physically threatened or harmed because of their gender identity (the trevor project, 2022). seventy-three percent of these youth experience symptoms of anxiety and 58% experience symptoms of depression and 1 in 5 transgender or non-binary youth have attempted suicide in the past year (the trevor project, 2022). moreover, discrimination restricts transgender individuals from receiving healthcare (hughto et al., 2015). for example, in minnesota, around 20% of transgender folk reported that they had been denied healthcare completely and many others said that they have had poor healthcare experiences (health partners, 2017). this discrimination affects the quality of life that transgender individuals have, especially affecting the mental health of transgender folk. minority stress theory can be used to better understand the rates of mental health hardships that transgender individuals face. minority stress theory states that marginalized communities experience unique and constant exposure to harsh stressors because of their identity. due to the presence of such chronic stress and continuous discrimination which stigmatizes these individuals, they are at a higher risk of developing mental health issues (meyer, 2003). the hardships that transgender folk experience have caused high rates of suicide ideation and attempts among transgender youth (grossman & d’augelli, 2010). for example, being misgendered and discriminated against by society can cause transgender individuals to experience significant psychological distress. additionally, due to high levels of transgender individuals face an abundance of stigma and prejudice from society, making them vulnerable to discrimination, violence, increased stress, and mental health deterioration (hughto et al., 2015). this study looked at the extent to which a brief humanizing intervention can decrease prejudice against transgender individuals using methods designed to reduce social desirability bias. unlike past work, the current study implemented a control group that was not subjected to any intervention. participants (n=302) were randomly assigned to one of three conditions: the control condition, the transman letter condition, and the musician letter condition. only cisgender participants within the gender binary were used in the analysis (n=293). the humanizing intervention involved having participants read a letter written by a transgender man in which he comes out to his parents. the musician letter condition involved having participants read a letter written by a young man telling his parents that he is quitting college to pursue a career in music. the control condition did not include any letter. participants then responded to various dependent measures such as attitudes towards transgender individuals and empathy. few effects of the intervention were observed, which were inconsistent with past research. however, the results of this study showed an impact on participants’ perception of how parents should react to their children coming out and a decrease in the standard gender differences in empathy. thus, the results offer a nuanced understanding of the extent to which humanizing interventions can reduce prejudice towards transgender individuals. keywords: social psychology, prejudice reduction, humanizing intervention, transgender 128128 discrimination, transgender individuals are more likely to experience loneliness and a lack of belongingness to a community. this triggers transgender folk to engage in negative self-appraisal and have low self-esteem and low self-worth. in turn, this leads to higher levels of suicidal ideation and attempts within the transgender community (hendricks & testa, 2012). although society can negatively affect transgender individuals’ health, social support, in comparison, can mitigate the presence of psychological distress (mclemore, 2018). reducing transphobia although it can be helpful to provide transgender individuals with support and resources to cope with societal discrimination, this support does not directly address nor decrease discrimination. because the transgender community is subject to higher rates of discrimination and violence, it is imperative to study prejudice reduction methods that can ameliorate the quality of life of trans folk (tompkins et al., 2015). although the body of literature in this field has been growing recently, there is still relatively little research looking at the efficacy of interventions that reduce transphobia, or prejudice towards transgender folk. the existing body of research surrounding this topic investigates a number of different types of interventions that reduce prejudice. educational interventions involve giving participants scientific information about the lives of transgender individuals to increase the former’s awareness of transgender lives and decrease transphobia (chan et al., 2009). one study aimed to measure the efficacy of an educational webinar training by subjecting participants to three awareness trainings: an anti-stigma training, a panel training, and a webinar, each of which provided educational information about transgender lives such as the effect of transphobia on transgender lives and the different forms of gender affirmation (mizock et al., 2017). participants’ transphobic attitudes were tested before and after the training. although all the training showed a reduction in transphobia, the webinar proved to be an especially valuable tool for spreading awareness because of the flexibility it offered being internet-based. this finding is consistent with previous literature which suggested webinar training, in general, was more effective in disseminating information than other forms of educational training (mizock et al., 2017). furthermore, another study focusing on healthcare workers also suggested that educational training increased awareness about the needs of transgender individuals and led to better healthcare for the transgender community (mcdowell et al., 2020). although educational training is effective at reducing transphobia, they tend to focus mainly on the scientific explanation of transgender lives, highlighting the biological and definitional framework of being transgender. these trainings fail to include the valuable layer of humanizing transgender individuals by showing the lived experiences of transgender folk and inciting empathy. in order to humanize transgender individuals, researchers thought to broaden transgender awareness beyond just the biological explanation by sharing information about personal transgender experiences. sharing these experiences is meant to not only educate people about transgender lives but to also incite empathy, which can reduce bias (whitford & emerson, 2019). empathy is the act of understanding another person’s thoughts and feelings. previous literature indicates that empathy has played a significant role in decreasing prejudice against the lesbian, gay, and bisexual community provoking participants to imagine what other people’s lives may be like (hodson et al., 2009). past studies looked at how prejudice reduction affected a specific marginalized community and ran studies to see if the same effect would occur in a separate minority community. thus, researchers saw how empathy affected prejudice against the lgb community and hypothesized that it could have that desired effect on the transgender community. intergroup contact theory has been used to humanize transgender folk and incite empathy. intergroup contact theory states that, under the right conditions, the interaction of one group with another can lead to more positive attitudes between the two groups (allport, 1954). participants in one study on intergroup contact were randomly assigned into two groups: one which received a panel presentation by a transgender person followed by a lecture presentation two days later, and another which received the same presentations but in reverse order (walch et al., 2012). the group who received the transgender panel presentation first showed less stigma against transgender individuals compared to those who received the lecture first. thus, it can be inferred, experiencing humanizing contact with a transgender person before learning more factual information about them primes participants to respond more positively to learning informatouma sawaya & mccarty 129 intervention on prejudice towards transgender individuals tion about transgender individuals. this study showed that although brief, meaningful contact with the transgender presenter resulted in more stigma reduction that lasted for a prolonged period in comparison to the other condition. although contact can reduce transphobia, it puts a lot of pressure, burden, and responsibility on transgender folk, and it may not be logistically feasible. to address these concerns, a follow-up study explored whether imagined intergroup contact can have the same effect as actual intergroup contact (moss-racusin & rabasco, 2017). participants either engaged in imagined intergroup contact with a cisgender person or with a transgender person and were then asked to rate how they felt about these people and whether transgender folk were likable and hirable. imagined intergroup contact reduced transphobia and eliminated the difference previously present around hireability and likeability between cisgender and transgender persons. in other words, imagined intergroup contact was an efficacious intervention to decrease transphobia. inspired by this work, the effect of virtual contact with transgender individuals has also been studied (boccanfuso et al., 2020). in this follow-up, participants were randomly assigned into two groups that had virtual contact through a text-chat program with someone who either told them that she was a cisgender woman or that she was a transgender woman. participants were then asked to respond to a questionnaire that assessed transgender stigma. results showed that this intervention successfully reduced transphobia in cisgender men but not in cisgender women. the reason behind this effect is the fact that cisgender men typically have more prejudice towards transgender individuals. contact with transgender folk more heavily affects “prejudice-prone populations” and can alter their prejudice the most (hodson, 2011). the aforementioned literature focused on studying the efficacy of education and contact interventions alone as opposed to comparing them to one another and testing their efficacy. case & stewart (2013) intended to fill in some of the gaps in the literature by designing a study made of three experimental interventions and comparing their efficacy. participants were recruited from different social science courses in a state university in texas and assigned to one of three interventions: providing participants with a list of facts about transgenderism (educational intervention), providing participants with a letter from a transgender adolescent to his parents (humanizing intervention), and showing participants a snippet of a documentary about transgender students in college (humanizing intervention). the documentary included the parents’ reactions to the letter. the humanizing interventions were meant to incite empathy from participants toward transgender individuals. participants were instructed to answer a questionnaire before and after the interventions that measured their attitudes toward transgender individuals. no intervention was more effective than the other. motivated by the comparison of humanizing and educational interventions, tompkins and colleagues (2015) also randomly assigned participants to experience either a humanizing or educational intervention. the humanizing condition showed participants that transgender folk are actual people with lives and incited empathy towards their struggles by having them watch a documentary about a transgender child who was supported by her parents in her transition. in the education condition, participants read about the diagnostic criteria for gender identity disorder and then watched an interview with an expert who explained the process of transitioning and provided factual information about transgender individuals devoid of emotions. after participating in one of these two interventions, the participants completed self-report measures of feelings and attitudes towards transgender individuals. participants in the humanizing condition endorsed less transphobic attitudes than those in the education condition. this finding suggests that humanizing interventions may be most effective at reducing transphobia among participants (tompkins et al., 2015). the present study although past research has compared the efficacy of different interventions designed to reduce transphobia, it has not employed strong control conditions. the current study focused on a humanizing intervention, as some research suggests they are more successful at reducing transphobia than education interventions (tompkins et al., 2015). specifically, the current study was encouraged to use one of the humanizing interventions from case and stewart (2013). their letter intervention involved participants reading a letter written by an adolescent who came out to his parents as a transgender man. the letter’s goal was to invoke a sense of empathy within participants when they completed a transphobia questionnaire and the 130 results of this group were compared to the results of other types of interventions. both this study and others (e.g. case & stewart, 2013; tompkins et al., 2015; mizock et al.,2017) lacked independent control conditions that could have provided them with a baseline and would have strengthened their ability to assess the efficacy of the interventions. researchers did use a pretest measure, but pretest measures can increase participants’ awareness about the true purpose of the study and lead participants to artificially give less transphobic answers. while previous research was an important initial step in studying approaches to transphobia reduction, these prior studies also shared the weaknesses of having a small sample size and utilizing college student samples, who typically have a less conservative outlook on gender identity than the general population (campbell & horowitz, 2015). the current work seeks to extend prior research by addressing some of their potential weaknesses. thus, this study will primarily look at the extent to which a brief empathetic intervention can decrease prejudice against transgender individuals while also reducing social desirability bias. social desirability bias is the tendency of research participants to answer questions in a manner they assume the researchers desire (crowne & marlowe, 1960). this study often refers to transphobia as prejudice towards transgender individuals the current work supplements past research by using a separate control group that was not subjected to any intervention and then completed the same questionnaire as participants in the other groups. this condition provides an independent baseline to compare with the results of the interventions. participants in the key intervention condition were instructed to read a letter written by a young man coming out to his parents as a transgender man, which was brought about by the letter presented in case & stewart (2013). this intervention is meant to instigate empathy towards him and reduce transphobia. the current work also extends prior research by testing another condition, a parallel version of the transman letter condition about a young adult telling his parents that he will be dropping out of college to pursue music. this intervention intends to instill empathy in participants towards the young adult to study if empathy in general affects individuals’ prejudice against transgender folk. after completing one of the three conditions, participants answered self-report measures of transphobia and a number of other dependent variables related to prejudice and intergroup attitudes. we expected to find a significant main effect of our manipulation such that participants in the transman letter condition would have more positive reactions across all of our dependent variables, including lower levels of transphobia and prejudice, compared to participants in the control group (hypothesis 1). this prediction is consistent with prior research which shows that implementing a humanizing intervention (transman letter condition) that incites empathy can decrease prejudice against transgender individuals (tompkins et al., 2015). additionally, we explored whether participants in the musician letter condition would differ from participants in the control and transman letter conditions. this letter about a young man dropping out of college to be a musician was meant to incite empathy from the participants toward his difficult situation. this condition enabled the current study to look at whether transphobia can be decreased solely by enticing empathy generally, as opposed to empathy about trans lives specifically. previous literature shows that humanizing interventions are able to reduce prejudice towards minority groups such as people from different racial groups, people with mental illness, and people in the lgb community (whitford & emerson, 2019). if these effects hold true for transphobia, then participants in the musician letter condition may have less negative opinions towards transgender folk versus the control condition. however, since the empathy produced from the musician letter condition is not inspired by the vulnerability of the transgender man’s experience, it was predicted to have less of an impact on transphobia compared to the transman letter condition (hypothesis 2). although the current work focuses on the effect of our manipulation, this study also explored the role of participant gender. this study explored whether cisgender men would generally have more negative responses across dependent variables, including higher levels of transphobia, compared to women (hypothesis 3). men tend to hold more power in society compared to other gender identities, benefit from maintaining the status quo, and therefore feel more threatened by non-normative experiences (west & borras-guevara, 2021). indeed, previous research has shown that men have more negative attitudes toward transgender individuals than women (tebbe & moratouma sawaya & mccarty 131 intervention on prejudice towards transgender individuals di, 2012; tompkins et al., 2015). this study also explored whether our manipulation would interact with participant gender (hypothesis 4). methods participants this study was conducted through amazon’s mechanical turk (mturk) which is a website used by researchers to recruit and compensate participants for a variety of kinds of tasks including psychological studies (buhrmester, kwang, & gosling, 2011). three hundred and two participants were recruited from the united states only and completed the study. they were compensated $2.50 for their participation. we ran an a priori power analysis using g*power to determine sample size (faul, erdfelder, buchner & lang, 2009). given our design, we set alpha to .05 and assumed a small effect size of partial eta squared .035. the analysis indicated that 270 participants would provide us with 80% power. we decided to run up to 300 participants in case we needed to exclude any participants, and due to an mturk glitch, 302 participants responded. 195 participants indicated that they identify as female, 98 identified as male, 2 identified as transgender men, and 3 identified as non-binary individuals. the remaining 4 either chose not to respond or added a category of their own. as our analyses required roughly equal groups of participant gender, we only had the statistical power to analyze cisgender male and cisgender female participants (n = 293). the participants’ average age was 35.53 years old (sd = 12.04). the majority (70.9%) of participants identified as white/ caucasian, 13.6% identified as african american, 7.5% identified as asian/pacific islander, and 6.4% identified as hispanic. the rest of the participants indicated they identified with another racial category or selected multiple identifications (for more information about demographics see table 1 and table 2). design the study used a 3-letter condition (no letter group vs. musician letter group vs. transgender letter group) x 2 participant gender (male participants vs. female participants) between-subjects design. procedure and manipulation the study was conducted using the web survey software, qualtrics. participants were asked to complete a survey called “other people’s stories.” they were then randomly assigned to one of three groups: one with no letter, one instructed to read a letter about an individual coming out to his parents as a transgender man, and one with a letter about a student who is telling his parents he wants to drop out of college to pursue music. the transgender letter was taken from case & stewart (2013); originally, the letter was found in “true selves: understanding transsexuality’’ (brown & rounsley, 1996). this book includes real-life experiences of transgender people to provide insight into their families and help them better understand the hardships that transgender people go through. this is a real letter from a transgender man coming out to his parents. for this study, the letter was slightly edited: due to ethical concerns, parts that mentioned suicide/ suicidal ideation were removed so as to not expose the participants to such topics. the musician’s letter was based largely on the transgender letter. it was created to make sure there was a group of participants who were exposed to a letter simulation that did not involve transgender experiences. the musician and transgender letters were intended to be as parallel as possible, but with the musician’s letter involving a child disclosing something difficult to their parents unrelated to gender. an example of the difference between these two letters can be seen here: in the musician’s letter the following was said “for the longest time, i had been deeply unhappy with my majorthe life plan i am supposed to want,” whereas the transgender letter said, “for the longest time, i had been deeply unhappy with the body i am inthe body i am supposed to feel comfortable in.” see appendices a and b for the complete letters. after reading the transgender letter, musician letter, or no letter, the participants were all instructed to answer the same series of questions. the questionnaire included variables detailed in the dependent measures section below, as well as filler questions such as the big five personality measure (morizot, 2014). all scales included a prefer not to respond option. finally, participants were debriefed regarding the true purpose of the study, which was to understand the effect of empathy on prejudice against transgender individuals. participants were asked to re-consent given this information and offered the opportunity to have their data discarded. all participants re-consented and allowed for the use of their data. dependent measures transphobia. participants were asked to respond to nine questions regarding their attitudes towards gen132 der-diverse and transgender individuals on a scale from 1 (strongly disagree) to 7 (strongly agree) (nagoshi et al., 2008). an example question is “i believe that a person can never change their gender” (α=.93). attitudes towards transgender individuals. participants were asked to respond to 20 questions measuring the way people feel about transgender individuals on a scale of 1 (strongly disagree) to 5 (strongly agree) (walch et al., 2012). an example question is “i avoid transgender individuals whenever possible” (α=.97). feelings thermometer. participants completed an adapted version of the feelings thermometer (murphy et al., 2011) which asked them to rate how warm they felt towards groups on a scale of 0 to 100 (0 being not warm at all and 100 being completely warm). the groups they were asked to rate their feelings towards were transgender men, transgender women, and non-binary individuals (α=.98). inclusion of other in self. participants completed an adapted version of the inclusion of other in the self scale (aron et al., 1992). participants were presented with seven sets of increasingly overlapping circles, one labeled ‘self’ and the second labeled “other.” these sets of circles began with no overlap and got progressively more overlapping. participants were asked to choose the circle that best represents their relationship with a group, with “self” being themselves and “other” representing: transgender men, transgender women, and non-binary individuals. they were asked to do so three times for the three different groups (α=.95). exploratory dependent measures interpersonal reactivity index (iri). participants were asked to respond to 16 questions measuring levels of empathy on a scale from 1 (does not describe me well) to 5 (describes me very well) (davis, 1980) (α=.81). this scale is made up of four different subscales, each comprised of four items. example questions of the four subscales perspective taking, fantasy, empathetic concern, and personal distress respectively are: “i try to look at everybody’s side of a disagreement before i make a decision” (α=.81). “i really get involved with the feelings of the characters in a novel” (α=.84). “i often have tender, concerned feelings for people less fortunate than me” (α=.77). “ in emergency situations, i feel apprehensive and ill-at-ease” (α=.78). privilege and oppression inventory (poi). this scale was included as an exploratory measure to observe the effect that the intervention had on participants’ perception of their social power and other people’s marginalization within society. participants were asked to respond to 22 questions regarding their awareness of privilege and oppression in society on a scale from 1 (strongly disagree) to 6 (strongly agree) (hays et al., 2007). an example question is “being white and having an advantage go hand in hand” (α=.97). ambivalent sexism inventory. this scale was included in order to observe whether the intervention could impact participants’ levels of ambivalent sexism. ambivalent sexism is made up of two sub-groups: benevolent sexism and hostile sexism. benevolent sexism is characterized by seemingly positive comments that are actually damaging to a person. hostile sexism is characterized by blunt and negative comments that adhere to harmful gender stereotypes. participants were asked to respond to 22 statements concerning their views on men and women within society on a scale of 1 (disagree strongly) to 6 (agree strongly) (glick & fiske, 1996) (α=.88). this scale is divided into two subscales each comprised of eleven items. an example of the first subscale, benevolent sexism, is “in a disaster, women ought not necessarily to be rescued before men” (α=.84). an example of the second subscale, hostile sexism, is “women are too easily offended” (α=.83). system justification. this scale was added to observe the effect of the intervention on how fair participants believe social systems are and whether or not they support the current social system. participants were asked to respond to 8 items measuring how fair participants feel that social systems are on a scale of 1 (strongly disagree) to 9 (strongly agree) (kay & jost, 2003). an example item is “in general, you find society to be fair” (α=.86). need for closure. this scale was added as an exploratory measure of how this intervention could impact participants’ need for certainty and order and measure participants’ ability to accept uncertainty. participants were asked to respond to 15 questions regarding their need for certainty and how much they value order on a scale from 1 (strongly disagree) to 6 (strongly agree) (neuberg et al., 1997). an example question is “i don’t like to be with people who are capable of unexpected actions” (α=.87). reactions to coming out. participants were asked to rate the degree to which they should respond with five different reactions parents could have to their son coming out to them on a scale of 1 (strongly disagree) to 7 (strongly agree). the potential reactions to coming touma sawaya & mccarty 133 intervention on prejudice towards transgender individuals out were based on data from an article that reported first-person reports of parents dealing with their kids coming out as transgender (wren, 2002). an example item is: “take adam to see a specialist and change his mind’’ (α=.75). using the same scale, participants were then asked to respond to the same five reactions, except this time, they were asked to imagine how they would respond if they were in the shoes of those parents. an example item is “get the proper professional help to support adam and his decisions” (α=.76). manipulation checks and demographics participants were asked four questions and all items had a “prefer not to respond” option. the first manipulation check asked participants “did you read a letter at the beginning of this study” with answer options: “yes”, and “no.” the second manipulation check asked participants: “ if yes, what was this letter about?” and had answer options: “someone telling their parents that they are actually a man and will be going through a gender transition”, “someone telling their parents that they will be dropping out of college to pursue music”, and “i did not read a letter.” the third manipulation check asked participants: “who wrote the letter that you read” with answers: “a transgender man (a man assigned female at birth)”, “a transgender woman (a woman assigned male at birth)”, “a cisgender man (a man assigned male at birth)”, “a cisgender woman (a woman assigned female at birth)”, “the gender of the letter was not specified”, and “i did not read a letter.” finally, the fourth manipulation check asked: “if you read a letter, how did it end?” with answer options: “with love, adam”, “with love, alice (soon to be known as adam)”, and “i did not read a letter.” demographics. after completing the questions, participants were asked to answer a few demographic measures such as gender, age, and race. results manipulation checks chi-square tests of independence were performed on each manipulation check. participants’ responses to the first manipulation check regarding whether or not they read a letter were significantly associated with the actual letter condition, χ2 (2, n = 292) = 211.56, p < .001. all participants in both the transman letter condition and the musician letter condition reported that they read a letter at the beginning of the study. 80.00% of participants in the control condition reported that they did not read a letter at the beginning of the study. this could be due to the fact that early in the study participants were told that other participants would be reading a letter. thus, participants were instructed to answer the questionnaire knowing that other participants have read a letter. participants’ responses to the second manipulation check that asked them what the letter was about were significantly associated with the actual letter condition, χ2 (4, n = 292) = 471.76, p <.001. 98.9% of participants in the transman letter condition correctly reported that they read a letter about a transman coming out to his parents. 99.01% of participants in the musician condition correctly reported that they read a letter about an aspiring musician. 81.00% of participants in the control condition correctly reported that they had not read a letter. participants’ responses to the third manipulation check that asked them about the gender identity of the person writing the letter were significantly associated with the actual letter condition, χ2 (10, n = 290) = 4 70.51, p <.001. 87.91% of the participants in the transman letter condition reported that the person writing the letter was a transgender man. 98.02% of participants in the musician letter condition reported that the person writing the letter was either a cis-gender man or they indicated that the gender identity was not disclosed. both of these options were considered to be correct because the letter’s author used a name that is stereotypically male and did not specify their gender identity explicitly. 81.63% of the participants in the control condition indicated that they did not read a letter. participants’ responses to the fourth manipulation check that asked them how the letter ended were significantly associated with the actual letter condition, χ2 (4, n = 290) = 445.00, p <.001. 91.3% of the participants in the transman letter condition reported that the letter ended with “with love, alice (soon to be known as adam).” 100.00% of participants in the musician letter correctly reported that their letter ended with “with love, adam.” finally, 81.82% of the participants in the control condition correctly indicated that they did not read a letter. primary analyses between-subjects 3 (letter condition: no letter group vs. musician letter group vs. transgender letter group) x 2 (participant gender: male vs. female)anovas were conducted on each of our depen dent varia-. 134 bles.follow-up tukey tests were conducted on significant main effects of letter condition. although our pre-registration focused primarily on the effects of letter condition only, the analysis with participant gender is reported here since consistent participant gender effects emerged, and this analysis was also outlined in the pre-registration. transphobia. a significant effect of participant gender emerged such that men reported greater overall transphobia (m = 3.51, sd = 1.49) than women (m = 3.03, sd = 1.54), f (1, 287) = 6.07, p = .014, ηp 2 = .02. there was no main effect of letter condition on transphobia, f (2, 287) = 0.60, p = .549, ηp 2 = .00, nor was there a significant interaction, f (2, 287) = 1.16, p = .316, ηp 2 = .01 attitudes towards transgender individuals. there was no main effect of participant gender on attitudes towards transgender individuals, f (1, 285) = 3.42, p = .065, ηp 2 = .01. there was also no main effect of letter condition on attitudes towards transgender individuals, f (2, 285) = 1.37, p = .256, ηp 2 = .01, nor was there a significant interaction, f (2, 285) = 1.89,p = .153, ηp 2 = .01. feelings thermometer. a significant effect of participant gender emerged such that women reported warmer feelings towards transgender men (m = 70.50, sd = 31.19) that did men (m = 60.82, sd = 33.34), f (1, 287) = 5.48, p = .020, ηp 2 = .02. similarly, a significant effect of participant gender emerged such that women reported warmer feelings towards transgender women (m = 69.49, sd = 32.27) than did men (m = 60.71, sd = 33.76), f (1, 287) = 4.38, p = .037, ηp 2 = .02. there was no main effect of letter condition on feelings towards transgender men, f (2, 287) = 0.26, p = .755, ηp 2 = .00, nor towards transgender women, f (2, 287) = 0.04, p = .964, ηp 2 = .00. additionally, nor was there a significant interaction between participant gender and letter condition when it came to transgender men, f (2, 287) = 1.80, p = .168, ηp 2 = .01 and transgender women f (2, 287) = 1.37, p = .256, ηp 2 = .01. there was no significant effect of participant gender on feelings towards non-binary individuals, f (1, 287) = 3.69, p = .056, ηp 2 = .01. there was no main effect of letter condition on feelings towards non-binary individuals, f (2, 287) = 0.28, p = .754, ηp 2 = .00, nor was there a significant interaction, f (2, 287) = .69, p = .503, ηp 2 = .01. inclusion of other in self. there was no significant effect of participant gender on how close they felt towards transgender men, f (1, 279) = .08, p = .785, ηp 2 = .00. there was no main effect of letter condition on feelings towards transgender men, f (2, 279) = 0.71, p = .491, ηp 2 = .01, nor was there a significant interaction, f (2, 279) = .211, p = .810, ηp 2 = .00. there was no significant effect of participant gender on how close they felt towards transgender women, f (1, 278) = .01, p = .925, ηp 2 = .00. there was no main effect of letter condition on feelings towards transgender women, f (2, 278) = 0.36, p = .698, ηp 2 = .00, nor was there a significant interaction, f (2, 278) = .28, p = .756, ηp 2 = .00. there was no significant effect of participant gender on how close they felt towards non-binary individuals, f ( 1, 278) = .01, p = .924, ηp 2 = .00. there was no main effect of letter condition on feelings towards non-binary individuals, f (2, 278) = 0.46, p = .630, ηp 2 = .00, nor was there a significant interaction, f (2, 278) = .27, p = .767, ηp 2 = .00. interpersonal reactivity index (iri). a significant effect of participant gender emerged such that women scored higher on perspective taking (m = 4.12, sd = 0.73) than men (m = 3.86, sd = 0.77), f (1, 286) = 7.14, p = .008, ηp 2 = .02. there was no main effect of letter condition on perspective taking, f (2, 286) = 0.52, p = .595, ηp 2 = .00. however, a significant interaction between letter condition and gender emerged, f (2, 286) = 4.35, p = .014, ηp 2 = .03. women scored higher on perspective taking (m = 4.23, sd = 0.67) than men (m = 3.88, sd = 0.86) in the control condition, f (1, 286) = 5.04, p = .026, ηp 2 = .02. women also scored higher on perspective taking (m = 4.22, sd = 0.73) than men (m = 3.70, sd = 0.70) in the musician letter condition, f (1, 286) = 10.90, p = .001, ηp 2= .04. however, there was no gender difference in the transman letter condition, f (1, 286) = 0.64, p = .424, ηp 2 = .00 (mwomen = 3.89, sd = .75; mmen = 4.02, sd = 0.73) (see figure 1). when broken down the other way, analyses show that there was no effect of letter condition among men, f (2, 286) = 1.42, p = .244, ηp 2 = .01, but there was an effect of letter condition among women, f (2, 286) = 4.45, p = .013, ηp 2 = .03. follow-up tukey tests indicate that women in the control condition and women in the musician letter condition scored higher on perspective taking than women in the transman let ter condition (p = .010 and p = .009 respectively). there was no difference in perspective taking between women in the control and musician letter conditions, touma sawaya & mccarty 135 intervention on prejudice towards transgender individuals p = .980. a significant effect of participant gender emerged such that women scored higher on fantasy (m = 3.86, sd = 0.90) than men (m = 3.53, sd = 1.04), f (1, 287) = 6.72, p = .010, ηp 2 = .02. there was no main effect of letter condition on fantasy, f (2, 287) = 1.08, p = .341, ηp 2 = .01. however, a significant interaction between letter condition and gender emerged, f ( 2, 287) = 6.45, p = .002, ηp 2 = .04. women scored higher on fantasy (m = 3.99, sd = .80) than men (m = 3.17, sd = 1.18) in the control condition, f (1, 287) = 17.58, p < .001, ηp 2 = .06. however, there was no gender difference in the musician letter condition, f (1, 287) = 2.19, p = .140, ηp 2 = .01. (mwomen = 3.91, sd = .96; mmen = 3.62, sd = .87). there was also no gender difference in the transman letter condition, f (1, 287) = .99, p = .319, ηp 2 = .00 (mwomen = 3.65, sd = .91; mmen = 3.86, sd = 0.92) (see figure 2). when broken down the other way, analyses show that there was no effect of letter condition among women, f (2, 287) = 2.30, p = .103, ηp 2 = .02, but there was an effect of letter condition among men, f (2, 287) = 4.57, p = .011, ηp 2 = .03. follow-up tukey tests indicate that men in the transman letter condition scored higher on fantasy than men in the control condition (p = .003). there was no difference in fantasy between men in the control and musician letter conditions nor was there a difference between the men in the musician letter condition and the transman letter condition, (p = .052 and p = .317). there was a significant effect of participant gender such that women scored higher on empathetic concern (m = 4.26, sd = 0.70) than men (m = 3.91, sd = 0.77), f (1, 286) = 14.64, p < .001, ηp 2 = .05. there was no main effect of letter condition on empathic concern, f (2, 286) = 0.02, p = .976, ηp 2 = .00, nor was there a significant interaction, f (2, 286) = .05, p = .951, ηp 2 = .00. a significant effect of participant gender was observed such that women scored higher on personal distress (m = 2.88, sd = 1.01) than men (m = 2.52, sd = 0.93), f (1, 287) = 9.58, p = .002, ηp 2 = .03. there was no main effect of letter condition on personal distress, f (2, 287) = 0.05, p = .952, ηp 2 = .00, nor was there a significant interaction, f (2, 287) = 1.84, p = .160, ηp 2 = .01. privilege and oppression inventory (poi). a significant effect of participant gender emerged such that women reported greater awareness of privilege and oppression (m = 4.49, sd = .97) than men (m = 4.10, sd = 1.16), f (1, 287) = 8.96, p = .003, ηp 2 = .03. there was no main effect of letter condition on awareness of privilege and oppression, f (2, 287) = .41, p = .665, ηp 2 = .00, nor was there a significant interaction, f (2, 287) = .67, p = .511, ηp 2 = .01. ambivalent sexism inventory. there was no significant effect of participant gender on benevolent sexism, f (1, 287) = 1.98, p = .161, ηp 2 = .01. there was no main effect of letter condition on benevolent sexism, f (2, 287) = 1.84, p = .161, ηp 2 = .01. however, a significant interaction between letter condition and gender emerged, f (2, 287) = 3.80, p = .023, ηp 2 = .03. men scored higher on benevolent sexism (m = 3.60, sd = .95) than women (m = 3.07, sd = 1.09) in the control condition, f (1, 287) = 6.30, p = .013, ηp 2 = .02. there was no gender difference in the musician letter condition, f (1, 287) = 1.75, p = .187, ηp 2 = .01 (mwomen = 3.35, sd = 1.10; mmen = 3.06, sd = 0.90), nor in the transman letter condition, f (1, 287) = 1.63, p = .203, ηp 2 = .01 (mwomen = 3.37, sd = 1.00; mmen = 3.66, sd = 0.91) (see figure 3). when broken down the other way, analyses show that there was no effect of letter condition among women, f (2, 287) = 1.72, p = .181, ηp 2 = .01, but there was an effect of letter condition among men, f (2, 287) = 3.30, p = .038, ηp 2 = .02. follow-up tukey tests indicate that men in the musician letter condition scored lower on benevolent sexism than both men in the control condition (p = .030) and men in the transman letter condition (p = .023). there was no difference between men in the control condition and the transman letter conditions, p = .836. a significant effect of participant gender emerged such that men reported more hostile sexism (m = 3.32, sd = .91) than women (m = 2.82, sd = .97), f (1, 285) = 17.75, p < .001, ηp 2 = .06. there was no main effect of letter condition on hostile sexism, f (2, 285) = .20, p = .822, ηp 2=.00, nor was there a significant interaction, f (2, 285) = .07, p = .933, ηp 2 = .00. system justification. a significant effect of participant gender emerged such that men reported more support for the status quo (m = 4.06, sd = 1.67) than women (m = 3.5, sd = 1.58), f (1, 286) = 7.86, p = .005, ηp 2 = .03. there was no main effect of letter condition on system justification, f (2, 286) = 2.72, p = .067, ηp 2 = .02, nor was there a significant interaction, f (2, 286) = 2.19, p = .114, ηp 2 = .02. need for closure. a significant effect of participant gender emerged such that women reported more need for closure (m = 4.13, sd = .82) than men (m = 3.92, sd 136 = .79), f (1, 287) = 4.12, p = .043, ηp 2 = .01. there was no main effect of letter condition on the need for closure, f (2, 287) = .72, p = .490, ηp 2 = .01, nor was there a significant interaction, f (2, 287) = .37, p = .690, ηp 2 = .00. reactions to coming out. a significant effect of participant gender emerged such that women reported more positive reactions to how parents should react to their kids coming out (m = 5.75, sd = 1.17) than men (m = 5.18, sd = 1.33), f (1, 283) = 13.06, p < .001, ηp 2 = .04. there was a significant main effect of letter condition, f (2, 283) = 4.93, p = .008, ηp 2 = .03. follow-up tukey tests indicate that participants in the transman letter condition reported more positive reactions to how parents should react to their kids coming out (m = 5.77, sd = 1.43) than participants in the control condition (m = 5.29, sd = 1.32) (p = .019). there was no difference between participants in the control condition and the musician letter condition (m = 5.63, sd = 0.95) nor was there a difference between participants in the transman letter condition and the musician letter condition (p = .121 and p = .694 respectively). there was no significant interaction, f (2, 283) = 1.61, p = .201, ηp 2 = .01. a significant effect of participant gender emerged such that women reported more positive reactions to how they would react to their kids coming out (m = 5.83, sd = 1.28) than men (m = 5.20, sd = 1.40), f (1, 283) = 13.46, p < .001, ηp 2 = .05. there was no main effect of letter condition, f (2, 283) = 2.22, p = .111, ηp 2 = .02. however, a significant interaction between letter condition and gender emerged, f (2, 283) = 3.09, p = .047, ηp 2 = .02. women scored higher on positive reactions to how they would react to coming out (m = 5.85, sd = 1.20) than men (m = 4.72, sd = 1.46) in the control condition, f (1, 283) = 16.55, p < .001, ηp 2 = .06. however, there was no gender difference in the musician letter condition, f (1, 283) = 3.66, p = .057, ηp 2 = .01 (mwomen = 5.92, sd = .95; mmen = 5.38, sd = 1.22). there was also no gender difference in the transman letter condition, f (1, 283) = .22, p = .641, ηp 2 = .00 (mwomen = 5.70, sd = 1.65; mmen = 5.57, sd = 1.39) (see figure 4). when broken down the other way, analyses show that there was no effect of letter condition among women, f (2, 283) = .45, p = .638, ηp 2 = .00, but there was an effect of letter condition among men, f (2, 283) = 3.85, p = .022, ηp 2 = .03. follow-up tukey tests indicate that men in the transman letter condition and men in the musician letter condition scored higher on positive reactions than men in the control condition (p = .010 and p = .039 respectively). there was no difference between men in the transman and musician letter conditions, p = .582. discussion the current study extends past research by further testing how efficacious a brief humanizing intervention is in reducing transphobia. in contrast to our hypothesis, we did not see a main effect of our manipulation on most of our dependent variables. the only dependent variable that was significantly affected by our manipulation was how participants reported parents should respond to their children coming out as transgender. specifically, participants in the transman letter condition reported more positive responses on how parents should react to their child coming out than participants in the control condition. this positive influence could be caused by the explicitness of the transman letter condition in describing a transgender man’s journey of self-discovery and the importance of having his parents support him. in turn, this could have motivated participants to acknowledge the ideal way in which a parent should react to their kid coming out. however, this manipulation may have not shifted participants’ intrinsic beliefs about how they should act if their own child came out to them (reiss, 2012). additionally, the effectiveness of the manipulation may have not been extended to the other dependent variables because they were numerous. although the questionnaire did include some filler questions, there was an abundance of transphobia questions which may have signaled to participants the true purpose of this study, thus leading to relatively low transphobia regardless of condition. future research could decrease the number of prejudice-related items and add more filler questions which would lessen the likelihood of the participants figuring out the true purpose of the study. our exploratory hypothesis which expected differ ences between the musician letter condition and both the control condition and the transman letter condition was not supported. the musician’s letter did not explicitly mention transgender issues in any way. although it did highlight a difficult time that the character was going through, it did not describe the specific hardships that transgender individuals face when coming out to their parents.this piece could have been integral to triggering empathy towards transgender inditouma sawaya & mccarty 137 intervention on prejudice towards transgender individuals viduals. thus, in this case, general empathy did not instigate a decrease in transphobia. in turn, the musician letter condition did not show the decrease in transphobic attitudes that was hypothesized to occur in comparison to the control condition. as expected, men exhibited higher levels of transphobia, hostile sexism, and system justification than women. in addition, women exhibited higher awareness of privilege and oppression and more need for closure in comparison to men. women also scored higher than men on all facets of the interpersonal reactivity index including perspective-taking, fantasy, empathy, and personal distress. women had warmer feelings towards transgender men and transgender women than men. in contrast to men, women reported more positive reactions to how parents should react to their kid coming out as well as how they would react to their kid coming out. these results are in alignment with our hypothesis and previous literature (tompkins et al., 2015; tebbe & moradi, 2012; glick & fiske, 1996) that men would have more negative responses across all dependent variables than women. these findings are consistent with the fact that men tend to hold more power in society compared to other gender identities, benefit from maintaining the status quo, and therefore feel more threatened by non-normative experiences (west & borras-guevara, 2021). however, there was no gender difference between men and women when it came to feelings towards non-binary individuals, attitudes towards transgender individuals, and inclusion of others in self. the lack of difference in feelings towards non-binary individuals might be due to a lack of awareness, interaction, and knowledge about non-binary folk (fiani & serpe, 2020). additionally, participants may have had a difficult time with answering the inclusion of others in the self scale as it asks them to rate how close they are to transgender individuals without clarifying what closeness refers to. participants could have thought that this question asked them to signify how close they feel to the transgender identity, or how closely they feel towards transgender people. the attitudes towards transgender individuals scale might have not triggered a gender difference because it was the second scale measuring transphobia within the survey. thus, perhaps some participants were made aware of the true purpose behind the study, making them concerned about social desirability. no interaction between participant gender and letter condition was obtained on transphobia, attitudes towards transgender individuals, feelings towards transgender individuals, inclusion of self, empathetic concern and personal distress, hostile sexism, system justification, need for closure, or how parents should react to their kid coming out. in contrast, a significant interaction between participant gender and letter condition emerged on the perspective-taking subscale of the iri which measures the tendency to imagine oneself in another person’s situation and see things from their perspective. women reported higher perspective-taking than men in both the control condition and the musician letter condition but not in the transman letter condition. this suggests that the transman letter condition affected perspective-taking such that it eliminated the standard gender differences obtained in the control condition and the musician letter condition. the transman letter condition explicitly explains how difficult it had been for the transgender man to go through life without being seen as a man. male participants may have related to that feeling which encouraged them to put themselves in another person’s shoes. furthermore, there was a significant interaction on the fantasy subscale of the iri which measures people’s tendency to imagine themselves in fictional situations. women scored higher than men in the control condition but there was no difference in the other two conditions. this finding suggests that both the musician and transman letter conditions are able to affect the gendered differences between men and women and their ability to imagine themselves in a situation they would usually not be in. the vulnerability present in both these letters may have encouraged men to step into a fictional situation. in addition, an interaction between participant gender and letter condition emerged on how participants would react to their kids coming out. women reported more positive reactions in the control condition than men, but there was no gender difference in the other two conditions. this finding again suggests that the musician letter and the transman letter conditions eliminate the gender differences obtained in the control condition. both the musician and transman letters showcased vulnerable experiences which may have influenced participants to take into consideration the characters’ hardships and eliminated typically seen gender differences in would reactions to coming out. a similar interaction was also obtained on benevolent sexism, which is a subter form 138 touma sawaya & mccarty of sexism expressed in a seemingly positive light, there is an interaction between gender and letter condition. men scored higher on benevolent sexism in the control condition than women but there was no gender difference in the musician letter condition and the transgender letter condition. the results suggest that the levels of benevolent sexism decrease in men when subjected to reading a letter. both letter conditions highlighted the vulnerability of two young men during a hard time in their lives which could have consequently decreased men’s benevolent sexism scores. since both letters showcased the struggle of two men, they may have led male participants to be less likely to endorse traditional gendered beliefs that are seemingly positive towards women (manzi, 2019). overall, the current work has a number of strengths. firstly, it is important to test the efficacy of brief humanizing interventions with the presence of an independent control condition. the control condition acts as a reference to the other two conditions and is essential to get an understanding of the true effect of interventions like reading a coming-out letter on transphobia outside of studies with set preand post-tests. previous literature (tompkins et al., 2015; case & stewart, 2013; mizock et al., 2017), uses pre-tests that tells participants something about the purpose of the study and increases social desirability bias. this study did not have a pretest condition, thus reducing the likelihood that participants are aware of the purpose of the study before experiencing the manipulation, and thus motivated to answer questions in a particular manner that is desirable to researchers. moreover, an appropriately large sample size (n=302) was determined by running a priori power analysis and recruitment. this study was able to obtain a larger and more diverse sample than prior research by using mturk recruitment. in comparison to previous studies (walch et al., 2012; tompkins et al., 2015), which utilized students as their participants, our participants had more varied life experiences. the mean age of our participants was approximately 35 and 37.1% of our participants had completed some level of college, 30.8% had various educational levels, and 14.9 % had a master’s degree. our sample reported relatively moderate political views ranging from conservative (26.2%) to moderate (37.8%) to liberal (56%). previous literature used undergraduate samples (tompkins et al., 2015; case & stewart, 2013; walch et al., 2012), which typically skew more liberal politically (campbell & horowitz, 2015). thus, this study offers a more politically diverse participant sample. another strength of our current work was our manipulation check data, which showed that participants were generally attentive and understood their respective letter conditions. although the current study had a number of important strengths, there are also weaknesses that can be addressed in future research. the current sample was not racially diverse. 65.2% of our participants identified as white/caucasian. previous research (case & stewart, 2013) has demonstrated higher rates of transphobia in people of color prior to interventions. thus, future research may explore the interaction of racial identity with humanizing interventions intended to reduce transphobia. future studies may find that humanizing interventions have a greater effect on people of color who previously had higher rates of transphobia. cisgender men have previously had higher levels of transphobia than cisgender women. humanizing interventions were able to eliminate some of the gendered differences between them (hodson, 2011). thus, a similar effect may occur with participant race. also, the vast majority (97.1%) of our participants identified as either men or women; there were few non-cisgender and non-binary participants. further research may attempt to recruit a more gender-diverse participant population and study potential internalized transphobia. internalized transphobia is when transgender individuals internalize the negative outlook and normative gender attitudes that society has put in place (scandurra et al., 2018). future research could look into the effect of humanizing interventions on internalized transphobia and whether empathy can decrease internalized transphobia. transgender individuals might empathize with the representations in humanizing interventions and see that their own struggles are valid. this empathy might extend to themselves thus decreasing their internalized trans phobia. additionally, future studies could explore the efficacy of a humanizing intervention by comparing the effect of letters written by people of different gender identities: transgender women, transgender men, and non-binary individuals. participants may have different preconceived biases towards people with these gender identities and the humanizing interven tion could affect participants differently depending on what condition they are exposed to. although there 139 is not much research on whether attitudes towards transmen, transwomen, and gender non-binary people differ, there is good reason to expect their lived experiences to be different, as transgender women have been subjected to higher rates of gender-based violence (gyamerah et al., 2021). additionally, people have less awareness of non-binary individuals (fiani & serpe, 2020) which could increase people’s transphobia. people are generally wary of the concepts and things that they do not know (carleton, 2016) which in turn may affect people’s attitudes towards non-binary individuals. humanizing interventions that would include these gender identities might elicit greater reductions in transphobia levels towards transgender women versus transgender men and non-binary individuals because of the high rates of violence towards them. moreover, future research could decrease the number of dependent variables within the study and add more filler questions in order to decrease potential social desirability bias. it would also be beneficial to also look at how long the effects of a humanizing intervention last through a longitudinal study. brief humanizing interventions might have a temporary effect on people’s prejudice towards transgender individuals, especially if the intervention was only administered once. in sum, this brief humanizing intervention did not have the direct impacts on transphobia that were initially predicted. unlike prior research which found more support for the effectiveness of brief humanizing interventions, this study included the general population instead of university students. additionally, this study reduced participant suspicion by implementing a control condition. thus, our findings suggest that prior research may have painted a rosier picture of the ease with which humanizing interventions can reduce transphobia. however, our findings still suggest that humanizing interventions may have promising effects. for example, we found that our manipulation influenced participants’ outlook on how they think parents should react to their kid coming out to them, signifying that participants believed parents should react in less transphobic ways to their kid coming out. thus, future research using humanizing interventions is 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(2002). ‘i can accept my child is transsexual but if i ever see him in a dress i’ll hit him’: dilemmas 142142 in parenting a transgendered adolescent. clinical child psychology and psychiatry;7(3), -377-397. https://doi.org10.1177/1359104502007003006 touma sawaya & mccarty 143 intervention on prejudice towards transgender individuals table 1 demographics of participants 144 touma sawaya & mccarty 145 intervention on prejudice towards transgender individuals table 2 the distribution of male and female participants in each condition 146 figure 1 the effect of gender and letter condition on iri-perspective-taking touma sawaya & mccarty 147 intervention on prejudice towards transgender individuals figure 2 the effect of gender and letter condition on iri-fantasy 148 figure 3 the effect of gender and letter condition on ambivalent sexism touma sawaya & mccarty 149 intervention on prejudice towards transgender individuals figure 4 the effect of gender and letter condition on would reactions 150 appendix a musician letter dear mom and dad, i have something very important to tell you about myself. you might not approve of it, but please try to keep an open mind as i try to explain this. also, please understand that what i’m about to tell you is not your fault. so whatever you do, please don’t blame yourselves. i know you’ve wondered why i’ve never had a girlfriend. you might have noticed that i spend most of my time with my “buddies.” well, i’m not slacking off, but i have actually been in a band. you see, my current major doesn’t match the way i see myself. mom and dad, i feel that i am a musician. you might not see this for me, but i know i am a musician. it’s what comes naturally to me. i have felt this way for as long as i can remember. i know you thought i was just messing around with my guitar, but it went much deeper than that. at the age of four, i remember thinking that i was a rockstar. then, i learned that musicians make music for a living. so i waited for the opportunity to pursue music. obviously, it never came. so every night, i asked god to please let me become a musician. it hasn’t happened yet. up until age twelve, things were just ok. i had some really good times with my buddies, but i was very sad and lonely knowing that i would soon have to give this all up to go to college. then in high school, things got a lot worse. there were so many things i wanted to do but couldn’t. there were band practices that i had to miss, but i had to keep my feelings locked up inside. i always had to pretend to be someone i wasn’t. i couldn’t just be myself. you have no idea how hard it was for me to try to act like i wanted to become a doctor. it was extremely difficult for me! to this day, it really tears me up inside! for the longest time, i had been deeply unhappy with my majorthe life plan i am supposed to want. but no matter what i did or how hard i worked, i could never feel passionate about medicine. at one time, i felt so unhappy that i had to call an emergency hotline because i didn’t know what else to do. every day is a struggle for me because i know i have to play a role i’m not comfortable in. it stresses me out so much! i’m sick and tired of the whole charade! at school, i present a cheerful image so they expect me to be all dedicated to my academic journey and happy. they’re used to seeing me with a smile on my face all the time. if only they knew the pain and torture i’m going through! well, mom and dad, what i’m trying to say is that i am going to quit college and start my music career. now, you don’t have to understand me, but please try to accept me. i can’t be who you want me to be. i’ve got to do what i know is right for me—not what anyone else might think is right. your support during this chapter of my life would mean the world to me. mom and dad, you’ve been so good to me. i just want to thank you for all you’ve done for me. i feel truly blessed to have parents like you. i love you. please don’t ever forget that, no matter what. with love, adam touma sawaya & mccarty 151 intervention on prejudice towards transgender individuals appendix b transgender letter edited from case, k. a., stewart, b. (2013) dear mom and dad, i have something very important to tell you about myself. you might not approve of it, but please try to keep an open mind as i try to explain this. also, please understand that what i’m about to tell you is not your fault. so whatever you do, please don’t blame yourselves. i know you’ve wondered why i never had a boyfriend. you might have noticed that all of my guy friends are more like my “buddies.” well, i’m not a lesbian, but i am very much attracted to women. you see, my body doesn’t match the way i see myself. mom and dad, i feel that i am a man. my body might tell you the opposite, but i know i am a man. it’s what comes naturally to me. i have felt this way for as long as i can remember. i know you thought i was just a tomboy, but it went much deeper than that. at the age of four, i remember thinking that i was a boy. then i learned that boys have a penis. so i waited for mine to grow. obviously, it never did. so every night, i asked god to please change my body into a male body. it hasn’t happened yet. up until age twelve, things were just ok. i had some really good times with my buddies, but i was still very sad and lonely. then in high school, things got a lot worse. there were so many things i wanted to do but couldn’t. there were girls that i really liked and cared about, but i had to keep my feelings locked up deep inside. i always had to pretend to be someone i wasn’t. i couldn’t just be myself. you have no idea how hard it was for me to try to act like a girl. it was extremely humiliating for me! to this day, it really tears me up inside! for the longest time, i had been deeply unhappy with the body i am inthe body i am supposed to feel comfortable in. but no matter what i did or how hard i worked out, i could never feel at home in my own skin. at one time, i felt so unhappy that i had to call an emergency hotline because i didn’t know what else to do. every day is a struggle for me because i know i have to play a role i’m not comfortable in. it stresses me out so much! i’m sick and tired of the whole charade! at work, i present a cheerful image. so they expect me to be all feminine and happy. they’re used to seeing me with a smile on my face all the time. if only they knew the pain and torture i’m going through! well, mom and dad, what i’m trying to say is that i am going to begin my gender transition into the body that i truly feel comfortable in. now, you don’t have to understand me, but please try to accept me. i can’t be who you want me to be. i’ve got to do what i know is right for me—not what anyone else might think is right.your support during this chapter of my life would mean the world to me. mom and dad, you’ve been so good to me. i just want to thank you for all you’ve done for me. i feel truly blessed to have parents like you. i love you. please don’t ever forget that, no matter what. with love, alice (soon to be known as adam) 152 appendix c reactions to coming out (using data from wren, 2002) rate the following statements according to your degree of agreement or disagreement using a 7-point scale ranging from 1= strongly disagree to 7 strongly agree adam’s parents should… support adam completelyeven if they do not understand him tell adam that he is not mature enough to make such major decisions take adam to see a specialist and change his mind get the proper professional help to support adam and his decisions accept adam if you were adam’s parent, you would… support adam completelyeven if you do not understand him tell adam that he is not mature enough to make such major decisions take adam to see a specialist and change his mind get the proper professional help to support adam and his decisions accept adam touma sawaya & mccarty interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 25 predictors of attitudes toward psychological counseling among lebanese college students hussein wehbe teachers college, columbia university the study investigated the effects of social stigma, self-stigma, and willingness to self-disclose personal distress on attitudes towards psychological counseling among lebanese college students. one hundred twenty-five participants enrolled in an introductory psychology course were surveyed. questionnaire packets included questions pertaining to demographic characteristics and four scales assessing attitudes towards counseling, social stigma, self-stigma, and self-disclosure. contrary to previous findings in the literature, our study found that students expressed favorable attitudes towards counseling. results also indicated that social stigma and self-stigma were negatively correlated with attitudes towards counseling, whereas comfort with self-disclosure had no relationship with attitudes showing inconsistency with past reviews. among the three factors hypothesized to impact attitudes towards counseling, only self-stigma had significant predictive power. the results and limitations of the study are discussed, and several implications and future directions for further research are identified. many people in need of psychological counseling underutilize available mental health services (shaffer, vogel, & wei, 2006). in order to serve more effectively those who need psychological services, practitioners in the lebanese community would benefit from a comprehensive understanding of factors that influence one’s decision to seek psychological help. possible factors that may influence one’s decision include: social stigma, self-stigma, and reluctance to self-disclose personally distressing information (shaffer et al., 2006; komiya, good, & sherrod, 2000).  social stigma public stigma labels counseling as being socially unacceptable (vogel, wade, & haake, 2006; komiya et al., 2000). thus, an individual may avoid seeking treatment and express unfavorable attitudes towards psychological services in an attempt to reduce possible social stigma (vogel, wade, & ascheman, 2009). research suggests that people tend to view individuals who seek mental health treatment less favorably than treatment nonseekers (sibicky & dovidio, 1986). individuals who seek psychological treatment for depression are often described as being emotionally unstable, responsible for their own symptoms, and lacking selfconfidence; however, depressed individuals who seek treatment for their condition are viewed more negatively than treatment nonseekers who also suffer from depression. vogel and colleagues (2009) developed the five item social stigma for receiving psychological help scale in order to investigate the degree to which social stigma is associated with treatment seeking behavior and prevents people from seeking mental hussein wehbe, department of counseling and clinical psychology, teachers college, columbia university. correspondence concerning this article should be addressed to hussein wehbe, 145 west 55th street, new york, ny 10019. email: hmw2120@columbia.edu. health services. the results of their survey showed that individuals with mental health disorders were not willing to seek psychological help as a result of perceived social stigma (vogel et al., 2009). self-stigma self-stigma refers to internalized stigma that individuals may have toward themselves due to being labeled as incompetent and socially unacceptable (vogel et al., 2006). the concept of self-stigma suggests that people may have negative attitudes towards seeking help because if they admit they have mental health problems they internalize the stigma and label themselves as being inadequate, weak, or inferior (vogel et al., 2006). studies have shown that individuals with mental health problems internalize negative perceptions of themselves (link, 1987; link & phelan, 2001). vogel and colleagues (2006) conducted a study among college students to investigate how aspects of one’s self-esteem (i.e., selfregard, self-confidence, satisfaction with oneself and one’s abilities, and overall sense of worth as a person) are subject to change if a person considers seeking psychological help. using the self-stigma of seeking help scale (ssosh; vogel et al., 2006), the authors found that study participants believed that seeking help from a psychologist or other mental health professionals would negatively affect one’s self-regard, self-satisfaction, self-confidence, and self-worth. self-disclosure studies have shown that the desire to avoid disclosing personal issues or painful feelings may affect treatment seeking decisions (vogel et al., 2006). in a study of college students’ attitudes toward self-disclosure, vogel and wester (2003) found that comfort with self-disclosing distressing information was highly associated with a willingness to seek psychological help. vogel and colleagues (2006) measured wehbe 26 the degree to which a person is comfortable self-disclosing personally distressing information using the distress disclosure index (ddi). results indicated that the desire to self-disclose personally distressing information significantly predicted attitudes toward seeking professional help (vogel et al., 2006). komiya and colleagues (2000) examined the effects of emotional openness on seeking psychological help in a sample of college students. results indicated that discomfort with expressing emotions accounted for a large percentage of the variance in negative attitudes towards psychological help. mental health in the arab society arab college students are prone to developing psychological distress, including symptoms of anxiety, distress, and depression, as a result of the abrupt transition to college life (al-krenawi, graham, al-bedah, kadri, & sehwail, 2009). problems such as moving away from home, dealing with academic demands, attaining appropriate study habits and making vocational decisions are a few examples that accompany such a transition (al-krenawi et al., 2009). arab college students, however, tend to avoid making contact with professional services (al-krenawi et al., 2009). alkrenawi and graham (2005) found that mental health patients in the arab population tend to express their psychological problems in terms of physical symptoms, thereby avoiding the stigma attached to mental illness. the present study seeks to explore lebanese college students’ attitudes towards psychological distress. the primary aim of the study is to investigate the factors involved in predicting attitudes towards counseling among lebanese college students. this study will extend the work of previous research by examining the comparative effects of three predictor variables (social stigma, self-stigma, and comfort with self-disclosure) on attitudes towards psychological counseling. no prior research has been conducted in lebanon with respect to the social stigma, self-stigma or selfdisclosure. as a result, this study will investigate which variable possesses the strongest predictive power in predicting attitudes towards counseling among lebanese college students. based on the findings reported in the literature, it was hypothesized that: (1) lebanese college students would endorse high levels of negative attitudes towards psychological counseling; (2) negative attitudes towards psychological counseling would be predicted by high levels of social stigma and self-stigma; (3) positive attitudes towards counseling would be predicted by high levels of selfdisclosure; and (4) the reluctance to self-disclose personally distressing emotions would account for significant and unique variance in predicting psychological help seeking behavior. method participants participation was entirely voluntary. the criterion for participation was that the subject be lebanese and at least 17 years of age. one hundred and twenty-five students were initially surveyed, of which 17 (13.6 %) were non-lebanese (i.e., jordanian, palestinian, columbian, cypriot, canadian, american, brazilian, and french). the final sample consisted of 108 participants (59 males and 49 females) of lebanese origin aged 17-22 years (see table 1). instruments attitudes toward seeking professional psychological help scale–short form. the measure consists of ten items rated from 1 (strongly disagree) to 5 (strongly agree) that were summed; lower scores reflected negative attitudes towards counseling (five items are reverse-scored). a sample item is “if i believed i was having a mental breakdown, my first inclination would be to get professional attention.” the internal consistency for this scale was α = .84 in a college sample (vogel et al., 2009). stigma of seeking professional psychological help scale (sspph). the sspph consists of five items rated from 1 (strongly disagree) to 5 (strongly agree) that assess perceptions of the societal stigma associated with seeking professional help, with higher scores reflecting greater perceptions of social stigma. a sample item is “people will see a person in a less favorable way if they come to know that he/she has seen a psychologist.” the sspph correlated with attitudes toward seeking counseling and had a reported internal consistency of α = .73 in college samples (vogel et al., 2009). self-stigma of seeking help scale (ssosh). the 10item ssosh assesses threats to one’s self-evaluation for seeking psychological help (e.g., “i would feel inadequate if i went to a therapist for psychological help”). items are rated from 1 (strongly disagree) to 5 (strongly agree) and higher scores reflect perceptions of self-stigma associated with treatment seeking. the ssosh has shown good internal table 1 frequencies of demographic variables demographic variables n % gender male 59 54.6 female 49 45.4 age 17 2 1.9 18 39 36.1 19 37 34.3 20 19 17.6 21 9 8.3 22 2 1.9 year in university freshman 4 3.7 sophomore 50 46.3 junior 38 35.2 senior 12 11.1 graduate 4 3.7 lebanese counseling attitudes 27 consistency, with cronbach α ranging from α =.86 to α = .90 in college samples (vogel et al., 2006). distress disclosure index (ddi). the ddi is a 12-item questionnaire measuring comfort with the self-disclosure of distressing emotions (e.g., “when i feel upset, i usually confide in my friends”). items are rated on a 5-point likerttype scale ranging from 1 (strongly disagree) to 5 (strongly agree), with six items being reverse-scored. items are summed up so that higher scores reflect a greater willingness to disclose personally distressing emotions. the ddi has been found to have good internal consistency (cronbach α = .93) in college samples (vogel et al., 2006). procedure sixty-three students enrolled in an introductory psychology course were given two questionnaire packets, one for themselves and one to give to a friend of the same age range (17-22 years) also enrolled in the same college. each packet had (1) a consent form informing participants of the purpose of the study, that their participation was voluntary, and ensuring confidentiality and anonymity of their responses; (2) a demographic questionnaire, assessing sociodemographic information on the participants’ gender, age, nationality, and year and major in university; (3) the attitudes toward seeking professional psychological help scale–short form (vogel et al., 2009); (4) the stigma of seeking professional psychological help scale (sspph; vogel et al., 2009); (5) self-stigma of seeking help scale (ssosh; vogel et al., 2006), and (6) the distress disclosure index (ddi; vogel et al., 2006). the students were asked to return the packets the next day to the researcher in exchange for course credit. all measures were administered in english. statistical analysis we first conducted preliminary statistical analyses to test for accuracy of entry and outliers, normal distribution of the study variables, and multicollinearity problems. we then calculated the means and standard deviation for each scale’s total scores. to assess the relationship between the study variables we conducted a correlation matrix. a stepwise multiple regression was then conducted to evaluate which variables (i.e., social stigma, self-stigma, self-disclosure, and general attitudes) would significantly predict attitudes towards psychological counseling. statistical analyses were performed using the spss statistical software package for microsoft windows (version 14.0, spss inc, chicago, il, usa). results prior to analysis, the data was examined for accuracy of entry and outliers. no univariate outliers were detected from the analysis (z scores >│3.26│) (tabachnick & fidell, 2001). reliability analyses of all the scales and items yielded high alpha coefficients for the self-disclosure and self-stigma scales and a good alpha coefficient for the general attitudes scale (see table 2). the reliability analysis for the social stigma scale reported unreliable results; therefore, any results associated with the social stigma scale should be interpreted with caution. given that several predictors were fitted into a model to predict an outcome variable, the statistical design that was implemented was a multiple regression analysis. the data was plotted and the assumption of normality was met. also, according to tabachnick and fidell (2001), since we were interested in the overall correlation and the individual predictors, our sample n should be larger than both (50 + 8m) and (104 + m), where m is the number of predictors. in this case our sample was larger than both (50 + 8(3)) = 74 and (104+3) = 107. hence, the assumption of ratio of cases to independent variable (iv) was met. the total means and standard deviations of the scales are presented in table 3. the total means of attitudes towards counseling, social stigma and self-disclosure were above average (given the range from 1, strongly disagree, to 5, strongly agree). the mean score for items above a midpoint score of 3 suggests high levels of favorable attitudes towards psychological counseling, high levels of perceived social stigma associated with counseling, and greater willingness to self-disclose personally distressing emotions to a counselor among the students in the investigated sample. the mean for self-stigma was around midpoint suggesting that on average, participants expressed no opinion on the items pertaining to self-stigma. the fact that participants expressed high levels of favorable attitudes towards counseling contradicted our first hypothesis and demonstrated inconsistency with the study conducted by al-krenawi and colleagues (2009). the pearson correlations between the variables are displayed in table 4. significant negative correlations were found between self-stigma and attitudes, social stigma and attitudes, and self-disclosure and self-stigma; the correlation between self-stigma and attitudes was the highest. table 2 reliabilities of scales scale number of items cronbach’s α self-stigma 10 .83 self-disclosure 12 .92 general attitudes 10 .74 social stigma 5 .67 table 3 means and standard deviations of all variables m sd n general attitudes 31.04 5.92 108 social stigma 14.10 3.81 108 self stigma 24.63 6.85 108 self-disclosure 40.88 10.09 108 wehbe 28 nonsignificant negative correlations were found between self-disclosure and social stigma, (p > .05), and selfdisclosure and general attitudes, (p > .05). a significant positive correlation was found between self-stigma and social stigma. higher perceptions of self-stigma related to seeking psychological services were associated with lower levels of willingness to disclose personally distressing emotions (p < .01). furthermore, higher perceptions of social stigma were associated with higher perceptions of self-stigma associated with seeking counseling (p < .01). to test for multicollinearity problems we followed recommendations by field (2005), and scanned a correlation matrix of all of the predictor variables to see if there were variables that correlated with each other very highly (r > .80). we also looked at the variable inflation factor (vif), which according to myers (1990) if above 10 is considered a potential sign for multicollinearity. finally, we looked at the tolerance values, given that values below 0.1 are a potential sign for multicollinearity (field, 2005). the values of the correlation matrix were all below r = .75 and both the tolerance and vif coefficients indicated that the assumptions of singularity and absence of multicollinearity were met. the durbin-watson statistics indicated that the assumption of independence of errors was met. the stepwise regression revealed a good fit of the variance explained. the results indicated that the overall model was significant r 2 = .405, f(106) = 72.23, p < .05, indicating that these predictors (social stigma, self-stigma, and self-disclosure) accounted for 40.5 % of the variance in attitudes towards psychological counseling. examining the standardized beta coefficients (β), self-stigma was the best predictor of attitudes towards psychological counseling in the investigated sample (see table 5). both social stigma and self-disclosure were excluded from the model. discussion the purpose of this study was to investigate the roles of social stigma, self-stigma, and self-disclosure in predicting attitudes towards psychological counseling among lebanese college students. all of the aforementioned variables were assessed through four different scales as previously mentioned. the study showed that among the three predictor variables, only social stigma and self-stigma showed a significant predictive power, with self-stigma being the variable with the greatest effect. the findings from our correlation analysis illustrated that higher perceptions of self-stigma and social stigma were associated with higher levels of negative attitudes towards counseling, while self-disclosure showed no significant relationship with such attitudes. regression analysis found only one strong predictor among the variables measured. contrary to our hypothesis, self-stigma appeared to be the only strong predictor of negative attitudes towards counseling. research has shown that social stigma and self-stigma are important factors of negative attitudes towards counseling. previous studies have found that individuals may decide not to seek help, even when they are experiencing emotional pain, because of the belief that labels such as “unreliable” or “emotionally unstable” would be applied to them and that such a decision would be a sign of weakness or an acknowledgment of failure (vogel et al., 2006). our findings are largely consistent with previous research. first, previous studies have found that participants’ attitudes towards psychological treatment were significantly associated with the social stigma and that participants’ selfstigma impacted psychological help seeking behavior (vogel et al., 2009; 2006). however, findings pertaining to selfdisclosure were inconsistent with vogel et al.’s (2006) study in which the desire to self-disclose personally distressing information significantly predicted attitudes toward seeking professional help. results were also inconsistent with the study by komiya and colleagues (2000) in which discomfort with expressing emotions accounted for a large percentage of the variance in negative attitudes towards psychological help. limitations despite the importance of these findings, some limitations should be noted. first, a major limitation in the study lies in the procedure. as previously mentioned, participants were given two questionnaire packets and were asked to complete one packet, and give the other to a friend. there is a possibility that participants failed to abide by the instructions of the study, and instead filled out both questionnaires. there is also the possibility that participants shared answers with their friends in an attempt to express similar views on the presented scales. second, we cannot generalize the results to the whole lebanese college population. in the study at hand, the sample size was not sufficiently large. a small sample size (n = 108) is probably not large enough to draw meaningful conclusions table 4 correlations between scales scales social stigma selfstigma selfdisclosure general attitudes social stigma 1 self stigma .42** 1 selfdisclosure -.06 -.28** 1 attitudes -.36*** -.64*** .156 1 *p < .05. **p < .01. *** p < .001 table 5 standardized β coefficients for the predictor variables model standardized β coefficient sig. self-stigma -.64 .000 social stigma -.12 .15 self-disclosure -.02 .76 lebanese counseling attitudes 29 and implications. moreover, low reliability for the social stigma scale was revealed. a disadvantage of relying on survey methods is that they are dependent on self-report and do not measure behavior directly. as a result, social desirability and demand characteristics may shape participants’ responses regardless of assurances of confidentially and anonymity. for instance, on items measuring attitudes, respondents may wish to deny unfavorable attitudes towards mental health services to present themselves in a positive light, as open minded individuals, especially considering that they were enrolled in a psychology course. as students with background knowledge in psychology, it is far more likely for them to be biased. implications and recommendations for future research in order to reach individuals who typically avoid psychological treatment, mental health education in school settings, work environments, and within institutions could be the optimal solution. educating the public about mental health services will help combat the adverse effects of stigma. psychologists and other health care providers may also reach individuals who typically avoid psychological treatment by using alternative means to implement psychoeducational goals such as broad-based advertisements (print, radio, and tv). such efforts would be directed towards those who might not seek help for psychological distress because of the social stigma or self-stigma related to psychological treatment (vogel et al., 2006). based on the aforementioned findings, several suggestions could be made for future research. evidence was presented in this study on how social stigma and self-stigma are associated with seeking psychological help. however, further research may examine potential mediating effects of personality. future investigations may also choose to examine the results of educational programs targeted toward reducing stigma (e.g., media efforts). another consideration for future research is to consider implementing longitudinal studies that integrate psychoeducation with ongoing investigations of attitudes towards counseling and mental health services in general. such an approach will help in reducing stigma and increasing willingness to seek counseling services. this type of design can assess how effective a psychoeducational model is over time. references al-krenawi, a., graham, r., j., al-bedah, a., e., kadri, m., h., & sehwail, a., m. (2009). cross-national comparison of middle eastern university students: helpseeking behaviors, attitudes toward helping professionals, and cultural beliefs about mental health problems. community mental health journal, 45, 26-36. doi:10.1007/s10597-008-9175-2 al-krenawi, a., & graham, j. r. (2005). marital therapy for muslim arab couples: acculturation and reacculturation. the family journal, 13(3), 300-310. doi:10.1177/1066480704273640. ben-porath, d. d. (2002). stigmatization of individuals who receive psychotherapy: an interaction between helpseeking behavior and the presence of depression. journal of social & clinical psychology, 21, 400-413. doi:10.1521/jscp.21.4.400.22594. field, a. (2005). discovering statistics using spss. london: sage publications. heights, ma: allyson and bacon. komiya, n., good, e., g., & sherrod, b., n. (2000). emotional openness as a predictor of college students' attitudes toward seeking psychological help. journal of counseling psychology, 47, 138-143. doi:10.1037/00220167.47.1.138. lent, w. r. (2004). toward a unifying theoretical and practical perspective on well-being and psychosocial adjustment. journal of counseling psychology, 51, 482509. doi:10.1037/0022-0167.51.4.482. link, b. g. (1987). understanding labeling effects in the area of mental disorders: an assessment of the effects of expectations of rejection. american sociological review, 52, 96–112. link, b. g., & phelan, j. c. (2001). conceptualizing stigma. annual review of sociology, 27, 363–385. shaffer, a., p. vogel, l. d., & wei, m. (2006). the mediating roles of anticipated risks, anticipated benefits, and attitudes on the decision to seek professional help: an attachment perspective. journal of counseling psychology, 53, 442-452. doi:10.1037/00220167.53.4.442. sibicky, m., & dovidio, j. f. (1986). stigma of psychological therapy: stereotypes, interpersonal reactions, and the self-fulfilling prophecy. journal of counseling psychology, 33, 148–154. doi:10.1037/00220167.33.2.148. tabachnik, b.g., & fidell, f. s. (2001). using multivariate statistics (4th ed.).new york, ny: allyn & bacon. vogel, l. d. & wester, r. s. (2003). to seek help or not to seek help: the risks of self-disclosure. journal of counseling psychology, 50, 351-361. doi: 10.1037/00220167.50.3.351. vogel, l., d., wade, g., n., & ascheman, l., p. (2009). measuring perceptions of stigmatization by others for seeking psychological help: reliability and validity of a new stigma scale with college students. journal of counseling psychology, 56, 301-308. doi: 10.1037/a0014903. vogel, l., d., wade, g., n., and haake, s. (2006). measuring the self-stigma associated with seeking psychological help. journal of counseling psychology, 56, 325-337. doi: 10.1037/0022-0167.53.3.325. graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 22 religious change and depressive symptoms among youth in foster care with or without a history of sexual abuse steven pirutinsky teachers college, columbia university research suggests that trauma, such as childhood sexual abuse (csa), disrupts key social-cognitive assumptions including religious beliefs. limited previous studies examined adult reports and compared group means on measures of religiosity. yet csa may both increase and decrease religiosity, and, therefore, group means may be deceptive. the current study explored religious change and depression among adolescents in foster care with and without csa over a two-year period (n = 407). results indicated that youth with a history of csa were no more likely to report changes in religious affiliation or belief over the study period, as compared to youth without a history of csa. among youth without a history of csa, changes in religious affiliation and beliefs were associated with increased depression. for youth with a history of csa, religious changes were unrelated to depressive symptoms. it appears that the impact of religious change is contextdependent, and further research using longitudinal designs appears warranted and necessary. research and theory suggest that trauma can disrupt basic assumptions about the world and oneself in key socialcognitive areas such as safety, trust, power, and self-esteem, leading to distress (mccann & pearlman, 1990; resick, monson, & rizvi, 2008). for some, these basic assumptions are linked to religious and spiritual beliefs.  therefore, many hypothesize that trauma may disrupt religion and spirituality (falsetti, resick, & davis, 2003; walker, reid, o’neill, & brown, 2009). considerable research has documented the negative impact of childhood sexual abuse (csa) on multiple indices of psychological functioning (jumper, 1995; paolucci, genuis, & violato 2001), and qualitative studies indicate that csa survivors report negative images of god (imbens & jonkers, 1992), lower religious practices and beliefs (hall, 1995; lawson, drebing, berg, vincellette, & penk, 1998), and spiritual disconnection (flaherty, 1992). on the other hand, religion and spirituality can be protective, as other studies have found that they help survivors reduce distress (weber & cummings, 1999), maintain resilience (valentine & feinauer, 1993), and construct meaning (glaister & abel, 2001). quantitative research has been limited and results mixed, with some studies reporting less belief among adults with a history of csa and others more belief (see falsetti et al., 2003 and walker et al., 2009 for reviews). previous studies have almost exclusively utilized retrospective reports of adults, comparing those with a history of csa to those without such history on mean level of religiosity and spirituality. yet the influence of csa on religiosity and steven pirutinsky, m.s., teachers college, columbia university. correspondence concerning this article should be addressed to steven pirutinsky; department of clinical and counseling psychology; teachers college, columbia university; box 303, 525 west 120th st., new york, ny 10027. email: sp2813@columbia.edu. spirituality is likely bi-directional; while some seek new sources of spiritual support and significance to cope, others may find their beliefs shattered (e.g., “god would not have allowed this to happen”) and renounce them (pargament, desai, & mcconnell, 2006). as demonstrated by bonanno and colleagues (2002), aggregating data obscures divergent patterns of response to trauma, as cross-sectional designs examining group means cannot capture individual increases and decreases. consequently, longitudinal research examining individual trajectories of change is necessary. religious change and distress the psychological impact of csa-related religious and spiritual change remains unclear. a large body of research suggests that religion plays a pivotal role in helping patients adjust and cope with stress, grief, and trauma (koenig, george, & siegler, 1988; pargament, 1997). common religious coping strategies include seeking a supportive relationship with god, benevolent religious reappraisals (e.g., seeing one’s situation as part of god’s plan), and obtaining interpersonal religious support (pargament, 1997). metaanalytical research suggests that positive forms of religiosity (e.g., intrinsic religiosity and positive religious coping) decrease distress (smith, mccullough, & poll, 2003). with regard to csa, there is some evidence that religion can moderate the development of axis i disorders among survivors of csa (walker et al., 2009). however, it is widely recognized that religion and spirituality can also have a negative influence on psychological functioning (see exline & rose, 2005 for a review). for example, religious coping may take a negative form, including anger at god, passive religious deferral (e.g., not doing anything and expecting god to solve one’s problems), religious doubts, and interpersonal religious struggles (pargament, smith, koenig, & perez, 1998). thus, while religion generally correlates with decreased pirutinsky 23 psychological distress, spiritual struggles such as religious doubt and change are related to increased distress (ano & vasconcelles, 2005; smith et al., 2003). the vast majority of these studies have been crosssectional (paloutzian, richardson, & rambo, 1999), and the long-term outcome of spiritual struggles remains unclear. for example, spiritual struggles may lead to religious transformations with long-term positive effects (james, 1902). this may be particularly apparent where traumatic events, such as csa, have damaged existing beliefs, since spiritual struggles leading to the transformation of these damaged beliefs may be beneficial. as suggested by cognitive therapies for traumatic stress (resick et al., 2008), recovery from trauma-related psychopathology includes reinterpretation of the event and restructuring of traumainduced cognitions. religious change may be an important avenue through which some survivors of csa transform distressful beliefs about the world and themselves. the current research aimed to address the limitations of previous research by exploring csa, religious change, and depressive symptoms over a two-year period. although the terms religion and spirituality often have distinct meanings— spirituality a broad term encompassing anything regarded as sacred, and religion a specific term referring to culture-based forms of relating to the sacred (hill & pargament, 2003)—the current study uses both terms loosely, reflecting the broad measures utilized to measure religious and spiritual change. the study was conducted among older adolescents in foster care, as recent research suggests that adolescence may be a particularly sensitive period for enduring religious change and development (good & willoughby, 2008). our hypotheses were twofold. first, we predicted that youth with a history of csa would report greater religious change over the study period. second, we predicted that religious changes would increase depression among youth without a history of csa (reflecting spiritual struggles), while among csa survivors, depression would decrease as they transform beliefs to more adaptive views. method participants participants were 407 youths in foster care residing in missouri, 178 (44%) males and 226 (56%) females, ranging in age from 16 to 17 years (m = 16.33, sd = .47) at time 1. ethnicity varied with 1% (n = 3) american indian, 51% (n = 206) african-american, 44% (n = 178) caucasian, and 4.1% (n = 12) other. average age of entry to foster care was 10.85 years (sd = 4.48), and average length of current placement was 20.5 months (sd = 36.91). current living situations included 8% residing with their biological parent(s) after a stay in out-of-home care, 19% in kin foster care, 29% in nonkin family foster care, 41% in congregate care, and 3% in semi-independent living situations. religious affiliation at time 1 included 7.7% (n = 31) catholic, 53.7% (n = 217) protestant, 2% (n = 1.2) muslim, 31.7% (n = 128) none, and 6.7% (n = 27) other. procedure the current study analyzed data from the mental health service use of youth leaving foster care survey (mcmillen, 2010) conducted from december 2001 to may 2003. the missouri children’s division identified 647 youth in their custody who resided in one of eight missouri counties and were turning 16 years and nine months of age (see larrabee-warner and mcmillen (2010) for a full description). approximately 30% of these youths were excluded from the study because they (a) were no longer in custody; (b) had a reported iq below 70; (c) did not speak english; (d) lived outside the study area; or (e) had runaway status. of the resulting 451 (70%) youths, 39 (8%) declined to participate, 4 (1%) could not be contacted, and one interview was not completed, resulting in a final sample of 407 youths. interviews were conducted near each youth’s 17th birthday (time 1) and again 24 months later (time 2) at their residence. although phone interviews were conducted in the intervening period, religious variables were only assessed in the initial and final interviews, and the current study used data from those waves exclusively. wherever statistically feasible, missing data was imputed using iveware (raghunathan, solenberger, & van hoewyk, 2002). missing data unable to be imputed was deleted case-wise for each analysis. the human subjects committee of washington university’s institutional review board approved all procedures. consent was provided by each youth’s custodial case manager and the youths assented to participate. measures childhood sexual abuse. history of sexual abuse was assessed through three previously used items (auslander, mcmillen, elze, thompson, jonson-reid, & stiffman, 2002), which read: (a) “has anyone ever made you touch their private parts, against your wishes?” (b) “has anyone ever touched your private parts (breasts or genitals) against your wishes?” and (c) “has anyone ever had vaginal sex, oral sex, or anal sex with you against your wishes?” youths who responded “yes” to any of these were defined as having a history of csa, and youths who responded “no” to all three were defined as having no history of csa. religious affiliation. at time 1 and time 2, youths were asked, “what is your religious preference?” response choices were catholic, protestant, jewish, muslim, none, or other. they were then assigned a religious change category based on the discrepancy between their affiliation at time 1 and time 2. those reporting identical affiliations at each time were assigned to either “remained religious” or “remained irreligious,” while those reporting different affiliations were assigned to one of three change categories: “none to religion,” “religion to none,” and “religion to religion.” religious belief. belief was measured using the multidimensional measure of religiousness/spirituality (fetzer institute & national institute on aging, 1999). it contained seven items rated on a four-point scale ranging from strongly disagree to strongly agree. items included “i religious change among youth 24 have faith in a power greater than me” and “i am not a religious person.” internal consistency was adequate (time 1 α = .87, time 2 α = .87). depressive symptoms. depressive symptoms were measured using the depression-arkansas scale, which has demonstrated adequate reliability and validity in previous studies in adult samples (smith et al., 2002; walter, meresman, kramer, & evans, 2003). it consists of 11 items, drawn from dsm-iv-tr criteria for depression, that asked how often youths experienced depressive symptoms on a four-point scale ranging from “not at all” to “nearly every day for at least 2 weeks.” items were summed to form a continuous measure of depressive symptoms (time 1 α = .84, time 2 α = .81). statistical analysis to examine the relationship between csa and religious change, a chi-square test was conducted comparing those with a history of csa to those without a history of csa on the religious affiliation change categories described above. an independent groups t-test comparing these groups on mean change in religious beliefs over the study period was also conducted. because change scores in opposite directions may average out, squared change in religious beliefs was also examined. to assess the relationship between religious change and depression, we conducted a hierarchical regression predicting depression at time 2, controlling for depressive symptoms at time 1. model 1 included change in affiliation, csa, and interaction terms. model 2 assessed change in religious beliefs (linear and quadratic), csa, and interaction terms. model 3 was a combined model that included both change in religious affiliation and belief, csa, and interaction terms. results change in self-reported religious affiliation was common in the sample (45%, n = 171), with 15% (n = 58) reporting a change of “none to religion,” 12% (n = 45) reporting a change of “religion to none,” and 14% (n = 68) reporting a change of “religion to religion.” many youths also reported variation in the strength of religious beliefs with 313 (79.8%) reporting a change of less than 1 sd, 49 (12.5%) reporting a change of 12 sds, and 21 (21%) reporting a change of greater than 2 sds. preliminary analyses comparing youths reporting a history of csa (n = 138, 35%) to youths reporting no history of csa (n = 254, 65%) revealed that religious affiliation at time 1 (χ2(4, n = 388) = 3.14, p = .55) and mean religious belief over the two time-periods (t(391) = 1.71, p = .19) did not differ significantly between these groups. zero-order correlations between religious belief and depression at time 1 were not significant (r = .01, p = .73). however, consistent with previous research, higher religious belief at time 2 was significantly correlated with lower depression at time 2 (r = .12, p = .02) while religious affiliation was unrelated to both depression at time 1 (t(390) = 0.61, p = .54) and 2 (t(390) = 1.60, p = .11). with regard to hypothesis 1, results indicated that affiliation change (χ2(4, n = 388) = 2.32, p = .68), change in belief (t(392) = 0.18, p = .86), and squared change (t(392) = 0.71, p = .48) were unrelated to csa. this suggests that, contrary to our predictions in hypothesis 1, csa may be unrelated to religious change. hierarchical regression testing table 1 model 1: religious affiliation change, csa, and depressive symptoms variable step 1 step 2 step 3 b se b β b se b β b se b β time 1 depressive symptoms .32*** .04 .37 .32*** .04 .36 .32*** .04 .36 csa .16 .26 .03 .14 .25 .03 .11 .27 .02 religious change change vs. no change .76*** .19 .19 .57** .20 .14 change: to r1 vs. to n2 .02 .24 .01 .07 .24 .01 change: n to r vs. r to r -.91* .42 -.10 -.73 .43 -.08 remaining: r vs. n -.01 .33 -.002 -.24 .36 -.04 religious change x csa change vs. no change -.53** .20 -.14 change: to r vs. to n .14 .24 .03 change: n to r vs. r to r .66 .43 .07 remaining: r vs. n -.44 .36 -.07 δr2 .14 .18 .02 f for δr2 31.90*** 6.13*** 2.66* note. 1r = religion; 2n = none; *p < .05; **p < .01; ***p < .001. pirutinsky 25 hypothesis 2 indicated that changes in religious affiliation from time 1 to 2 were related to increased depressive symptoms, but csa significantly moderated this relationship (model 1, table 1). a plot of predictions (figure 1) and posthoc tests suggested that among youth with a history of csa, religious change was unrelated to depressive symptoms (b = .04, t(370) = 0.12, p = .90). in contrast, among youth with a history of csa, change in religious affiliation was associated with increased depressive symptoms (b = 1.10, t(370) = 4.78 , p < .001). categories of change (e.g., “none to religion,” “religion to none”) did not differ significantly on depressive symptoms, suggesting that the impact was equivalent regardless of the direction of religious changes. model 2 examined the influence of change in belief on depressive symptoms at time 2, controlling for depressive symptoms at time 1. results indicated that change in religious belief was quadratically related to depressive symptoms (table 2), such that those with the greatest change (positive or negative) reported increased depressive symptoms at time 2 (figure 2). this was moderated by csa table 2 model 2: religious belief change, csa, and depressive symptoms variable step 1 step 2 step 3 b se b β b se b β b se b β time 1 depressive symptoms .33*** .04 .37 .32*** .04 .36 .33*** .04 .37 csa .16 .26 .03 .22 .25 .04 .52 .29 .10 change in beliefs (linear) -.26 .22 -.06 -.20 .24 -.04 change in beliefs (quadratic) .51*** .14 .17 .39* .15 .13 csa x beliefs (linear) .05 .24 .01 csa x beliefs (quadratic) -.31* .15 -.12 δr2 .14 .03 .01 f for δr2 31.88*** 7.56*** 4.18* note. *p < .05; **p < .01; ***p < .001. 15 17 19 21 23 25 religion to none none to religion religion to religion remained religious remained irreligious d e p re ss io n t im e 2 ( p re d ic te d ) non-csa csa figure 1. depression at time 2 by csa and religious affiliation change note. adjusted for depression at time 1. religious change among youth 26 history. that is, for youth without csa, change in religious beliefs (quadratic) was related to significantly increased depression at time 2 (b = .70, t(386) = 4.13, p < .001), while among youth with csa these were unrelated (b = .08, t(386) = 0.31, p = .76). the results of model 3 indicated that religious belief and affiliation remained significant predictors of depression even controlling for each other’s effect. in terms of interactions between changes in affiliation and changes in belief, increased religious beliefs among those who changed affiliation from “religion to none” was significantly related to sharply increased depression (b = .96, t(364) = 3.36, p = .001). no other interactions were significant, including threeway interactions with history of csa (∆r2 = .01, f(8, 352) = 0.56, p = .85). in summary, results indicated that religious change of any type was related to increased depression among youths without a history of csa, but was unrelated to depression among youth with a history of csa. discussion research suggests that csa relates to both increased and decreased religiosity and spirituality (falsetti et al., 2003; walker et al., 2009). however, these studies have been primarily retrospective, and csa can have bi-directional influences on religion and spirituality. therefore, only examining the average level of religiosity in those with and without csa likely obscures important changes. furthermore, the impact of religious change on psychological functioning remains unclear. the current research therefore explored csa, religious change, and depressive symptoms among foster-care youth over a two-year period. we hypothesized that youth with a history of csa would report greater religious change over the study period, as compared to youth without a history of csa (hypothesis 1). we also expected that these changes would relate to increased depressive symptoms among youth without csa and decreased symptoms among those with csa (hypothesis 2). contrary to expectations, in the present study, youths with a history of csa were no more likely than those without a history of csa to report changes in religious affiliation or belief over the study period. this suggests that csa does not systematically influence religious change. however, our sample was comprised of older foster care youths who were transitioning from foster care to independent living, and there was a high degree of religious change in the entire sample (47% reported change in affiliation, and 21% reported changes of at least 2 sds in religious belief). consequently, the specific impact of csa may not be apparent in youth experiencing such high levels of environmental changes. in addition, only superficial measures of religiosity (affiliation and belief) were available, and these may not capture more nuanced changes in religion and spirituality resulting from csa (gall, basque, damasceno-scott, & vardy, 2007). furthermore, the age at which csa occurred was not reported and important religious changes may have occurred prior to figure 2. depression symptoms at time 2 by change in religious beliefs and csa note. adjusted for depression at time 1. 15 17 19 21 23 25 -2 sd -1 sd no change +1 sd +2 sd religious belief change d e p re s s io n t im e 2 ( p re d ic te d ) non-csa csa pirutinsky 27 the collection of time 1 data. the nature and timing of csa may alter its influence as well, as repeated sexual abuse at an early age may have very different effects on religious development and change than a single isolated incident at age 16. the present study results further suggest that among youth without a history of csa, change in religious affiliation and beliefs was associated with increased depressive symptoms, likely reflecting spiritual and religious struggles (exline & rose, 2005). this was equally true of those experiencing an increase or decrease in religious belief and of those relinquishing or acquiring an affiliation. inconsistent changes, such as increased belief and affiliation change from “religion to none,” were related to sharply increased depression. these results parallel previous cross-sectional findings (exline & rose, 2005) and suggest that religious change is related to increased distress longitudinally. this may be due to intra-psychic factors such as loss of meaning (park, 2005), insecure attachment to god (kirkpatrick, 2005), or negative religious coping (pargament, 1997), or may reflect psychosocial changes such as loss of religious social support and community (putnam, 2009). in contrast, for youth with a history of csa, religious changes were unrelated to depressive symptoms, perhaps because, as hypothesized, religious change included positive transformations of their meaning-system (park, 2005). further research should consider using prospective longitudinal designs and statistical techniques such as growth modeling (e.g., bonnano et al., 2002) that allow consideration of individual trajectories and the nuanced processes supported by our results. beyond theoretical implications and directions for future research, these findings have applications in the treatment of youth with a history of csa. in particular, religious and spiritual change, although potentially distressful to caregivers and involved adults, may be a normative and healthpromoting process of transformation that can have positive mental health consequences and may be a component to healing from trauma. consequently, foster parents, caseworkers, parole officers, and clergy should support and encourage youth to adjust their meaning system in adaptive ways. moreover, explicit incorporation of religious, spiritual, and existential themes in psychotherapeutic treatment of csa survivors may be indicated and helpful. however, although the study of the relationship between religion and mental health has generated considerable recent interest (e.g., smith et al., 2003), integrating religious and spiritual struggles into treatment presents challenges, since individuals may be hesitant to bring these issues to professionals (pirutinsky, rosmarin, & pargament, 2009), and clinicians receive little training (walker, gorsuch, & tan, 2004) and can be reluctant to explore these issues (turneressel & waehler, 2009). one possible reason for this gap is the lack of empirical research integrating spiritual struggles into current conceptualizations of mental illness and clinical treatment (pirutinsky, rosmarin, pargament, & midlarsky, 2011). there is, however, a small body of research demonstrating that positive aspects of religion and spirituality can be successfully integrated into existing treatments (e.g., mccullough & larson, 1999), suggesting that negative aspects of spirituality can be similarly addressed. one promising treatment for this integration in the context of childhood sexual abuse is cognitive processing therapy (cpt; resick, monson, & rizvi, 2008). the fundamental focus of this treatment is to reintegrate prior beliefs and new beliefs, thereby reconstructing a coherent and positive worldview. to achieve theses aims, tfp incorporates a number of techniques. first, patients are asked to write an impact statement focusing on how the traumatic event has impacted their beliefs about themselves and others. this statement is used to conceptualize how the event has led to distorted or overgeneralized attributions of meaning. these faulty ideas are then challenged through socratic questioning, disputing thoughts, worksheet exercises, and the development of alternative, more balanced beliefs. religious struggles and doubts involve similar processes whereby an individual’s previous worldview is challenged and disturbed in some way, resulting in distress. similar techniques such as writing down the implications of these changes in worldview, identifying distorted or exaggerated conclusions, challenging these ideas, and developing more balanced and integrated alternatives, may be a fruitful avenue to address traumarelated religious and spiritual doubts, struggles, and transformations. limitations this research has several limitations. there were no prospective pre-csa reports on religion or depressive symptoms available, and information concerning the nature of csa (e.g., age of occurrence, repetition, violence, perpetrator identity) was not available. it also relied on cursory measures of religiosity, which may not reflect the particular beliefs, behaviors, and emotions relevant to csa and mental health. furthermore, spirituality, conceptualized as any manner of relating to the sacred, can be distinct from culture-based religiosity (hill & pargament, 2003), and the measures utilized did fully explore these constructs. future research should utilize more nuanced and proximal measures of religiosity and spirituality. in addition, the sample was subject to an overall high degree of stress and change, and those disruptions may have been confounded with religious change. however, given the difficulty of conducting longitudinal research of this type, these data give a muchneeded glimpse into the impact of csa and religious change on youth. as discussed above, further carefully designed research appears warranted and necessary. references ano, g. g. & vasconcelles, e. b. 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(1999). relationships among spirituality, social support, and healing from childhood abuse. paper presented at the annual convention of the american psychological association, boston, ma. 1 graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university neuroscience and law: the evidentiary value of brain imaging noel shafi teachers college, columbia university neuroimaging evidence should be restricted in terms of admissibility in the courts, and should only be considered reliable under scientifically valid clinical methods. this topic will be approached in four stages: (1) a brief introduction to neuroscience and law, (2) a discussion of evidentiary laws in the american legal system, (3) a review of modern neuroimaging and the admissibility and applicability of neuroimaging evidence in the courtroom using actual cases, and 4) a closing argument, including interdisciplinary perspectives on neuroscience and law. neuroimaging1has numerous legitimate legal applications, in addition to important clinical applications. neuroimaging methods are primarily used to study brain and behavior relationships, which contribute to clinical and research disciplines such as radiology, psychiatry, neurology, and clinical neuropsychology (bigler, 1991). however, there are numerous ways in which brain imaging can be interpreted and implicated in the court. in fact, neuroscience has been applied to many legal subfields, including, but not limited to: intellectual property law, tort law, consumer law, health law, employment law, constitutional law, and criminal law (tovino, 2007). thus, brain scientists can use neuroimages to determine the cognitive, behavioral, and physiological traits of clinical patients and legal defendants. the convergence between neuroscience and law is a recent phenomenon. in fact, “[t]he legal profession is at least two millennia older than the neurobiological profession, which is not much more than 150 years old at best, and in its current state of probing the mind of man and his subjective states is far younger than that” (zeki & goodenough, 2004, p. 1662). nevertheless, developments in neuroscience have led to unprecedented changes in legal proceedings, whereby the brain has increasingly become a subject of legal inquiry. as neuroscience now has many implications within the legal realm, the “neuro-law” subfield has developed. admissibility of scientific evidence: implications for neuroscience admissibility of neuroimaging evidence is commonly based on the purpose of submission, rather than the imaging itself. there is a great deal of controversy regarding if and when neuroimaging should be used. neuroimaging is not purely objective, but is “the product of a complex set of techniques, subjective decisions, technical choices, and informed interpretations” (baskin, edersheim, & price, 2007, p. 249). essentially, neuroimaging methods create a visual image of the brain and the imaging specialist interprets it. various interpretations can be derived from correspondence: noel shafi, noel.shafi@gmail.com brain imaging, including: the presence of structural abnormalities, functional deficits, personality traits based on physiological defects, and lie detection (pettit, 2007, p. 321323). brain images have physiological and behavioral correlates. correlation of neuroimaging to behavior is presently very limited. a majority of the findings are still inconclusive, although many remain informative, and potentially useful. “with respect to understanding the brain and certain behaviors, the state of scientific knowledge is nascent, but promising. the more complex and specific the behavior examined, the more speculative the connection” (baskin et al., 2007, p. 239). however, even the simplest behaviors involve highly sophisticated functions and interactions between multiple structures in the brain. the human brain is complex and, whether in the clinic or the courtroom, it should be analyzed and assessed by experts. in a clinical setting, neurologists, neuropsychologists and other health care professionals use neuroimaging for medical purposes, in order to detect or diagnose neurological disorders or brain injuries. technological advances and methodological improvements in neuroimaging techniques will continue to expand its use. meanwhile, neuroimaging will be applied in the courtroom for purposes that extend beyond medicine. in a courtroom setting, litigants use neuroimaging in civil litigation and criminal trials in order to affirm or deny claims of brain or spinal injury (pettit, 2007, p.321-322). some researchers assert that neuroimaging could be used to demonstrate the propensity for violence, the capacity to stand trial, as evidence of malingering, or to help establish or diminish the criminal responsibility of a defendant (aharoni, funk, sinnott-armstrong, & gazzaniga, 2008). recent research has also noted the use of brain imaging in detecting pain, but this method has not yet been scientifically validated for clinical use (kupers & kehlet, 2006). evidentiary rules have set parameters for the admissibility and reliability of scientific instruments, thereby limiting the application of neuroimaging. yet, as pettit (2007) states, “courts usually seem willing to consider brainimaging evidence under the same standards that they apply to other scientific evidence” (p. 339). legal history 27 shafi 28 demonstrates that neuroimaging is most useful when it is applied with clinical methods. ultimately, the rule of law and the current state of science determine the practicality of neuroimaging in the courtroom. the scientific reliability of neuroimaging evidence is an important part of legal admissibility. the legal standard for admissibility of evidence depends on the court system. state and federal courts have their own standards but generally defer to federal rules. federal rules are derived from previous court rulings, which established preliminary standards of admissibility. for example, daubert v. merrell dow pharmaceuticals (1993) and frye v. united states (1923) are two pivotal cases that contributed to the federal standard for the admissibility of scientific evidence. gardland and glimcher (2006) describe the daubert standard – a legal criteria for evaluating the reliability of scientific testimony and evidence in the courtroom. this standard is derived from a civil suit, daubert v. merrell dow pharmaceuticals, whereby the supreme court established four general guidelines for the admission of scientific evidence. in regard to the evidentiary law, the daubert standard states that trial judges should carefully consider: …whether the theory or technique in question can be (and has been) tested, whether it has been subjected to peer review and publication, its known or potential error rate, and the existence and maintenance of standards controlling its operation, and whether it has attracted widespread acceptance within a relevant scientific community (p. 580). can neuroimaging evidence satisfy any of these criteria? in daubert v. merrell dow pharmaceuticals (1993), the plaintiffs claimed that bendectin, a prescription drug and antinauseant, caused them serious birth defects when their mothers consumed it during pregnancy. experts for the plaintiff argued for medical causation, based on results from animal studies involving bendectin and human studies involving similar drugs. experts for the defendant argued that there was no evidence based on human studies indicating that the drug poses a risk for human birth defects. the defendants also cited the frye (1923) case, arguing that expert testimony for the plaintiff was not based on the scientific method. the court ruled in favor of the defendant and concluded that the studies relating to bendectin were inadmissible as evidence. this case demonstrates that litigants and scientists equally recognize that scientific studies do not always establish causality, and that animal studies should not always be equated with human conditions. this case also demonstrates that expert testimony on scientific evidence can potentially influence the admissibility of evidence, or even the outcome of the case itself. in frye v. united states (1923), the defendant was charged with second-degree murder; in his defense, he requested a systolic blood pressure deception test, or lie detector test. the defendant believed that the test results would proclaim his innocence. the court excluded the test results because the testing device was not generally accepted in the scientific community. the court explained their decision as follows: just when a scientific principle or discovery crosses the line between the experimental and demonstrable stages is difficult to define. somewhere in this twilight zone the evidential force of the principle must be recognized, and while courts will go a long way in admitting expert testimony deduced from a well-recognized scientific principle or discovery, the thing from which the deduction is made must be sufficiently established to have gained general acceptance in the particular field in which it belongs (p. 1014). this statement eventually became known as the “frye standard” for the admissibility of scientific evidence. both the daubert (1993) and frye (1923) cases developed standards for the admissibility of scientific evidence. however, it was the daubert standard that significantly contributed to the development of the federal standard, which was previously enacted. the frye standard was generally used from the 1920’s to the 1980’s; the courts eventually shifted to the federal standard in the 1970’s and, in the 1990’s, daubert (1993) ruled that frye would no longer be the standard rule of admissibility of scientific evidence (moriarty, 2008). federal rules of evidence (fre).the current federal standard for evidence in the courtroom is known as the federal rules of evidence (fre). the fre have provided a legal standard for the admissibility of evidence in united states federal courts since it was enacted in 1975 (mosteller, 2006). most u.s. state and federal jurisdictions refer to this standard. the fre contains several rules relevant to the admissibility, presentation and application of scientific evidence in the courtroom. generally, the judge decides whether the evidence is admissible, but only an expert witness can introduce and interpret the evidence (moriarty, 2008). relevancy and expert testimony are two central concepts in the fre that govern the admissibility of evidence. there are three rules of particular importance two pertaining to relevancy, and one pertaining to expert testimony (fre 401, fre 702 and fre 403 respectively). these rules are important because they help determine the admissibility of scientific evidence such as neuroimaging. they will be reviewed in order of mention. federal rules of evidence, fre 401 (definition of “relevant evidence”). in regard to relevancy, fre 401 (2008) states: relevant evidence means evidence having any tendency to make the existence of any fact that is of consequence to the determination of the action more probable or less probable than it would be without the evidence. neuroscience and law 29 researchers are still debating the relevancy of neuroimaging to courtroom proceedings; however, the evidentiary value of neuroimaging is not only a matter of relevance to the case, but also, the sufficiency of the evidence itself. husted and colleagues (2008) state that imaging studies “will not be relevant to every defense and, if utilized, should be only a component of the multi-faceted scientific data presented” (p. e15). others disagree, stating that “neuroscience is insufficiently advanced to offer precise data that will be genuinely legally relevant” (morse, 2006, p. 400). federal rules of evidence, fre 702 (opinions and expert testimony). whenever neuroscientific evidence requires specialized knowledge, there must be an expert witness to testify as to what the brain image means. without the appropriate expertise, the evidence would be rendered inadmissible. fre 702 (2008) states: if scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles and methods reliably to the facts of the case. in summary, rule 702 requires that testimony be factual, reliable, and applicable to the case. the previously mentioned factors will be evaluated in terms of how they apply to neuroimaging evidence. the following evaluation will only provide a general sense of the current medical-legal opinion on the admissibility of scientific evidence in the context of fre. sufficient facts are necessary to prove certain aspects of the case. if the facts are insufficient, then they will not contribute to legal decision-making. for this reason, factuality can itself determine admissibility, despite the reliability of the evidence. for instance, “even if the science is good enough to pass muster for admission as expert scientific evidence under federal and state evidentiary rules, it may still be inadmissible because it will not be probative” (morse, 2006, p. 400). so, it is not just a matter of whether neuroimaging is scientifically valid, but rather, whether or not it can provide enough information to establish important facts in the case. researchers le and hu (1997) explain that “[r]eliability concerns the extent to which a test, or any measuring procedure, yields the same results on repeated trials” (p. 160). reliability is equally important in clinical neuroimaging as it is in evidentiary law. aharoni and colleagues (2008) argue that “it is not clear when neuroscience findings should qualify as relevant, material, or competent, or reliable as defined by the rules of evidence” (p. 157). whether such qualifications can be met really depends on the type of neuroimaging device being used, and the reason it is being employed. for instance, the society of nuclear medicine brain imaging council (1996) states that the “use of functional neuroimaging in forensic situations including criminal, personal injury, product liability, medical malpractice, worker's compensation and ‘toxic torts,’ remains especially controversial” (p. 1257). the way neuroimaging methods are applied in legal cases is crucial. if applied unconventionally, brain scanning technology may undermine rather than contribute to justice. however, if the science is reliable, and provides relevant facts, litigants can introduce this evidence without compromising the integrity of their case. therefore, the reliability of the method should be a prerequisite for its admissibility. generally, regardless of the type of case being tried, factuality, reliability, and applicability remain critical factors in the admissibility of scientific evidence under fre 702. federal rules of evidence, fre 403 (relevancy and its limits). besides fre 702, there are other federal rules that further stipulate what judges may allow in the courtroom. in fact, “[e]xpert testimony that survives scrutiny under fre 702 might still be excluded under fre 403” (pettit, 2007, p. 327). fre 403 (2008) provides stipulations that potentially exclude some evidence from the courtroom if the probative value is minimal. this rule specifies additional criteria for admissibility of evidence. fre 403 (2008) states: although relevant, evidence may be excluded if its probative value is substantially outweighed by the danger of unfair prejudice, confusion of the issues, or misleading the jury, or by considerations of undue delay, waste of time, or needless presentation of cumulative evidence. in summary, rule 403 specifies four criteria for admissible courtroom evidence (whether it is prejudicial, confusing, misleading or excessive). there are several arguments regarding how neuroimaging may or may not meet any of these criteria. prejudice and justice are inevitably intertwined in the field of law. neuroscience can contribute to prejudice in the legal system in numerous ways. in criminal trials, rendering a verdict for the defendant simply based on a structural abnormality of the brain or a dysfunction of behavior oversimplifies the complexity of crime and creates undue prejudice. this may work for or against the defendant – the jury can relieve punishment for the crime if the defendant is believed to be insane or incompetent because of his anomaly, but the jury can also penalize the defendant because his brain disorder may indicate a propensity for criminal behavior. therefore, brain abnormalities should not automatically diminish the responsibility of the defendant, nor should it substantiate guilt. overall, neuroimaging evidence should be used in conjunction with other legal or scientific evidence. thus, prejudice is likely to enter the courtroom depending on the way the evidence is presented and how it is applied. neuroimaging technology is also potentially confusing for the jury. the expert witness must be able to simplify the information being presented, and accurately summarize shafi 30 relevant findings on the brain. brain evidence is especially difficult to present without confusion because “society has not yet reached a consensus as to whether, as a matter of morality or legality, neurological explanations should lead to exculpation” (baskin et al. 2007, p. 268). however, one legal expert believes that neuroimaging can revitalize the search for truth in the courtroom. feigenson (2006) states that the “courtroom display of such images should not only greatly assist triers of fact in understanding the fmri expert testimony [or any other type of neuroimaging device] but also disabuse them of the tendency to view the data representations naively and hence uncritically” (p. 251). thus, it is arguable that neuroimaging could enlighten the jury, rather than confuse them. baskin and colleagues (2007) argue that neuroimaging can mislead or bias the jury. in fact, “data from fmri, spect, and pet scans can be referenced and presented in dazzling multimedia displays that may inflate the scientific credibility of the information presented” (p. 268). defendants with insanity pleas can further complicate judicial decisions. one study examined the effect of neurological evidence on legal decision-making. gurley and marcus (2008) presented a group of 396 participants with hypothetical case summaries of defendants in criminal trials. the participants were asked to provide a verdict of guilty or not guilty by reason of insanity. this study found that participants were more likely to render a verdict of not guilty by reason of insanity when the hypothetical defendant had psychological or neurological problems, which were demonstrated by psychiatric or neuroimaging techniques. these results seem to demonstrate the favorability of brainbased evidence in the courtroom, and how it can bias the jury and the outcome of the verdict (gurley & marcus, 2008). to counteract this bias, baskin and colleagues (2007) suggest that medical witnesses interpret neuroimages with reservation, and be more speculative and less definitive in presenting their testimony in court. neuroimaging does not seem to present a problem of undue delay as other forms of scientific evidence might. whether neuroimaging in the court is a “waste of time” or a “needless presentation of cumulative evidence” depends on the ability of brain imaging specialists to contribute new facts to the case; considering the history of neuro-law cases, it seems that brain scans can do just that. structural and functional neuroimaging i: clinical and courtroom applications modern neuroimaging techniques such as magnetic resonance imaging (mri), computerized tomography (ct), single photon emission computed tomography (spect), positron emission tomography (pet), and functional magnetic resonance imaging (fmri), will be reviewed in terms of their clinical and legal applications. spect, fmri, and pet are functional brain scanning technologies, while mri and ct are structural scanning technologies. the former is concerned with physiological functions, whereas the latter is concerned with physiological features. neuroimaging techniques create a visual image of different structures or functions in the brain (see figures 1-2 for a basic review of brain anatomy). each neuroimaging modality is based on distinct methods of operation, and has varying degrees of scientific validity and reliability. the question is whether or not the neuroimaging methods in the clinic have evidentiary value in the court. figure 1. displaying the cortical surface of the brain. adopted from fallon (2006). figure 2. anterior, posterior, ventral and dorsal views of the brain. adopted from badre (2008). neuroscience and law 31 lawyers and scientists typically consider the capabilities and limitations of neuroimaging techniques before making any conclusions about a patient, client, plaintiff, or defendant. the following segment of this paper will review several examples of how law has interacted with neuroimaging in recent legal history. the author will first begin by analyzing the scientific reliability and legal applicability of structural neuroimaging, such as mri and ct, and functional neuroimaging, such as pet, spect and fmri. several legal cases involving each neuroimaging modality will be reviewed, followed by a brief discussion on the admissibility and reliability of neuroimaging evidence submitted in court. magnetic resonance imaging (mri). magnetic resonance imaging (mri) is a structural brain imaging technique focusing on the structure of the brain. mri is a noninvasive procedure, unlike pet and spect. mri displays visual images of the brain by “using a powerful magnet to obtain its images” (baskin et al., 2007, p. 248). the authors describe mri scans as a static visualization of the brain. mri has numerous capabilities. mri has high spatial resolution and is scientifically established as a reliable measurement of brain injury (mettingr, rodiger, de keyser, & van der naalt., 2007). specifically, “structural mris can often detect acutely diffuse axonal injury,2 small hemorrhages,3 edema,4 or contusions5 that characterize tbi” or traumatic brain injury (baskin et al. 2007, p. 254). also, “mri produces images superior to ct scans, both in its ability to differentiate gray from white matter and its clear visualization of brain structures” (moriarty, 2008, p. 31). furthermore, “the great advantage of mri is the absence of radiation, which is important for the assessment of the young and in benign conditions” (rankin, 2008, p. 239). some researchers consider mri an effective tool and an admissible form of evidence for postmortem evaluations of traumatized brains (harris, 1991). overall, mri is designed to detect or diagnose physiological abnormalities of the brain. however, mri also has limitations. mri scans are unable to accurately predict age or gender (baskin et al., 2007). moreover, ewers and colleagues (2006) state that “[v]ariability in mri-based measurement between clinical sites may potentially influence the accuracy of biological measures and thus compromise applicability of mri-based diagnostic criteria across sites” (p. 1051). differences in clinical standards do exist, and that there is a subjective element in mri analysis in the clinic, and consequently, in the court. the following case exemplifies the evidentiary value of mri in diagnosing head injuries. in state of delaware v. vandemark (2004), the defendant filed a motion, or a request 2 axonal injuries are characterized by lesions in the white matter of the brain. 3 hemorrhages are instances of internal or external bleeding. 4 edema is an accumulation of fluid in bodily tissue or cavities causing swelling to occur. 5 cerebral contusions are bruises in brain tissue caused by injury. to the court, to “bar testimony about shaken baby impact syndrome or inflicted head trauma” (p. 1). the defendant was “charged with assault by abuse involving a child” (p. 1) approximately sixteen months old at the time the injury was thought to occur. the child was hospitalized and underwent neuroimaging soon after the injury. a ct scan detected a small subdural hematoma6 with a “mass effect on the left side” of the child’s brain (p. 1). a mri was also performed, and found “an extensive subacute left-sided subdural hematoma” throughout the left hemisphere (p. 2). the court recognized the greater sensitivity of mri over ct, in that it was able to better display the extent of the hematoma in the brain. medical experts in this case agreed that the head injuries sustained by the child were “consistent with…inflicted head trauma” and that the injuries were “not accidental” (p. 2). one physician testified that the shaking of a child or blunt force inflicted on the child, or both, causes injuries; this notion is generally accepted in the relevant scientific community, namely, pediatrics (p. 4). mri and ct scans substantiated the evidence supporting head injury, and coincided with expert testimony regarding the diagnosis of shaken baby impact syndrome. the court concluded that the testimony was relevant and reliable, and would therefore, be admitted into evidence in the subsequent trial. the motion by the defendant to exclude evidence on inflicted head trauma was denied (p. 17-18). in this case, mri and ct evidence was both admissible and reliable. as demonstrated in the previous case, mri and ct can provide proof of injury, but may not always provide sufficient evidence for medical causation. the following case highlights the problem of making causal inferences from neuroimaging. in siharath, rider and rider v. sandoz pharmaceuticals corporation (2001), the plaintiffs sought “compensatory and punitive damages” alleging that parlodel, a drug manufactured by the defendant, caused seizures7 and stroke8 (p. 1349). the defendant filed a motion to exclude evidence insinuating medical causation. plaintiff siharath took the prescription for several days, and soon after, experienced “three seizures and a subarachnoid hemorrhagic stroke” (p. 1349). the plaintiff’s physician was unable to establish a cause or provide a diagnosis. the second plaintiff, ms. rider, experienced involuntary movements in her right leg. she later underwent a ct scan, which indicated that she had “an acute intracranial hemorrhagic stroke,” and a mri scan, which also confirmed that she had suffered “a left parietal hemorrhage” (p. 1350). the experts for the 6 a hematoma is defined as a collection of blood in bodily tissue or organs usually caused by hemorrhaging; a subdural hematoma is a mass of blood accumulating within the dura mater, and is caused by head injury. 7 seizures are characterized by abnormal neural activity accompanied by changes in sensation and behavior. 8 strokes are defined as a sudden loss of brain function caused by changes in blood supply to the brain, usually causing changes in movement, vision or speech. shafi 32 plaintiffs provided testimony that relied on case reports, partly because there was a lack of epidemiological studies on parlodel. the expert witness for the plaintiff, an expert on adverse drug reactions, argued that parlodel causes strokes. the defendant argued that case reports do not satisfy the scientific method. the court finally agreed with the defendant, although the mri and ct evidence confirmed the injuries in the plaintiffs’ brains. despite the fact that the mri and ct scans indicated separate incidents of stroke in two plaintiffs with the same prescription, it does not establish a causal relationship between the drug and the results of the brain scan. the court ruled in favor of the defendant, who filed for “summary judgment on issues of medical causation” (siharath, 2001, p. 1374). in this case, mri and ct evidence was admissible, but unreliable. the following case is an example of how neuroimaging evidence can be used, in conjunction with neuropsychological evidence, to establish a link between brain injury and intellectual capacity. this case demonstrates that brain scan evidence can coincide with or support the basis of other scientific evidence in the courtroom. in united states v. sandoval-mendoza (2006), the defendant appealed his conviction for conspiracy to sell methamphetamine, arguing that he was influenced by government agents to commit the crime, and that the presence of a brain tumor can explain his susceptibility to influence. one defense witness, a psychologist, testified that the defendant had an unusually large pituitary tumor, which caused irreversible brain damage. the court acknowledged that pituitary tumors may affect thyroid production, causing mood disorder, and damage to the frontal, temporal and thalamic regions, which may cause problems in “memory, decision-making, judgment, mental flexibility, and overall intellectual capacity” (p. 653). another defense witness, a neurologist, testified that the mri showed that sandoval-mendoza had a tumor which shrank after treatment. afterwards, the frontal lobe herniated into the empty space previously occupied by the tumor; the tumor then caused atrophy in the left temporal lobe and further damage in other areas. the court recognized that this kind of damage to the brain affects judgment, memory, and emotional memory. both witnesses agreed that such brain damage causes disinhibition, but does not necessary increase “susceptibility to inducement to commit crimes” (p. 653). prosecution witnesses, also consisting of neurologists and neuropsychologists, testified that although the mri showed a pituitary tumor, the connection between cognition and behavior remains questionable, and that the tumor should not be attributed to disinhibition (p. 653-654). the court also recognized that although expert testimonies on both sides were contradictory, they were not potentially confusing and that “the jury was capable of weighing the conflicting medical expert opinion testimony against the rest of the evidence presented and determining whether or not predisposition existed” (p. 656). in this case, mri evidence was admissible, although its reliability is disputable. computerized tomography (ct) computerized tomography (ct) is a structural imaging technique and x-ray technology used to visualize internal organs, including the brain. ct is also a noninvasive technology that revolutionized diagnostic neurology (khoshbin & khoshbin, 2007, p. 179). ct “produces an excellent combination of both high spatial and temporal resolution” (rankin, 2008, p. 239). ct is also a valid clinical method of assessing head trauma (metting et al., 2007, p. 699). moreover, moriarty (2008) states that ct and mri scans are typically presented in u.s. courts as evidence for brain trauma or neurological disease; he argues that there “is general agreement and substantial proof of reliability that ct scans and mri technology can detect brain injury, damage or atrophy9” (p. 40-41). according to metting and colleagues (2007), “ct is one of the first developed and most commonly applied imaging techniques in the acute phase of head injury” (p. 699) and “the overall sensitivity of ct to abnormalities in acute head trauma is 63-75%” (p. 700). however, the implication that such injuries have on mental capacity remains unknown. in some cases, ct scans are being admitted as evidence in the courtroom for purposes it was not designed. although brain scans may have important implications on the mental capacity or sanity of an individual, it is minimally capable of defining the former, and is currently incapable of proving the latter. the following cases demonstrate that ct evidence can be used or misused accordingly. the first case is a court case involving ct evidence supporting the insanity defense. the second case involves ct evidence establishing mental capacity. in united states v. hinckley (1982), the defendant was tried for his attempt to assassinate president ronald reagan. the defense presented an insanity defense, which they based, in part, on ct scan evidence. the expert witness, a psychiatrist, argued for the defense and testified that the ct scan showed atrophy in the brain. the psychiatrist then argued that atrophy is associated with schizophrenia. a radiologist was also consulted and testified that the scans showed brain abnormalities, but did not have any causal implications on the behavior or sanity for the defendant. nevertheless, the jury found hinckley not guilty by reason of insanity. it is likely that ct evidence had an effect on the verdict (khoshbin & khoshbin, 2007, p. 184), by diminishing the responsibility of the defendant and supporting his insanity defense. such an inference from neuroimaging is not based on scientific evidence. this is one example of how brain scans can be used in a way it was not intended. neuroimaging is not capable of proving insanity. although the images coincided with the psychiatric 9 atrophy is a physiological process characterized by cell death, causing a progressive decline in tissue. neuroscience and law 33 assessment, it was unable to substantiate it. in this case, ct evidence was admissible, but seemingly unreliable. in re estate of meyer (2001), the plaintiffs sued because they were unrightfully denied benefits from meyer’s trust. the plaintiffs argued that meyer was not mentally capable of creating the trust and was possibly manipulated by his lawyer. moriarty (2008) noted that the court allowed the plaintiffs to introduce ct scans of meyer which indicated various abnormalities including “brain atrophy, vascular dementia10 and focal brain changes” (p. 41), which supported the claim that meyer lacked the capacity to create the trust. as mentioned earlier, ct scans have the ability to localize damage in the brain. however, the association between atrophy, dementia, and ct evidence is questionable. both early and recent reports have questioned the reliability of ct in measuring cognitive decline (bird, 1982; van straaten, scheltens, & barkhof, 2004). according to the court, neuroimaging provided substantial proof to explain meyer’s mental state, or lack thereof. in this case, ct evidence was admissible, but reliability is debatable. as shown in some of the previous cases, structural imaging in the courtroom is relatively reliable. functioning imaging is also applicable in legal cases. single photon emission computerized tomography (spect) single photon emission computerized tomography (spect) is a functional imaging technique that measures metabolic activity and cerebral processes in various structures. scientists can use functional imaging to study the neurochemistry of the brain and develop a cognitive profile based on an increase or decrease in blood flow (baskin et al., 2007, p. 250). spect has a wide variety of clinical applications. spect imaging studies have generated data on psychiatric and neurological disorders, like dementia, epilepsy, schizophrenia, and depression, but with mixed results (bonne, krausz, & lerer, 1992). spect also has several disadvantages. granacher (2008) notes the clinical and legal limitations, stating that “the reliability of spect…when applied forensically to mtbi [mild traumatic brain injury] or tbi cases, will not meet all daubert criteria” (p. 326), and that “general acceptance of the theory and technique within the relevant scientific community…has not been achieved” (p. 327). metting and colleagues (2007) note the technological limitations, stating that spect has low spatial resolution, limited availability, and is not routinely used as a clinical tool for assessing head injury. at the present time, there is no scientific consensus on the validity of spect. furthermore, “[r]eliable analysis of spect date remains a major challenge” (bonne et al., 1992, p. 298). 10 vascular dementia is a common neuropsychiatric disorder characterized by cognitive decline and impairment, producing focal effects in the brain. in previous cases, it was demonstrated that the causality of brain injury can not be easily established. in the following case, it seems equally difficult to establish causation between brain injury and post-injury symptoms. in lanter v. kentucky state police (2005), the appellant sought “workers’ compensation benefits due to a head injury” (p. 45) sustained during a police training incident. lanter had previously received partial disability benefits. however, the appellant wanted total disability benefits and requested several brain scans to determine the extent of his injury. in order to receive total benefits, the claimant must demonstrate that his work-related brain injury caused continuous emotional, neurological, and behavioral symptoms. several brain scans of different types were admitted as evidence. the medical experts performed mri, eeg11 and spect scans. one expert diagnosed the appellant with a cerebral contusion and post-concussive syndrome (lanter, 2005). another expert performed and analyzed additional spect scans, which “revealed functional defects in the right parietal and left occipital lobes of the claimant’s brain” (p. 48). however, these results did not indicate that the injury caused his behavioral symptoms. the claim for disability benefits was denied, in part, because the medical experts for the plaintiff did not establish causation between injury and affect. spect evidence in this case was admissible, but unreliable. other cases have also admitted spect imaging as evidence for brain injury claims. for example, in boyd v. bell (2005), the appellant, a former athlete, sustained head injuries during sports activity. the appellant (boyd) requested spect scanning to determine the cause and extent of his organic brain injury in order to apply for additional disability benefits. the radiologists appointed to the case confirmed the head injuries, but noted that the exact cause was uncertain. subsequently, the court ruled against the appellant, denying his claim for disability benefits, partly because there was no way to prove that his current physiological abnormalities were due to head injuries he sustained in the past. spect evidence in this case was once again admissible, but unreliable. the following case shows that although spect imaging is unlikely to establish causation, it can be used to demonstrate incompetence. in united states v. kasim (2008), the defendant, a pediatrician, was accused of conducting fraudulent insurance practices. the defendant filed for a competency evaluation in 2008. his defense team found that, in 2003, “kasim was diagnosed with anoxic encephalopathy caused by an acute myocardial infarction,” as well as sleep apnea during hospitalization (p 8). the eeg produced abnormal results the following day. days later, eeg and mri results performed on kasim were normal. numerous 11 the electroencephalogram (eeg) is a functional technique used to assess “cerebral maturation, for determining a patient’s physiological (awakening and sleep) and pathological (comas) level of wakefulness and in epileptology” (praline et al., 2007, p. 2149). shafi 34 medical expert witnesses were consulted for further scanning. a spect was later performed, indicating a reduction in blood flow in the temporal and frontal lobes. the frontal and temporal lobes are associated with executive functioning and memory, respectively. the defendant exhibited deficits in both areas of cognition during neurological and psychological testing. one medical witness diagnosed kasim with frontal lobe dementia, based on the spect results. although at least one physician disagreed with the diagnostic validity of spect in cases of dementia, or the extent of reduced blood flow in the frontal region, almost all agreed that the defendant exhibited cognitive deficits. despite the discrepancies in the neuroimaging results from spect, eeg, and mri, several medical witnesses testified that normal results from eeg and mri scans do not necessarily imply normal brain functioning. the court considered spect as an objective test of cognitive abilities. also, the court found that “kasim’s demeanor during various medical evaluations portrayed poor judgment, an inability to concentrate, and an inability to understand the charges at hand” (p. 46). the court concluded that the defendant was incompetent to stand trial. neuroimaging evidence contributed to the outcome of the case, which was in favor of the defendant. spect evidence in this case was admissible and reliable. positive emission tomography (pet) positive emission tomography (pet) is a functional imaging technique that measures metabolic processes, including “blood flow, blood volume, and metabolism” (baskin et al., 2007, p. 248). it is a relatively invasive procedure that requires an injection of radioactive elements (or tracer molecules) into the circulatory system, which eventually interact with other molecules to produce measurable changes in activity. essentially, pet scans “use radioactivity to map differences in metabolic activity in areas of the brain” (pettit, 2007, p. 320). they can also be used to “measure reduced tissue perfusion” (baskin et al. 2007, p. 250), a characteristic of neurodegenerative disease, where a decrease in blood volume is observed in specific tissue. according to metting et al. (2007), “pet studies generally show cerebral dysfunction beyond the structural abnormalities demonstrated by ct and mri” (p. 703); however, pet has low spatial resolution and is not routinely used for assessing mild or moderate traumatic brain injuries. although pet is more sensitive than spect, it is inferior in terms of specificity (ebmeier, donaghey, & dougall, 2005). pet also has additional limitations in methodology. the society of nuclear medicine brain imaging council (1996) explains methodological issues with structural neuroimaging. the council names seven sources of interpretive error in using spect and pet: (1) “differences in patient behavioral conditions during acquisition”; (2) “processing and display variations”; (3) “nonstandardized definitions of normal and abnormal”; (4) “availability of scanner-specific or archived normative databases”; (5) “nonuniform use of quantitative analyses in conjunction with descriptive readings”; (6) “availability of few published standards defining the criteria for disease pattern identification”; and a (7) “lack of published determinations of sensitivity and specificity for scans to indentify specific diseases and syndromes before their routine clinical use” (p. 1257). the clinical limitations of spect and pet should be acknowledged in the courtroom. interpretative errors in neuroimaging could certainly compromise expert testimony. for this reason, and others, the courts have increasingly “rejected the use of scans when performed for less than wellestablished clinical indications” (p. 1257). yet, despite the skepticism on introducing neuroimaging to litigation, many courts are accepting brain scans as reliable evidence. for instance, pet and spect have relatively high rates of admissibility. in fact, feigenson (2006) states that “pet and/or spect evidence has been admitted in more than four-fifths (73 of 89, 82.0%) of cases in which it has either been admitted or excluded” (p. 237). feigenson (2006) also states that there have been over 130 court opinions involving pet and spect evidence in u.s. federal and state courts. the rate of admissibility for pet and spect does not substantiate reliability, however. in the following case, unreliable evidence was admitted for the defendant, to confirm his claim of incompetence due to alzheimer’s disease. in united states v. gigante (1997), the defendant was being prosecuted by the federal government for several counts of murder and other serious charges. the defendant requested a pet brain scan to confirm alzheimer’s disease (ad) and demonstrate incompetency.12 according to the court opinion, the expert witness for the defense found that the “defendant was suffering from organic brain dysfunction, possibly due to alzheimer's disease or multi-infarct dementia” (p. 147). the witness was unable to determine the cause, but concluded that the defendant was incompetent to stand trial. the prosecution team, however, found evidence that such abnormalities can be attributed to drug use (p. 147). the court noted that gigante was taking medication at the time. this case exemplifies that neurological deficit does not imply psychological dysfunction, especially considering the confounding variables in the neuroimaging results. also, the defendant exhibited brain abnormalities which may or may not have existed during the commitment of the crime. the evidence probably undermined, rather than supported, the defendant’s case.13 in this case, pet evidence was admissible, but unreliable. 12 there is one fundamental problem with the defense in this case. in regard to a pet-based diagnosis of alzheimer’s dementia, “there are postmortem criteria...but in vivo histological findings are rarely feasible” and “guidelines have generally not supported the routine use of functional imaging in the diagnostic evaluation of dementia” (ebmeier et al., 2005, p. 49). 13 this case was also reviewed elsewhere (pettit, 2007, p. 335-336). neuroscience and law 35 sometimes neuroimaging is excluded as evidence because it is being used for reasons that are not clinically valid, such as diagnosing injuries that lack clinical criteria in pet studies. in mccormack v. capital electric construction company (2005), the plaintiff, a carpenter, filed for negligence after being electrocuted during work. the plaintiff attempted to introduce pet brain scans to confirm his injuries and gain compensation. experts testified that the scans showed abnormal brain activity. however, the defendant argued that the pet “scans were inadmissible…as an unreliable method of diagnosing electric shock injuries” (p. 399). the court ruled in favor of the plaintiff, not because of pet, but because of the alternative scientific evidence presented, including neuropsychological and medical evaluations. although the pet scan of the plaintiff provided the court with important information relating to the case, it was not sufficient to substantiate his claim. pet evidence in this case was admissible, but unreliable. in yet another legal case, the reliability of pet evidence depends on the availability of control groups in clinical studies; these studies are used to validate neuroimaging methods. in penney v. praxair, inc. (1997), the plaintiff sustained a motor vehicle accident, and sought awards for brain damage. experts for the plaintiff testified that pet scans detected brain abnormalities, which indicated that penney had sustained traumatic brain injuries. however, the court found that the plaintiff “did not prove its results were not affected by his age and his medications” (p. 330). pet results are believed to be compromised by age, medical history or medications. the reliability of pet results also depends on the control groups used in pet studies. in this case, the plaintiff’s age did not match the controls used for pet experiments at the time. nevertheless, the court ruled in favor of the plaintiff, awarding damages to the plaintiff “for past and future medical expenses related to injuries he allegedly sustained” (p. 330). furthermore, according to the court, the admissibility of scientific evidence does not strictly depend on general acceptance in the scientific community, but the relevance and reliability of the method employed (daubert, 1993). in this case, pet evidence was inadmissible and unreliable. functional magnetic resonance imaging (fmri) functional magnetic resonance imaging (fmri) is a brain scanning technology that measures “localized brain activity by determining blood flow and oxygen utilization in portions of the brain” (applebaum, 2007, p. 461). aharoni et al. (2008) states that, “in general, abnormal activation could manifest as hypoactivation, hyperactivation, positive or negative activation, or some erratic pattern” (p. 152). baskin et al. (2007) notes fmri and other forms of functional imaging are “most advantageous for studying neurochemistry” (p. 248). also, fmri is “widely used for imaging the neural correlates of psychological processes and how these brain processes change with learning, development and neuropsychiatric disorder” (aron, gluck, & poldrack, 2006, p. 1000). the introduction of fmri advanced the study and science of the brain, and is considered to be technologically superior to pet and spect (khoshbin & khoshbin, 2007). however, fmri has numerous limitations. the interpretation of brain activity patterns remains a question of debate among neuroscientists. neuroimaging studies examine cognitive functions associated with specific brain patterns of neural activity. however, there is no indication that any particular pattern is necessary for any specific behavior (desmond & chen, 2002). several confounded variables, such as head movement and anatomical differences, also undermine the interpretation of fmri results (desmond & chen, 2002). also, another limitation in fmri is its “meager temporal resolution” (aharoni, 2008, p. 158). feigenson (2006) describes six additional reliability issues noted with fmri usage: (1) fmri scans provide relative measures of brain activity, not absolute measures; (2) fmri data in neuroimaging studies are not always based on a same level of significance (e.g. p < .05); (3) fmri data usually represents group averages of brain activity, and results may not apply to individuals; (4) anatomical variability compromises the accuracy of structural localization; (5) there are several confounded variables that may effect physiology, neurochemistry or cognition (e.g. drugs and toxins); and (6) generalizing the results from fmri is difficult considering the lack of uniformity in the experimental methods used for neuroimaging studies14 (p. 240-241). feigenson (2006) also refers to one brain researcher, who states that “[t]here is no single-subject reliability” in fmri findings (robinson, 2004, p. 716). furthermore, fmri also has several limitations in regard to diagnosis of injury. granacher (2008) states that “[t]he evidentiary usefulness of functional neuroimaging to provide mild tbi in a court of law lacks a sufficient scientific database and lacks sufficient scientific standards” (p. 327). nevertheless, fmri is a “noninvasive technique,” which “does not require exposure to ionizing radiation” and creates anatomically precise images of the brain, while assessing the neural correlates of cognition and behavior (metting et al., 2007, p. 705). researchers speculate that fmri is likely to be the future of truth (or lie) detection in legal proceedings, and is superior to the polygraph15 in accuracy and reliability (kittay, 2007). applebaum (2007) explains that lie detection with fmri is based on the assumption that lying activates 14 some argue that the development of science sometimes depends on diverse modifications of its methods. a universal method is potentially detrimental especially if the method retains weaknesses that would otherwise be corrected in an alternative scientific approach to research methodology (chalmers, 1999, p. 161-162). 15 a polygraph is an instrument used to record physiological data and changes in the sympathetic nervous system. the examiner records the responses and determines whether the examinee is lying based on bodily reactions. shafi 36 brain areas associated with executive functioning. higher cognitive processes would be necessary to suppress a truthful response and plan for deceit. defendants being scanned by authorities would exhibit abnormally high levels of brain activity in frontal areas when lying to investigators. this is one way in which fmri would be considered useful. however, appelbaum (2007) names seven limitations that exist with fmri lie detection: (1) there is no scientific consensus on the neural basis of deception; (2) fmri studies use group norms to define activation levels in test participants, but these norms may not apply to individuals; (3) fmri studies of lie detection are fairly recent and lack substantial data; (4) false-positive and false-negative rates are not currently available, so an accuracy assessment is not possible; (5) external validity is yet to be established – laboratory use and findings may differ from, or may not apply to, courtroom use; (6) there are confounded variables like attention and emotion that would potentially affect the results of fmri lie-detection; and (7) even if a physiological basis for lying and deception is defined, a measurement would have to be devised to differentiate between absolute truth and partial truth, or absolute lies and partial lies (p. 461). in theory, fmri is a potential psychological profiling tool. arrigo (2007) states that fmri can be used for “interrogating suspects of criminal wrongdoing or extracting information from actual violations of the law” (p. 462). in this regard, fmri is inadequate, and such a method of use raises important questions concerning humanitarian ethics and constitutional law.16 arrigo (2007) contends that fmri “represents a form of coercion” and a violation of privacy rights (p. 463-466).17 with further research and development, it is only a matter of time before fmri lie detection is introduced in the courts to pick up where the polygraph left off. arrigo (2007) speculates that interactions between criminal justice and neuroscience will set a legal foundation for biological laws to determine the criminal culpability of the defendant (p. 474). as of yet, “there are no cases to date admitting fmri evidence as proof of deception or truth-telling” (moriarty, 2008, p. 46). furthermore, as one legal expert notes, “it is not clear…how courts will react to a scientifically valid lie 16 suggested readings are the fourth and fifth amendments of the united states constitution which further elaborate on the legal implications of privacy and testimony that relate to fmri in the courtroom (pettit, 2007). 17 arrigo (2007, p. 464-466) applies anti-modernist and sociological theories of french philosopher, michel foucault, to explain the diametric struggle between social authority and individual privacy. the implication for neuroimaging is that it contributes to the former, while undermining the latter. in this context, science is not a tool for justice, but merely a biosocial commodity of power and enforcement, used by legal and psychiatric authorities to deconstruct and normalize the individual. from this perspective, neuroimaging represents the most pervasive force against humanity, exerting itself onto one of the most intimate parts of the human experience: thoughts. detector” (bellin, 2008, p. 711). mosteller (2006) asserts that “if there were a truly accurate lie detection technology, over time it would have a substantial impact both on how criminal cases are handled before trial and on how they are tried” (p. 539). truth or lie detection with neuroimaging is still a process in development, and a subject of intense interest in neuroscience and law (mosteller, 2006). there have been few cases involving fmri evidence, and like with any other neuroimaging technique, “there may be real concerns about the reliability and relevance of fmri based expert testimony” in legal proceedings (feigenson, 2006, p. 251). the following case is concerned with the relationship between violence and cognition, rather than information extraction or lie detection. in entertainment software association [esa] v. blagojevich (2005), the plaintiff sued the state (represented by the defendant, blagojevich, governor of the state of illinois) and attempted to enjoin, or forbid, the enforcement of a state law designed to prohibit the promotion of violent or explicit video games to minors without parental consent. the state wanted to regulate the distribution of games because they believed exposure to violent media causes a lack of behavioral inhibition in minors. the defendant used an fmri study (kronenberger et al., 2005) to justify anti-video game legislation. the defendant referred to this study as evidence demonstrating that exposure to violent media has a negative effect on child behavior and brain function. using fmri, the kronenberger et al. (2005) study found reduced frontal lobe activity in subjects with disruptive behavior disorder in comparison to controls; a relationship between violent media exposure and changes in brain functioning was also found in both experimental subjects and controls. the plaintiff consulted dr. h.c. nusbaum, a cognitive psychologist and expert witness, who challenged the testimony of dr. w.g. kronenberger in court. in his review of the esa v. blagojevich (2005) case, feigenson highlights some weaknesses which dr. h.c. nusbaum noted from dr. w.g. kronenberger’s testimony and fmri study (feigenson, 2006). first, the experimental design was fundamentally flawed: participants only simulated video-game playing while being scanned, so alternations in brain wave activity can not be associated with the actual playing of violent games but only a mere simulation. second, reduced frontal activity does not necessarily indicate susceptibility to violent or aggressive behavior, because other regions of the brain are also involved in aggression. kronenberger testified that reduced activity in the frontal lobe indicates lack of impulse control. nusbaum disagreed, and testified that the frontal lobe has various functions; a reduction in frontal activity can be attributed to other mental and physical processes besides exposure to violent media. thus, a causal relationship between negative behavior and altered brain activity can not be drawn. the court found that the kronenberger et al. (2005) study was invalid, and could not support the defendant’s neuroscience and law 37 claim that violent media exposure causes negative behavior, thereby ruling in favor of the plaintiff’s motion to enjoin the law prohibiting the sale of violent games to minors (esa v. blagojevich, 2005). further developments in functional imaging techniques are necessary before implementing this technology in a legal context. in this case, fmri evidence was admissible, but unreliable. in summary of the previous cases, it seems that neuroimaging methods have a limited degree of admissibility and reliability in the court, despite their extensive use in the clinic. the applicability of structural and functional neuroimaging depends on the type of case being presented. from the examples provided, mri is able to confirm head injury (e.g. state of delaware v. vandemark, 2004), but is unable to establish causation between injury and stroke (e.g. siharath v. sandoz pharms. corp., 2001) or to determine susceptibility to criminal behavior (e.g. united states v. sandoval-mendoza, 2006); ct is certainly capable of defining mental capacity to some extent (e.g. in re estate of meyer, 2001), but unable to prove insanity, although surprisingly influential in at least one case (e.g. united states v. hinckley, 1982); spect can help determine competency to stand trial (e.g. united states v. kasim, 2008), but is unable to establish causation between injury and affect (e.g., lanter v. kentucky state police, 2005), or the exact cause of organic brain problems (e.g. boyd v. bell, 2005); pet can detect traumatic brain injuries or brain abnormalities (e.g. penney v. praxair, inc., 1997), but is unable to diagnose neurodegenerative diseases like alzheimer’s (e.g. united states v. gigante, 1997) or electric shock injuries (e.g. mccormack v. capital electric, 2005); and finally, fmri is unable to establish a connection between exposure to violence and aggressive behavior (e.g., esa v. blagojevich, 2005), but is quite possibly the future of lie detection technology. structural and functional neuroimaging ii: a comparison of methods structural and functional neuroimaging have significantly contributed to legal decision-making, providing key information about anatomy and behavior in neurolaw cases. however, there are considerable limitations to the applicability of neuroimaging methods; controversy remains as to whether such techniques are being used according to their capability. researchers maintain that brain scans are only capable of providing anatomical, rather than behavioral information. “at the present time, imaging technology reveals the anatomical structure of and blood flow patterns in the brain but cannot directly provide information about behavior” (illes et al., 2009, p. 108). moreover, in u.s. courts, behavioral inferences from neuroimages are likely to be excluded as evidence (moriarty, 2008). nevertheless, neuroimaging modalities are used in a variety of legal contexts (moriarty, 2008). structural imaging, like mri and ct scans, have been used in the courts as proof of physical or mental illness (e.g., in re care and protection of sharlene, 2006; in re estate of meyer, 2001; state of nebraska v. kuehn, 2007; moriarty, 2008, p. 40-41); functional imaging, like pet and spect scans, has been used in civil cases (e.g., blodgett-mcdeavitt v. university of nebraska, 2004; green v. k-mart corp., 2004; lanter v. kentucky state police, 2005), criminal cases (e.g., people v. goldstein, 2004; people v. williams, 2004; state of washington v. marshall, 2001; united states v. mezvinsky, 2002) and in the penalty phase of capital cases (e.g., hoskins v. state of florida, 1999; state of tennessee v. reid, 2006). regardless of why the evidence is being submitted, litigants should carefully consider the reliability of neuroimaging prior to admission. as one researcher notes, “[h]istorically, neurological data have been given great evidentiary weight, often before the scientific basis warranted this degree of confidence” (baskin et al. 2007, p. 258). therefore, the evidentiary value of neuroimaging should be equally weighed in the scales of law and science to determine admissibility. structural imaging seems to be more admissible and reliable than the functional type, because it has been used and tested for a greater period of time. however, this should not negate the potential of functional imaging. although structural imaging has a more extensive history in the legal system, functional imaging will certainly compete with its technological predecessor, both in terms of applicability and accuracy. while some emphasize the reliability of structural imaging (pettit, 2007), others emphasize the potential of functional imaging (mobbs et al., 2007). generally, u.s. courts have questioned the reliability of pet, spect and fmri in contrast with mri and ct, but researchers will continue to refine both structural and functional techniques for clinical and legal use. conclusion: interdisciplinary perspectives on neuroscience and law the evidentiary value of neuroimaging evidence depends on the validity of its use and its relevance to the case. brain imaging is more applicable in some court cases than others. in conclusion, it seems that neuroimaging evidence is generally admissible, but usually unreliable when it lacks a scientifically valid method. clinical applications in neuroimaging are more likely to be admitted and deemed reliable as evidence. yet, the admissibility of unreliable evidence is a reality that compromises legal integrity and scientific credibility. there is still medical-legal debate on the extent to which neuroimaging and law should interact. most scientists and lawyers believe that neuroimaging can provide important details regarding the brain in both clinical and courtroom settings, but, there is no legal or scientific consensus on which neuroimaging technology should be admissible or reliable – this will remain an open question for some time. the evidentiary value of neuroimaging depends on its scientific reliability and legal admissibility. technology will increase the former, and consequently, improve the latter. with all likelihood, science will continue to advance, shafi 38 whereas law will continue to adapt. both neuroscientists and lawyers should maintain their current dialogue on the legal implications of neuroscience and law. the integration of both fields does not necessarily imply a compromise in either: “developments in neuroscience may well have substantial impact on how the law views people and behavior, but the legal system should be able to assimilate and use even revolutionary science [such as neuroimaging] without upending its own fundamental structure” (garland, 2004, p. 5). references aharoni, e., funk, c., sinnott-armstrong, w., & gazzaniga, m. 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(2004). law and the brain: introduction. philosophical transactions: biological sciences, 359, 1661-1665. author note the author is a recent graduate with a m.s. degree in neuroscience and education from teachers college. this article was originally submitted as a master’s thesis in december of 2008 as a humble attempt to examine the newly emerging field of “neurolaw.” i would like to dedicate this paper to my step-father. i would also like to offer my thanks to all those who motivated me to write. http://moritzlaw.osu.edu/osjcl/articles/volume3_2/symposium/morse-pdf-04-05-06.pdf http://moritzlaw.osu.edu/osjcl/articles/volume3_2/symposium/morse-pdf-04-05-06.pdf 153 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university understanding migration and resettlement experiences of uzbek immigrants in the united states anastasiya tsoy1, khanh t. dinh1, & sharifa djurabaeva2 1 university of massachusetts lowell, department of psychology, 2 dennis-yarmouth high school, massachusetts this qualitative study utilized a thematic six-step analysis process of interview data to identify prominent themes in the life experiences of 20 uzbek immigrants regarding their migration to and resettlement in the united states; it also examined gender differences in their experiences. the results indicated that at the time of migration, most uzbek participants were well-educated, middle class, and in their mid-20s. the primary reasons for their migration were limited socioeconomic and employment opportunities, and the declining educational quality in uzbekistan. uzbek participants reported some difficulties in their resettlement, including language barriers, cultural challenges, and financial stress. most participants felt welcomed by the host community, believed in the “american dream,” considered themselves successful, and envisioned their future in the us rather than in uzbekistan. across all interview questions, women tended to focus on their children’s well-being and the opportunity to gain personal freedom in terms of education and employment, whereas career aspirations and achievement of financial stability were the focus for men. the results from this study provide much-needed information about the life experiences of uzbek immigrants in the us and have implications for future research with this understudied population from central asia. keywords: uzbek immigrants, migration, resettlement, cultural adjustment, gender differences the immigrant population in the united states (us) is the largest in the world; more than 40 million people living in the us were born in another country (budiman, 2020). with future waves of immigration, the demographics of the us population will continue to change, resulting in increased diversity and awareness of new immigrant groups. over the past two decades, the number of uzbek immigrants in the us increased from 22,800 in 2000 to 65,126 in 2019 (us census bureau, 2020), making them the largest group of immigrants from central asia. for most uzbeks who migrated to the us after 2000 (us department of homeland security, 2021), the pathway for legal immigration has been the diversity immigrant visa program (dv program) or green card lottery. among central asian countries, uzbekistan is the country with the highest number of dv program lottery winners (4,494), followed by tajikistan (1,209), kazakhstan (1,020), kyrgyzstan (753), and turkmenistan (306) (us department of state, 2018). over the last decade, researchers have explored migration and cultural adjustment of immigrants from post-soviet countries but with a limited number of participants from uzbekistan (birman & taylor-ritzler, 2007; birman & trickett, 2001; roytburd & friedlander, 2008). therefore, the primary goals of this qualitative study were to address this gap in the research literature and to identify the prominent themes related to the migration and resettlement of uzbek immigrants in the us. in addition, we placed particular emphasis on exploring potential gender differences across these experiences. migration of uzbek immigrants to the us the first wave of migration from uzbekistan to the us began in 1991, after perestroika (refers to the restructuring of the soviet political and economic system during the 1980s; for more information, see e.g., https://www.history.com/topics/cold-war/perestroika-and-glasnost) and the breakup of the soviet union. the uzbek community in the us has grown quickly (jackson, 2010; kordunksy et al., 2012; moskin, 2006), and currently, uzbek immigrants reside in more than nineteen states (us census bureau, 2020). however, it is difficult to precisely quantify the number of uzbek immigrants living in the us because prior to 2000, uzbek immigrants were recorded as originating from the former soviet union. official routes of migration employed by uzbeks include the dv program, student and tourist visas, and asylum (us department of homeland security, 2021). however, the fastest way to come to the us remains the dv program. in 2020, the number of uzbeks who applied for the dv program was 1,674,787 (2,572,653 with derivatives or 8% of the uzbek population), making uzbekistan the nation with the second-highest application rate after ghana (us department of state, 2022). uzbek migration is influenced by both push and pull factors, where push factors (e.g., political repression, lack of education, poverty) impact citizens’ motivation to leave uzbekistan, and pull factors (e.g., better opportunities, employment, safety, political stability, psychological and physical well-being) attract people to relocate (castles, 2013; lee, 1966). the primary 154 reasons uzbeks migrate to other countries are the lack of job opportunities, followed by low life satisfaction, job insecurity, and unemployment (seitz, 2019). researchers also noted that outdated education in uzbekistan negatively impacts the quality of training, making uzbeks less suited for the current job market, leading to unemployment and low life satisfaction (library of congress, 2007; ruziev & burkhanov, 2018). uzbekistan’s slow transition to a market economy also has been challenging for uzbek citizens to adapt successfully under the new political and economic system (batsaikhan & dabrowski, 2017). these various push factors may reflect the pre-migration stress experienced by uzbeks prior to their migration to the u.s. for many immigrants, regardless of their status or reasons for migration, the relocation process is challenging and stressful (dinh, 2009; heleniak, 2004; vinokurov et al., 2020; yakushko, watson et al., 2008). immigrants experience depression, isolation, and homesickness both during and after migration. immigrants may also experience pre-migration stress and face additional challenges after their relocation (american psychological association [apa], 2012, 2013). resettlement of uzbek immigrants in the us uzbek immigrants reside primarily on the west and east coasts (us census bureau, 2020) and live in russian-speaking ethnic enclaves (vinokurov et al., 2020). for example, many uzbeks living in new york city have recreated makhallas (neighborhoods or local communities), built thriving environments for the uzbek community (e.g., supermarkets, restaurants, offices with bilingual staff), and replaced well-known post-soviet jewish neighborhoods, such as brighton beach, sheepshead bay, bensonhurst in brooklyn (kordunksy et al., 2012), forest hills, rego park, and kew gardens in queens (jackson, 2010; moskin, 2006). approximately 59% of uzbek immigrants are proficient in english, and 53% have bachelor’s degrees or more advanced degrees (us census bureau, 2020). however, most uzbek immigrants prefer to speak russian at home and maintain their customs, traditions, and post-soviet values (birman et al., 2005; birman et al., 2014). although most recent uzbek immigrants are blue-collar workers, established immigrants have pursued careers in the arts, business, academia, and medicine. additionally, uzbek immigrants have established nonprofit organizations to raise awareness and serve the needs of the uzbek and central asian communities in the us (e.g., turkestanian american association, uzbek american association of chicago). the resettlement of immigrants and their adjustment to new social and cultural norms can be stressful, a process that can last from several months to several years or more (dinh, 2009; schwartz et al., 2006). immigrants experience acculturative stress from various factors, including language barriers, social and cultural challenges, trauma-based problems, hostile attitudes from host communities (e.g., anti-immigrant comments), and discrimination (apa, 2012, 2013; dinh & le, 2019; roytburd & friedlander, 2008; vinokurov et al., 2020; yakushko, backhaus et al., 2008). many immigrants from post-soviet countries, including uzbekistan, value ethnically dense communities within the us (vinokurov et al., 2020), where they can receive social support and maintain many facets of their pre-migration lifestyle (birman & trickett, 2001; birman et al., 2005). gender differences in uzbekistan central asian cultures are generally considered collectivistic and have traditional gender roles. like other central asian countries, uzbekistan is patriarchal: men serve as “breadwinners” while women fulfill the primary duties as homemakers and family caregivers (kamp, 2018). in uzbekistan, early marriages, where one or both spouses enter marriage at the age of 18 or under, vary from 46% to 61%, depending on the region of the country (the state committee of the republic of uzbekistan on statistics, 2019). typically, women tend to enter marriage earlier than men. even though the literacy rate among school-age girls (7-15 years old) in uzbekistan is 99.9%, young married women are limited in their access to higher education; they also face other risks associated with early marriage, including depression and domestic violence (bacchus et al., 2018; buzi et al., 2015; chandra-mouli et al., 2015). additionally, girls and women in uzbekistan have restricted freedom of choice, including reproductive rights (kamp, 2018), especially after marriage. these gender disparities in education enable uzbek men to further leverage the benefits of a patriarchal society and leave fewer opportunities for women in both education and employment. the current study although there has been interest in understanding the experiences of asian immigrants in the us, little research has explored the lives of immigrants tsoy et al. 155 migration and resettlement of uzbek immigrants from central asia, especially those from uzbekistan. this study, the first of its kind, was designed to address this gap. using a thematic six-step analysis process (braun & clarke, 2006; braun et al., 2019), this study identified common themes in the uzbek migration and resettlement narratives, including the reasons for emigration from their homeland and the experiences of establishing a new life in the us. in addition, we explored potential gender differences in these migration and resettlement experiences. research team in qualitative research, it is important to present the research team’s background information that is relevant to the current research work. the research team for this study was comprised of three researchers at the master’s or doctoral level in their training and academic career. the first and third authors were born in uzbekistan. they are fluent or proficient in english, russian, and uzbek languages and familiar with uzbek culture and immigration issues. the second author was born in vietnam and has conducted extensive research with asian and latinx immigrant and refugee populations in the u.s. method participants twenty uzbek immigrants residing in the us (10 female participants and 10 male participants, according to participants’ self-identification and pronouns preference), ranging in age from 20–48 years old (m = 32; sd = 6.88), participated in the study. nineteen participants were born in uzbekistan, and one was born in russia but arrived in uzbekistan by the age of one and was raised there. most participants identified as uzbek (n = 14) or mixed ethnicity (n = 3; uzbek-russian, uzbek-korean-russian, uzbek-greek). 90% of participants achieved a bachelor’s degree or higher and 10% were in the process of completing a bachelor’s degree. regarding socioeconomic status, 70% identified as middle class, 20% as lower class, and 10% as upper-middle class. in terms of living accommodations, 65% rented a house or apartment and 35% owned a house. please see table 1 for a summary of participants’ demographic information. migration and resettlement-related demographic information the participants’ year of immigration ranged from 1993 to 2017, with an average of 8.55 years of residence in the us. the mean age of participants at the time of migration was 23.25 years old, ranging from 8 to 42 years old. 30% of participants migrated through the dv program, 20% via student visa, 15% via tourist visa, 15% via work and travel program, 15% via unification with family, and 5% did not specify visa type. all participants were us citizens or permanent residents at the time of their interview. most participants migrated to the us alone, while other participants migrated with parents, siblings, or spouses and children. at the time of their migration, 10 participants had relatives in the us and 18 had friends from uzbekistan who were living in the us. at the time of their interview, participants were residing in 10 states and the district of columbia. the primary languages in participants’ homes in uzbekistan were a mix of uzbek and russian (n = 13), uzbek alone (n = 4), and russian alone (n = 3). after migration, many uzbeks used a mix of english and russian at home (n = 8), followed by english (n = 4), russian (n = 3), a mix of uzbek, english, and russian (n = 3), a mix of english, russian, and croatian (n = 1), and a mix of uzbek and english (n = 1). none of our participants used uzbek as their primary language at home after migration. an equal number of female and male participants learned english in uzbekistan (n = 16). please see table 2 for additional migration and resettlement-related demographic information. procedure following approval by the institutional review board to conduct this research study, we recruited participants through social media posts on facebook, linkedin, and instagram (please see appendix a: recruitment invitation for social media postsenglish version). the recruitment invitation, in russian and english, was posted on uzbek immigrant facebook groups (e.g., uzbeks in usa, american uzbekistan association, uzbek cultural garden of cleveland) and on the first author’s linkedin and instagram pages and was reposted by the members of these social groups 65 times within the first 72 hours. interested participants contacted the first author through social media messaging platforms who then confirmed their eligibility through follow-up emails. to be eligible, the study required participants to be at least 18 years old, have been born in uzbekistan or the uzbek union of soviet socialist republic (uzbek ussr), and reside in the u.s. as u.s. citizens or permanent residents. excluded from study participa156 tion were uzbek individuals on student or work visas. a total of 63 individuals expressed an interest in participating in the study. those eligible for the study were scheduled for an individual interview on a “first come, first serve” basis until the 20-interview goal was reached for the study, with 10 female and 10 male participants. we decided on 20 interviews because according to guest et al. (2006) and morgan et al. (2002), the first five-six interviews produce most of the information for qualitative research and after the 20th interview, there is little new information to be gained from additional interviews. prior to the scheduled interview, each participant received an email reminder that provided interview instructions and an informed consent form (please see appendix b). study participants received no financial compensation or other incentives. each participant took part in a one-hour audiotaped interview and had the option to be interviewed in english or russian. the selection of language options was based on the first author’s experiences in the uzbek primary and secondary educational systems, in which students have more exposure to the teaching of the russian language than the uzbek language. the language options were also based on the first author’s stronger fluency in the russian language over the uzbek language, making it easier to conduct the interviews and do the transcription and translation work. however, during the interview participants were not restricted from using the uzbek language, so they were free to add specific words or phrases related to cultural context (e.g., gap – gathering). interviews in english (n = 11) were transcribed by a transcribing service (temi). interviews in russian (n = 9) were translated and transcribed by the first author, who is fluent in english and russian, and proficient in uzbek languages. the first author checked these interviews for cultural nuances, such as noting the specific vocabulary used by participants (e.g., kelin – bride, makhalla – community, neighborhood). measures participants responded to demographic questions about their age, gender, place of birth, ethnicity, current residence, educational level, marital status, spoken languages, socioeconomic status, and year of migration. after the completion of demographic questions, the interviewer asked participants a set of open-ended questions related to migration and resettlement experiences. in relation to their migration, we were interested to learn about their reasons for migration to the us (e.g., why did you leave your home country?). in relation to their resettlement, we explored their adjustment to the us (e.g., did you feel welcomed? did you have any challenges? what were your expectations about life in the us?) for the full set of interview questions, please refer to appendix c. data analysis a thematic analysis approach was used for coding and analysis to identify the most common themes across participant interviews (braun & clarke, 2006; braun et al., 2019; clarke & braun, 2015). the primary goal was to explore the lives of uzbek immigrants in the context of migration and resettlement. therefore, a data-driven approach was used to generate the themes inductively (braun & clarke, 2006). to ensure analyst triangulation (patton, 2015), two coders (first and third authors) individually coded interviews and then reviewed the findings. the coders reached inductive thematic saturation on the eleventh interview when no new codes or themes emerged from the data (saunders et al., 2018). to reduce errors in translation or loss of cultural nuances, the coders paid close attention to interviews in which the participant spoke in both russian and uzbek. to accurately capture meaning across different languages, both coders were fluent or proficient in all three languages (english, russian, and uzbek) and were familiar with uzbek culture and practices. the data analysis employed braun and clark’s (2006, 2016) six-step process of thematic analysis to measure reliability, especially when codes were derived inductively. first, the coders read all interviews multiple times to familiarize themselves with the data. in this initial stage, they did not develop any codes nor analyzed any themes. however, the first author wrote casual memos on potential insights and observations (boyatzis, 1998; denzin & lincoln, 2000). the second phase included the completion of the initial coding of the transcripts by the first author, who recorded these codes in a codebook. the coders used in vivo coding and assigned labels to sections of data (e.g., sentences or paragraphs) by using a specific word or short phrase. after the first author coded all interviews, the second coder coded 20% of the interviews (four interviews) as recommended to meet the saturation and accuracy criteria (boyatzis, 1998; guest et al., 2006). in the third phase, the coders categorized the most common codes, based on both coders’ responses, and identified tsoy et al. 157 migration and resettlement of uzbek immigrants potential themes. any discrepancies in coding were discussed and resolved through consensus. during the fourth phase, the coders reviewed the themes and the relationships between them. the coding and analysis yielded four main themes in two categories that highlighted participants’ experiences. once the themes and the overall structure of the analysis have been identified, the fifth phase focused on defining these themes and extracting quotations from the interviews to illustrate the data. in the final sixth phase, in the results section of this paper, we contextualized our analysis, presenting the major themes, and in the discussion section, we highlighted the main contributions and limitations of our study (clarke et al., 2015). results the interview data yielded four key themes (table 3): (a) migration for better opportunities under the migration category; and three themes under the resettlement category, (b) support and challenges in new home, (c) expectations and adaptation, and (d) “american dream” and future plans. we also presented our findings on gender differences within each category. migration for better opportunities most participants (n =19) migrated to the us voluntarily, excluding one participant who responded that their migration was involuntary due to their age (the participant was a minor at the time of relocation). 95% of participants stated that the main reason for their migration was an overall lack of opportunities in uzbekistan in concert with financial stability in the us. for example, a 31-year-old male participant reported, “i saw more opportunities here [us]. i decided to leave because i had no future prospects in there [uzbekistan]; [laughing] our generation, come on, they all left, the majority left.” overall, push factors for many participants were critical in their decision to migrate, including unemployment and financial instability (n = 4) and limited opportunities for their children, such as poor educational quality (n = 8). among pull factors, participants mentioned employment opportunities (n = 5), ability to travel (n = 1), unification with family (n =1), and furthering their education (n = 1). regarding gender differences, twice as many women (80%) as men (40%) highlighted push factors as their primary reason for migration. of the four male participants who responded that push factors were their primary reasons for migration, three were minors at the time of their relocation but only one mentioned involuntary migration. women (n = 8) reported limited economic opportunities to sustain a family and limited educational opportunities for their children, whereas men highlighted limited job opportunities as their primary reasons for migration. among pull factors, one woman reported unification with a spouse and another woman mentioned furthering education as their primary reason for migration, whereas men’s responses focused on employment opportunities in the us. familiarity with the host country dictated the migration pattern for participants. before permanent relocation to the us, three female participants had studied in the us as exchange students. no male participants studied in the us prior to migration. ten participants visited the us to familiarize themselves with the host country before relocation; these participants held a nonpermanent visa at the time of their visit (e.g., student, work-travel, tourist visa), of whom, six (all women) stayed in the us one month or longer. all six women and two men returned to uzbekistan before migrating to the us permanently. the other two male participants pursued permanent visas while visiting the us (i.e., they changed a student visa to a green card application). resettlement support and challenges in new home relating to resettlement experiences, 75% of participants (n = 15) reported feeling welcomed and receiving support from the host community (e.g., neighbors, teachers). additionally, 10% of participants (n = 2) reported receiving support from a russian-speaking immigrant community where they were living. despite participants highlighting the host community as welcoming and open-minded toward learning about their experiences and home country, a 33-year-old male participant recalled being bullied in school because he did not speak english, “the first probably 2 years were difficult at school, the adjustment period because we’re, we didn’t speak the language…we did not fit in very well.” another male participant also faced discrimination but from a russian-speaking person. one female participant who felt unwelcome for several years responded that she had no access to communication with either a russian-speaking community or an american community due to her isolated residential area and inability to drive. regarding gender differences, more women (90%) than men (60%) reported feeling welcomed 158 and supported by the mainstream host community. 50% of participants (n = 10) reported experiencing difficulties in their resettlement process. five participants noted the language barrier and cultural differences as the most difficult aspects of their adjustment, followed by financial struggles (n = 3), paperwork (n = 1), and separation anxiety (n = 1). for some women (n = 2) and men (n = 3), language and cultural differences played a role in their adjustment, “when i came over, i did speak no english at all. it was difficult transition because, you know, different culture, different traditions, different way of life, different pace” (26-year-old male participant). two female participants and one male participant faced financial difficulties. however, the former associated these difficulties with the pressure of having to financially support their family in uzbekistan: i somehow had to convince them [parents] that if i go to the us, i will be working and i will be sending money. moreover, um, that was the only thing i think my mother liked about going to the us that i would be supporting them financially. that was the only reason how she allowed me to go. (28-year-old female participant). expectations and adaptation 70% (n = 14) of participants had expectations before they migrated to the us; 65% (n = 13) thought that adaptation and achieving goals would be faster and easier. for example, a 32-year-old male participant stated, “i thought... everything is easy, and money grows on the trees…i did not expect it to be that challenging….” a few other participants also highlighted the notion of money growing on trees. many participants, even those who did not have expectations, noted that social media and movies influenced their perception of life in the us and cultivated the idea of easy goal achievements i have never heard about the state where we came [to]. all that [i] heard was new york, los angeles, miami, three cities that everyone knows, unfortunately… when you watch movies, you watch it from the lens of hollywood, and of course, movies are movies, but you have this notion like, ‘oh, ok, so america is like this.’ unfortunately, when i came, reality hit me, everything what i expected fell down because it was tough, especially when i came to ohio, and i saw 2 meters of snow. (24-year-old female participant). in relation to gender, more men (n = 8) than women (n = 6) reported having expectations about life in the us; one woman expected more freedom of expression and five women stated that life would be easier in professional and personal matters, but eight men expected that the process of adaptation itself would be easier. only two participants, both men, mentioned hard work as a factor in achieving their goals, “without effort, you won’t even pull a fish out of a pond.” five participants shared that they did not have any expectations due to their age. four women noted maturity and preparedness to migrate. for example, a 41-year-old female participant stated, “i’m actually a person with my experience and age [old enough], and whatever lessons i learned in my life, i don’t have any expectations.” one male participant shared that he had no expectations because he was underage at the time of his migration. another male participant did not respond to this question. “american dream” and future plans nearly all participants (90%) believed in the “american dream,” and more than half (55%) considered themselves successful. also, more than half of the participants (n = 13) described the “american dream” as an opportunity to achieve goals, as exemplified in a statement by a 33-year-old male participant, “[the] ‘american dream’ means whatever you dream of that you want to do in life, you can do it by working very hard, by committing time, by committing effort that you can accomplish those.” regarding gender differences, fewer women (80%) than men (100%) believed in the “american dream.” 90% of men (n = 9) but only 10% of women (n = 1) described their “american dream” as the achievement of professional goals and financial stability. 40% of women (n = 4) associated the “american dream” with freedom of choice and expression. for 30% of the women (n = 3) and 10% of the men, the “american dream” was linked to family goals, such as raising children and balancing their professional and personal life. all participants defined what success meant to them; while 90% of the men defined success as achieving goals and gaining financial stability, only 10% defined it as having a family. for 70% of the women, success was an ability to work and study the subject of their choice, whereas 30% of the women defined success as creating and building family relationships. when asked about success, of the 55% of participants who defined themselves as successful, six were women and five were men. tsoy et al. 159 migration and resettlement of uzbek immigrants regarding future plans, reverse migration was not an option for 13 participants (65%). although six participants (two women and four men) considered returning to uzbekistan permanently, they all discussed the importance of first achieving their life goals in the us. because of close family bonds back home, only one participant was confident in their decision to return to uzbekistan permanently. regarding gender, seven women and six men expressed their desire to stay and build their future in the us. most female participants (n = 7) stated they would like to stay as an “independent woman,” or “wanted to escape living in uzbek mentality.” some male participants (n = 4) also expressed similar sentiments about not wanting to return to uzbekistan, as shown in the following statement, “i feel like my outlook and values have become different, perhaps even my mentality has changed. it is most likely that i will struggle adapting to that life and my profession allows to live more comfortably here” (35-year-old male participant). discussion our study sought to explore the life experiences of uzbek immigrants in relation to their migration and resettlement in the us. particularly, we aimed to explore the reasons for their migration, understand various aspects of their resettlement, and examine potential gender differences in their experiences. migration and resettlement experiences similar to the experiences of other immigrants (e.g., marcus, 2009; paat, 2013), there were various push and pull factors underlying the reasons for uzbek immigrants to start a new life in the us. many participants shared that limited socioeconomic and employment opportunities and a declining level of educational quality in their homeland influenced their decision to migrate to the us. concurrently, pull factors, such as their expectations for a better life in the us (i.e., improved socioeconomic, employment, and educational opportunities), unification with family members, and perceived opportunities to experience more personal freedom and liberties (e.g., freedom to make decisions for themselves, freedom to pursue their life interests, freedom to travel) further reinforced their conviction to leave their home country. these migration narratives of uzbek immigrants contribute to the rich history of voluntary and involuntary migrations of various cultural groups to the us (e.g., barkan, 2013; takaki, 1998). the resettlement process of uzbek immigrants encompassed positive and negative experiences, pointing to the complex dynamics of adjusting to a new cultural context like the us. for example, most participants felt welcomed by the host community, but some experienced discrimination and bullying. most participants also reported proficiency in english, but some described considerable language and cultural difficulties. these factors, either positive or negative aspects, can have major influences on subsequent adjustment and adaptation to u.s. society. in this study, most participants migrated to the u.s. alone, meaning they left much of their family and social network in uzbekistan, so the extent of support they received from the host or existing russian-speaking communities may be crucial in their resettlement and consequently in navigating any related challenges, including language, cultural, economic, employment, educational, or other difficulties. findings from previous research have shown the importance of social support from the host and existing immigrant communities in the resettlement process and the well-being of various immigrant groups (e.g., jasinskaja-lahti et al., 2006; msengi et al., 2015). furthermore, the degree of discrepancies in the expectations they had about life in the us pre-migration and their actual life in the us post-migration also may have influenced the quality of their resettlement experiences (negy et al., 2009). despite the various challenges in the migration and resettlement processes, nearly all participants expressed a belief in the “american dream” and stated that freedom of choice, financial stability, and the ability to provide for their families represent the primary pillars of their “american dream.” although various scholars have written about the myth of the “american dream” (e.g., tittenbrun, 2015), for uzbek immigrants, their positive belief and hopefulness in this dream might have buffered some of the stresses and challenges they faced in the resettlement process. previous research has shown the connection between positive attitudes toward migration and positive adjustment to a host country (gong et al., 2011; vinokurov et al., 2020). indeed, half of the participants in this study reported little or no difficulties in their resettlement process and more than half considered themselves successful. however, it is also important to note that most participants in this study reported high levels of education, english proficiency, and so 160160 cioeconomic status, as well as having opportunities to visit the us prior to their permanent relocation, which all can facilitate more positive resettlement outcomes for immigrants (e.g., zlobina et al., 2006). like many immigrant groups before them, most participants envisioned their future in the us rather than returning to their homeland, citing various economic, social, and cultural reasons. because most participants often linked achieving their life goals and being successful to financial stability and personal freedom, this connection may be a primary reason as to why they did not imagine their future life in uzbekistan where they perceived limited economic and educational opportunities and individual rights. this is not to say there are not limited opportunities or individual rights in the us, but rather this reflects the participants’ perceptions of life in their home country versus life in the us. additionally, many participants mentioned their “change in mentality” and newly adopted values in the us. these changes may be related to the number of years they have spent in the us, as supported by the findings of kwak and berry (2001), showing that time spent in a host country is positively associated with changes in identity development, assimilation, and the development of new cultural and personal values. gender differences there were patterns of gender differences across interview questions regarding migration and resettlement experiences. for most women, push factors were the primary reasons for their migration (limited economic and educational opportunities for themselves and their children in uzbekistan), whereas pull factors were the primary reasons for men (employment and economic opportunities in the us). more women than men felt welcomed by their host community, whereas more men than women expressed a belief in the “american dream.” these differences may have a differential impact on subsequent adjustment for women and men in us society (dion & dion, 2002). additionally, women tended to define success as the freedom to pursue educational and employment opportunities and to attend to their family’s well-being, whereas men’s definition of success focused on individual goal achievements and financial stability. these differences in migration and resettlement experiences appear to reflect gender socialization and gender roles of women and men in uzbekistan (e.g., kamp, 2018), which can play out in the process of their adaptation to us society. limitations of the present study we recognize several limitations in our study. although we carefully tried to recruit uzbek immigrants from diverse educational and socioeconomic backgrounds, most participants reported having a bachelor’s degree or higher, english proficiency prior to migration, and middle-class status at the time of the interview. therefore, the study results may reflect sample selection bias; immigrants of differing socioeconomic and educational backgrounds from those in our study may have other perspectives on migration and resettlement. future work should consider the experiences of uzbek immigrants from diverse educational, social, and economic backgrounds, as these factors would provide a more comprehensive and nuanced understanding of the life experiences of uzbek immigrants in the us. a second limitation was the languages in which the interviews were conducted, either english or russian, although many participants used a few uzbek words or phrases in their interviews. we recognize these language options might have restricted participation by immigrants from rural uzbekistan, where the majority speak the uzbek language. future studies should consider including uzbek immigrants from rural areas and interviewing them in uzbek, as it may reveal more diverse perspectives on migration and resettlement experiences. in addition, we recruited participants through social media platforms predominantly used in the united states (e.g., facebook, linkedin, instagram) and therefore reached individuals who have high english language proficiency and have adjusted well in the us. the results may be different for those with less english proficiency and less exposure to the host community where the primary language is english. similar to conducting participant interviews in uzbek, recruitment on uzbek-speaking platforms (e.g., telegram) may also bring additional perspectives and insights into the life experiences of uzbek immigrants. implications for future research despite the limitations, the results from this study have implications for future research with uzbek immigrants and other groups from central asia. our study identified specific push and pull factors for uzbek migration to the us, but we suggest that future research examines more in-depth the contextual aspects surrounding these factors. for example, a focus on the family context and dynamics would provide richer data for understanding the reasons underlying tsoy et al. 161 migration and resettlement of uzbek immigrants their decision to start a new life in a new country far from their homeland. additionally, an examination of the current sociopolitical context of uzbekistan, a post-soviet country, would provide a more macro understanding of the reasons for uzbek migration to the us. similarly, we also identified some prominent themes in their resettlement experiences that can inform future research to replicate and expand on the current findings. for example, our understanding of resettlement experiences would benefit from future inquiries on the elements that constitute a welcoming host or receiving society as they can determine subsequent life outcomes for uzbek immigrants. furthermore, because uzbek immigrants comprise the largest group from central asia to receive the dv program status in the us, this provides opportunities to conduct longitudinal research, utilizing both qualitative and quantitative methodologies to delve into the processes of pre-migration, migration, and post-migration over time. finally, we suggest any future research with immigrants from uzbekistan or central asia to attend to gender issues as they may play a role in aspects of migration and resettlement. altogether, these future research directions would yield a more complete picture of the life experiences of uzbek immigrants. conclusion this qualitative study is the first of its kind to explore the life narratives of uzbek immigrants in the us, focusing on their migration and resettlement experiences. through a six-step thematic analysis, the participants’ narratives highlighted four major themes, as well as the push and pull factors that compelled them to leave their home country and establish a new life in a new cultural context. although there were some challenges in their experiences, many perceived their new life as part of the “american dream,” full of possibilities to achieve the educational, economic, and career goals they had for themselves and their family. their new country is where they envisioned their future and thus, they have become a part of the rich and complex tapestry of immigration to the us. references american psychological association. 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(2006). sociocultural adjustment of immigrants: universal and group-specific predictors. interna164 tsoy et al. tional journal of intercultural relations, 30(2), 195211. https://doi.org/10.1016/j.ijintrel.2005.07.005 165 table 1 participant demographic information migration and resettlement of uzbek immigrants 166 table 2 migration and resettlement-related demographic information tsoy et al. 167 migration and resettlement of uzbek immigrants table 3 participants themes 168 tsoy et al. 169 migration and resettlement of uzbek immigrants 170 tsoy et al. 171 migration and resettlement of uzbek immigrants 172 tsoy et al. 173 migration and resettlement of uzbek immigrants 174 tsoy et al. 175 migration and resettlement of uzbek immigrants 176 tsoy et al. 98 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university �аǔljƞș�ȅǟ�ƺ�^ǩǿǡǹǔে^ǔșșǩȅǿ�2ǿƞǔȗκǔǿƞǩȅǿ� targeting perfectionism in college students haley e. ward and michael g. wheaton, ph.d., department of psychology, barnard college perfectionism is a well-established transdiagnostic factor that contributes to the maintenance and exacerbation ȅǟ� ƺ�λǩǐǔ� ȗƺǿǡǔ�ȅǟ�ȓșρljǧȅȓƺƞǧȅǹȅǡρঀ��ǹƞǧȅȣǡǧ� ǔаǔljƞǩκǔॹ�ǿȅșƞ� ƞȗǔƺƞǿǔǿƞș� ǟȅȗ�ȓǔȗǟǔljƞǩȅǿǩșǿ�ƺȗǔ� ǩǿƺljljǔșșǩljǹǔ� ƞȅ� ƞǧǔ� general population, and are time-, resource-, and cost-intensive. online single-session interventions (ssis) display promise in preventing and treating negative mental health symptoms; however, no studies have examined the effectiveness of an online ssi targeting perfectionism. to address this, the present study sought to evaluate a novel computerized, self-guided ssi. the two primary aims of the study were: 1) to assess the intervention’s acceptability, likability, and utility, and 2) to examine whether the intervention reduces perfectionistic attitudes, depression, anxiety, and stress in a college student population. at baseline, students at a liberal arts college (n=79) were randomized to receive a 40-minute perfectionism ssi or a stress-management control. participants rated the perfectionism intervention as highly helpful, acceptable, and likable. the perfectionism intervention was associated λǩƞǧ�ǡȗǔƺƞǔȗ� ǩǿȓȗȅκǔǿǔǿƞș� ǩǿ�ȓǔȗǟǔljƞǩȅǿǩșǿॹ�ǐǔȓȗǔșșǩȅǿॹ�ƺǿπǩǔƞρॹ�ƺǿǐ�șƞȗǔșșআ�ǧȅλǔκǔȗॹ�ƞǧǔ�ǐǩаǔȗǔǿljǔș� ǩǿ�ȗǔǐȣljƞǩȅǿș� ljǔƞλǔǔǿ� ƞǧǔ� ǡȗȅȣȓș�λǔȗǔ�ǿȅƞ� șƞƺƞǩșƞǩljƺǹǹρ� șǩǡǿǩйljƺǿƞঀ�(ǩκǔǿ� ƞǧǔ� șǿƺǹǹ� șƺǿȓǹǔ� șǩφǔॹ� ƞǧǔ� șƞȣǐρ�λƺș� ǹǩƿǔǹρ�ȣǿǐǔȗȓȅλǔȗǔǐ� ƞȅ� ǐǔƞǔljƞ� ǐǩаǔȗǔǿljǔș� ljǔƞλǔǔǿ� ljȅǿǐǩƞǩȅǿșঀ� 'ȣƞȣȗǔ� ȗǔșǔƺȗljǧ� λǩƞǧ� ǹƺȗǡǔȗ� șƺǿȓǹǔ� șǩφǔșॹ� ƺ� ǹǔșș� ȓȅƞǔǿƞ� ljȅǿƞȗȅǹ� ǡȗȅȣȓॹ�ƺǿǐ�ljǹǩǿǩljƺǹ�ȓȅȓȣǹƺƞǩȅǿș�ǩș�ǿǔǔǐǔǐ�ƞȅ�ƞǔșƞ�ƞǧǔ�ǔаǔljƞș�ȅǟ�ƞǧǔ�ǩǿƞǔȗκǔǿƞǩȅǿ�ǿȅȗǔ�ǔπƞǔǿșǩκǔǹρঀ�fǔκǔȗƞǧǔǹǔșșॹ�ƞǧǩș� study demonstrates that single-session perfectionism interventions hold promise and merit future investigation. keywords: perfectionism, single-session interventions, online interventions, college students xǔȗǟǔljƞǩȅǿǩșǿ�ǩș�ǐǔйǿǔǐ�ƺș�ƞǧǔ�șƞȗȅǿǡ�ǿǔǔǐ�ƞȅ�ȓǔȗǟȅȗǿ� ƺƞ� ƺ� мƺλǹǔșș� ǹǔκǔǹ� ƺǿǐ� ƞȅ�ǿǔǔƞ� ǔπljǔșșǩκǔǹρ� ǧǩǡǧ� standards (flett & hewitt, 2002). although perfectionism is multidimensional and can have adaptive elements, it is considered a transdiagnostic factor associated with many forms of psychopathology (shafran & mansell, 2001; egan, wade, & shafran, 2011). the type of perfectionism that contributes to psychopathology is known as maladaptive perfectionism, which is characterized by the pursuit of personally demanding standards and the basing of self-worth on performance outcomes in one or more important life domains, despite negative consequences (shafran, cooper, & fairburn, 2002). maladaptive perfectionism involves critical self-evaluations, concerns about making mistakes and being negatively evaluated by others, and fear of failure (frost, marten, lahart, & rosenblate, 1990; egan, wade, shafran, & antony, 2016). many individuals with high levels of maladaptive perfectionism have core beliefs that they are weak, мƺλǔǐॹ�ƺǿǐ�ȣǿλȅȗƞǧρ�শ�ǔșșǔȗॹ�'ǹǔƞƞॹ�૭�/ǔλǩƞƞॹࢵࢱࢱࢳ�ষঀ� given these characteristics, it is unsurprising that perfectionism is elevated across eating (limburg, watson, hagger, & egan, 2017), anxiety (gnilka, ashby, & noble, 2012), depressive (hewitt & flett, 1991), and personality disorders (overholser & dimaggio, 2020). perfectionism has particular relevance to obsessive-compulsive personality disorder (ocpd), as one of the diagnostic criteria for ocpd involves perfectionism that interferes with normal task completion (american psychological association, 2013; egan, wade, & shafran, 2011). likewise, obsessive-compulsive disorder (ocd) often involves perfectionistic tendencies; the obsessive-compulsive cognitions working group postulates that perfectionism is one of six central cognitive processes involved in obsessive-compulsive disorder (occwg, 1997). in addition to the heightened perfectionism common among clinical populations, a substantial number of individuals who do not meet the diagnostic criteria for any given disorder have high levels of maladaptive perfectionism (grzegorek et al., 2004). in nonclinical samples, perfectionism is highly correlated with subthreshold symptoms of various forms of psychopathology (kearns, forbes, & gardiner, 2007). for instance, ferrari (1995) found that perǟǔljƞǩȅǿǩșǿ� șljȅȗǔș� λǔȗǔ� șǩǡǿǩйljƺǿƞǹρ� ȗǔǹƺƞǔǐ� ƞȅ� ȅljșǔșsional thoughts, compulsive acts, anger-suppression, anger expression, social desirability, and compulsive checking in a nonclinical college student population. perfectionism levels are also associated with hopelessness, non-suicidal self-injury, and suicidal ideation and attempts (o’connor, 2003; o’connor, 2007). more broadly, perfectionism gives rise to high levels of stress and worry, behavioral impairments, physical health problems, impaired daily functioning, inferior academic performance, and interpersonal problems (shafran et al., 2002; flett & hewitt, 2002). 99 treatments for perfectionism treatments for perfectionism are based on models that suggest cognitive and behavioral components may maintain the core biases and attitudes in perfectionism শ^ǧƺǟȗƺǿ� ǔƞ� ƺǹঀॹ� �ষঀ�eȅȗǔࢳࢱࢱࢳ șȓǔljǩйljƺǹǹρॹ�ǿƺǹƺǐƺȓƞǩκǔ� thinking patterns and cognitive biases such as dichotomous thinking, selective attention toward mistakes, rumination, self-criticism, self-blame, and overgeneralization play a role in maintaining perfectionism and its poor outcomes (egan et al., 2016; shafran et al., 2002). such biases may contribute to procrastination behaviors, higher standard-setting, and inability to complete tasks (egan et al., 2016; sirois, 2014). perfectionism is also antithetical to self-compassion (brown, 2008; naǐǔƺȣॹࢱࢳࢱࢳ�ষॹ�ƺș�ǩǿƞǔȗǿƺǹ�șǔǹǟ৉ǐǩƺǹȅǡȣǔ�ǩș�ȕȣǩƞǔ�ǧƺȗșǧ�ƺǿǐ� ǩǿκȅǹκǔș� ƺȣƞȅǿƺƞǩlj� ȓǔȗǟǔljƞǩȅǿǩșǿ৉ƞǧǔǿǔǐ� ƞǧȅȣǡǧƞș� ƺljȅȣƞ�ƞǧǔ�șǔǹǟॹ�ǵȣǐǡǿǔǿƞșॹ�ƺǿǐ�ǔǹǔǿǔǿƞș�ȅǟ�șǔǹǟ৉ǿǔǡǹǔljƞ� (ferrari, 1995; hewitt, 2020). self-criticism may even mediate the relationship between perfectionism, psychological distress (james et al., 2015), and depression (ferrari, yap, scott, einstein, & ciarrochi, 2018). because of these cognitive and behavioral maintenance factors, a perfectionistic cycle is often quite resistant to change, thus some researchers suggest that perfectionǩșǿ�ǩș�ƺ�йπǔǐ�ȓƺȗƞ�ȅǟ�ȓǔȗșȅǿƺǹǩƞρ�শ/ǔλǩƞƞ�ǔƞ�ƺǹঀॹࢸࢲࢱࢳ�ষঀ� however, it might be more helpful to look at perfectionism as a cognitive vulnerability factor related to psychopathology that can change with targeted treatment (egan et al., 2011). indeed, perfectionistic beliefs can be changed through cognitive-behavioral therapy (cbt). common elements of cbt target cognitive and behavioral processes in perfectionism via psychoeducation, cognitive restructuring, and self-compassion techniques (egan et al., 2016; nadeau, 2020). a growing body of evidence shows that cbt for nonclinical and clinical populations reduces perǟǔljƞǩȅǿǩșǿॹ�λǩƞǧ�ǿǔǐǩȣǿ�ƞȅ�ǹƺȗǡǔ�ǔаǔljƞ�șǩφǔș�শ?ǔƺȗǿș� et al., 2007; lloyd, schmidt, khondoker, & tchanturia, 2015). targeting perfectionism may also lead to a reduction in other psychological disturbances characteristic of mental disorders (egan et al., 2011; lloyd et al., 2015). in particular, studies have found that depression, anxiety, and eating problems are ofƞǔǿ� ȗǔǐȣljǔǐ� λǩƞǧ� ǿǔǐǩȣǿ� ǔаǔljƞ� șǩφǔș� ǩǿ� ljȅƞǧ� ljǹǩǿǩcal and nonclinical samples (e.g. kearns, forbes, & gardiner, 2007; steele & wade, 2008; shafran et al., 2017). there is also evidence supporting the utility of self-compassion interventions for perfectionism ǩǿ� ǿȅǿljǹǩǿǩljƺǹ� ȓȅȓȣǹƺƞǩȅǿșॹ� ƺǹƞǧȅȣǡǧ� ǔаǔljƞș� ȅǿ� ȗǔducing secondary disorders are less consistent (rose, mcintyre, & rimes, 2018; nadeau, 2020). therefore, combining more traditional cognitive-behavioral components with self-compassion techniques may be ljǔǿǔйljǩƺǹ�ǩǿ�ƺǹǹǔκǩƺƞǩǿǡ�ȓǔȗǟǔljƞǩȅǿǩșǿॹ�ƺș�șȣǡǡǔșƞǔǐ�ǩǿ� prior research (fairweather-schmidt & wade, 2015). although there has been a recent surge in randomized controlled trials evaluating treatments for perfectionism (lloyd et al., 2015), for many individȣƺǹș� ȓșρljǧȅƞǧǔȗƺȓρ� ǩǿƞǔȗκǔǿƞǩȅǿș� ȗǔǿƺǩǿ� ǐǩгljȣǹƞ� ƞȅ� access given the face-to-face and individualized nature of treatment (andersson, 2016). cost, transportation issues, waiting lists, lack of trained mental health professionals, and stigma—typical barriers in facing treatment—might limit access to perfectionism interventions. and such barriers may be particularly strong for under-resourced populations (andrade et al., 2014). further, those with subclinical problems (e.g. someone who is perfectionistic and anxious but doesn’t meet criteria for a disorder) would be unlikely to go to great lengths to seek out an intervention. this lack of access points to a clear need for more accessible mental health programs targeting perfectionism. internet-based interventions as a response to lack of access, internet-based interventions have been rapidly developed. interǿǔƞেljƺșǔǐ� ǩǿƞǔȗκǔǿƞǩȅǿș� ƺȗǔ� ǔаǔljƞǩκǔ� ǟȅȗ� ƺ� κƺȗǩǔƞρ� ȅǟ� mental health disorders and problems (e.g. parks et al., 2018), including perfectionism (e.g. rozental et al., 2017). online interventions for perfectionism utilize the same techniques present in in-person treatment (e.g. cognitive restructuring, self-compasșǩȅǿষॹ�ƺȗǔ�ƞρȓǩljƺǹǹρ�șǔǹǟেǡȣǩǐǔǐॹ�ƺǿǐ�ȅǟƞǔǿ�ȗǔȓȅȗƞ�ǔаǔljƞ� sizes comparable to in-person treatments (suh et al., 2019). for example, suh and colleagues’ meta-analysis on 10 face-to-face and online interventions for ȓǔȗǟǔljƞǩȅǿǩșǿ�ȗǔȓȅȗƞǔǐ�ƞǧƺƞ�ƞǧǔȗǔ�λǔȗǔ�ǿȅ�șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔș� ǩǿ� ǐǔǹǩκǔȗρ� ǿȅǐƺǹǩƞρ� ȅǿ� ǔаǔljƞ� șǩφǔș� ǟȅȗ� perfectionism, depression, and anxiety (suh et al., 2019). at present, there have been several randomized controlled trials evaluating online programs which have demonstrated great value in reducing the burden created by perfectionism (e.g. egan et al., 2014). however, one potential problem with both faceto-face and online perfectionism interventions is their length lloyd and colleagues’ (2015) meta-analysis of 8 ssi targeting perfectionism 100100 perfectionism interventions reported that the number of treatment sessions ranged from 8 to 14, resembling the typical length of cognitive-behavioral therapy. non-completion rates were high in many of the studǩǔșॹ�λǧǩljǧ�ƺȗǔ�ȗǔмǔljƞǩκǔ�ȅǟ�ƞȗǔƺƞǿǔǿƞ�ƺǐǧǔȗǔǿljǔ�ǿȅȗǿșআ� ȅǿǔ�ǩǿ�йκǔ�ƺǐȣǹƞș�λǩǹǹ�ǐȗȅȓ�ȅȣƞ�ȅǟ�ƞȗǔƺƞǿǔǿƞ�ljǔǟȅȗǔ�ƞǧǔ� recommended dose is complete (olfson et al., 2009). poor retention is even more common among online interventions. for instance, in the study conducted by ^ǧƺǟȗƺǿ� ƺǿǐ� ljȅǹǹǔƺǡȣǔș� শࢸࢲࢱࢳষॹ� ƞǧǔȗǔ� λƺș� șǩǡǿǩйljƺǿƞ� non-engagement and non-completion of modules, with 71% of participants completing fewer than half ƞǧǔ�ǿȅǐȣǹǔș�ƺǿǐ�ȅǿǹρࢵࢲ�ঀࢶઔ�ȓǔȅȓǹǔ�ljȅǿȓǹǔƞǩǿǡ�йκǔ�ȅȗ� more modules. strikingly, even participants who had high rates of non-completion and non-engagement had reduced perfectionism. change in perfectionism was largest at the beginning of the intervention, indicating that potential may lie in briefer, more compact interventions. this is consistent with other research reporting that the number of sessions is often unrelatǔǐ�ƞȅ�ƞǧǔ�ǿƺǡǿǩƞȣǐǔ�ȅǟ�ƞǧƺƞ�ƞȗǔƺƞǿǔǿƞঢ়ș�ǔаǔljƞ�শvǔǩșφ�ǔƞ� al., 2017). rozental and colleagues (2017) and shafran ǔƞ�ƺǹ�শࢸࢲࢱࢳষ�ǿȅƞǩljǔǐ�ƞǧǔșǔ�ǔаǔljƞș�ǩǿ�ƞǧǔǩȗࢹ�েλǔǔƿ�ǹȅǿǡ� online interventions for perfectionism, and they suggested that brief, online interventions may have positive impacts on perfectionism and maximize scalability. one form of brief intervention that has been developed in response to the high likelihood that an individual will access a treatment only once is sinǡǹǔেșǔșșǩȅǿ� ǩǿƞǔȗκǔǿƞǩȅǿș� শ^^2șষঀ� ^^2ș� ƺȗǔ� ǔаǔljƞǩκǔ� ǟȅȗ� adults (campbell, 2012), youths (schleider & weisz, 2017), and college students (samson & tanner-smith, 2015) with diagnosed psychiatric disorders and subclinical issues. ssis have been demonstrated to improve anxiety, depression, problematic drug and alcohol use, and risk factors for mental health problems such as hopelessness, anxiety sensitivity, physiological șƞȗǔșș� șǔǹǟেǧƺƞǔॹ� ȓǔȗljǔǩκǔǐ� ljȅǿƞȗȅǹॹ� йπǔǐ�ǿǩǿǐșǔƞॹ� ƺǿǐ� agency (tanner-smith et al., 2015; schleider, dobias, sung, mumper, & mullarkey, 2020; schleider, dobias, sung, & mullarkey, 2020). gains are often maintained at follow-up, and participants typically rate single-session interventions as likable, acceptable, and useful (duan & bu, 2017; wasil et al., 2021; samson & tanner-smith et al., 2015; schleider & weisz, 2017). these interventions are particularly useful when delivered in an online, self-guided format because they can be made widely accessible, reducing the barriers to mental health care (schleider et al, 2020a). although short-term therapies have been shown to reduce perfectionistic tendencies and related problems ƺǿǐ�ƺȗǔ�ljȅǿȓƺȗƺljǹǔ�ǩǿ�ǔаǔljƞ�șǩφǔș�শ�ȅǐǐ�ǔƞ�ƺǹঀॹࢺࢲࢱࢳ�আ� lloyd et al., 2014; fairweather-schmidt & wade, 2015), only one study has examined a single-session perfectionism intervention (lasota, ross, & kearney, 2017), which lasted for several hours in-person and focused on psychoeducation, setting high standards, fear over mistakes, and reducing stress. to-date, no brief online perfectionism interventions have been ƞǔșƞǔǐঀ�(ǩκǔǿ�ƞǧƺƞ�ȅǿǹǩǿǔ�^^2ș�ƺȗǔ�ǔаǔljƞǩκǔ�ǩǿ�ȗǔǐȣljǩǿǡ� mental health concerns (schleider & weisz, 2018b), ƺǿǐ�ȅƞǧǔȗ� ƞρȓǔș�ȅǟ�ljȗǩǔǟ� ǩǿƞǔȗκǔǿƞǩȅǿș�ƺȗǔ�ǔаǔljƞǩκǔ� ǩǿ� reducing perfectionism (e.g. dodd et al., 2019; fairweather-schmidt & wade, 2015), an online ssi aiming to decrease perfectionism might be particularly useful. the brevity and accessibility of such an intervention may amplify its potential impact, decreasing costs, time, and other problems associated with receiving a normal length and/or in-person intervention. � �ȅǹǹǔǡǔ�șƞȣǐǔǿƞș�ǿƺρ�ljǔ�ƺ�ǡȅȅǐ�йƞ�ǟȅȗ�ƺ�șǩǿǡǹǔেșǔșsion intervention targeting perfectionism, considering that many students have problems with perfectionism, anxiety, and depression (lasota et al., 2017), and mental health issues appear to be on the rise in college students (curran & hill, 2017). perfectionism may be an etiological and maintenance factor of these mental health problems in college student populations for two primary reasons. first, work and studies are the two top domains of life in which people report being the most perfectionistic (stoeber & stoeber, 2009). living in an academic environment could potentially lead to the exacerbation of perfectionistic tendencies. second, college students are constantly evaluated based on their work and social skills and must meet certain self-presentation and performance-based standards (klibert et al., 2014), which may contribute to the stress surrounding academic performance and the pressure to succeed that college students often report as a top stressor (bedewey & gabriel, 2015). an enκǩȗȅǿǿǔǿƞ� йǹǹǔǐ� λǩƞǧ� ǔπljǔșșǩκǔ� șƞȣǐρǩǿǡॹ� ƺljƺǐǔǿǩlj� ȓȗǔșșȣȗǔॹ� ƺǿǐ� șƞȗǔșș� λȅȣǹǐ� ȣǿǐȅȣljƞǔǐǹρ� ǩǿмȣǔǿljǔ� perfectionism and may have particular relevance to highly competitive colleges that maintain a culture of perfectionism. of relevance, molnar and colleagues (2020) found that 14% of college students have extremely elevated levels of perfectionism, while other ward, wheation 101 ssi targeting perfectionism studies have found that two thirds can be categorized as perfectionists, with a quarter of those individuals meeting criteria for maladaptive perfectionism (grzegorek et al., 2004). these rates have increased over the past decade, concurrent with rates of other mental health problems (curran & hill, 2017). the increasing rates of perfectionism in college students may be contributing to the increase in mental illness among college populations, treatment-seeking behaviors, and other stressors (pacewicz, gotwals, and blanton, 2018). considering this information, there is an urgent need for brief, online interventions that reduce perfectionism and protect against the development of anxiety and depression among college students (klibert et al., 2014). targeting perfectionism in an online single-session intervention might help reduce the burden placed on college counseling centers, reduce distress among students, and prevent future dysfunction. although traditional perfectionism programs are ǔаǔljƞǩκǔ�ǟȅȗ�κƺȗǩȅȣș�ljǹǩǿǩljƺǹ�ƺǿǐ�ǿȅǿljǹǩǿǩljƺǹ�ljȅǿljǔȗǿșॹ� no research to date has assessed the impact of a brief, online perfectionism program in a college population. the present study the present study extends prior research by conǐȣljƞǩǿǡ� ƞǧǔ� йȗșƞ� ȗƺǿǐȅǿǩφǔǐ� ljȅǿƞȗȅǹǹǔǐ� ƞȗǩƺǹ� ȅǿ� ƺ� self-administered, online ssi designed to reduce perfectionism in a college student population. to assess ƞǧǔ�ǔаǔljƞǩκǔǿǔșș�ȅǟ�ƞǧǔ�ȓȗȅǡȗƺǿॹ�λǧǩljǧ�ǩș�ljƺșǔǐ�ȅǿ�ȓșρchoeducation, cognitive restructuring, and self-compassion, a randomized controlled trial was conducted comparing the program with a stress-management control. it was hypothesized that the online single session intervention will decrease perfectionism in college șƞȣǐǔǿƞșॹ�λǩƞǧ�șǔljȅǿǐƺȗρ�ǔаǔljƞș�ȅǿ�ǐǔȓȗǔșșǩȅǿॹ�ƺǿπǩǔƞρॹ� and stress. participants were also asked to rate the intervention’s acceptability and utility and we hypothesized it would be rated as acceptable, likable, and useful. methods participants participants were undergraduate liberal arts college students who were enrolled in introductory psychology courses. participants were recruited via an online platform (i.e. sona) that allows students to sign up for studies in order to gain research credits. in total, 91 students participated in the present study; however, йκǔ�ȓƺȗƞǩljǩȓƺǿƞș�λǔȗǔ�ȗǔǿȅκǔǐ�ǟȅȗ�ǟƺǩǹǩǿǡ�ljȅƞǧ�ƺƞƞǔǿtion checks in each assessment or—admitting they did ǿȅƞ�λƺƞljǧ�ƞǧǔ�κǩǐǔȅș�ȅȗ�ǡǩκǔ�ƞǧǔǩȗ�ljǔșƞ�ǔаȅȗƞ�ǩǿ�ljȅǿpleting the perfectionism intervention, leaving a total of 86 participants with usable pre-and post-data. additionally, only 79 participants completed and passed the follow-up assessment. participants were randomized to either the perfectionism (n=45) or control intervention (n=41). in total, participants were 89.5% female ƺǿǐࢵ�ঀࢸઔ�ȅƞǧǔȗॹࢱࢹ�ઔ�λǔȗǔ�ǩǿ�ƞǧǔǩȗ�йȗșƞ�ƺǿǐ�șǔljȅǿǐ�ρǔƺȗ� of college, 37.2% non-hispanic white, 5.8% african �ǿǔȗǩljƺǿॹ� �ઔࢳঀࢸࢴ �șǩƺǿইxƺljǩйlj� 2șǹƺǿǐǔȗॹ� ƺǿǐ� �ઔࢹঀࢺࢲ other or hispanic. as displayed in table 1, the two ǡȗȅȣȓș� ǐǩǐ� ǿȅƞ� ǐǩаǔȗ� ȅǿ� ƺǿρ� ǐǔǿȅǡȗƺȓǧǩlj� κƺȗǩƺljǹǔșঀ materials � �ρșǟȣǿljƞǩȅǿƺǹ� �ƞƞǩƞȣǐǔș� ^ljƺǹǔেxǔȗǟǔljƞǩȅǿে ism (das-pa; weissman & beck, 1978). the das was originally developed to study depression and has several subscales, including perfectionism, which λƺș� ǩǐǔǿƞǩйǔǐ� ƺș� ƺ� șȣljșljƺǹǔ� ljρ� �ǔljƿ� ƺǿǐ� ljȅǹǹǔƺǡȣǔș� (1991). the subscale measures perfectionistic attitudes and has excellent internal consistency. scores on the subscale are predictive of later depression and anxiety (jacobs et al., 2009). the likert scale is a continuum from 0 (fully disagree) to 6 (fully agree). big three perfectionism scale (btps; smith, saklofske, stoeber, & sherry, 2016). the btps evaluates three higher-order factors (rigid perfectionism, self-critical perfectionism, and narcissistic perfectionism) through 10 lower-order perfectionism facets (self-oriented perfectionism, self-worth contingencies, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, other-oriented perfectionism, hypercriticism, grandiosity, entitlement). this scale was selected over older, more traditional perfectionism measures (mps and fmps) due to accessibility and its assessment of the perfectionistic attitudes targeted more directly in the intervention. other-oriented perfectionism, socially prescribed perfectionism, and parental standards, which are assessed in other common measures of perfectionism, are not addressed in the intervention. although the btps is new, it has strong psychometric properties (smith et al., 2016). participants respond on a likert scale from 0 (disagree strongly) to 4 (agree strongly). �ǔȓȗǔșșǩȅǿॹ� �ǿπǩǔƞρ� ƺǿǐ� ^ƞȗǔșș� ^ljƺǹǔșেࢲࢳ� (dass-21; lovibond & lovibond, 1995). the dass21 is a 21-item self-report questionnaire consisting of 102 ward, wheation three subscales: depression, anxiety and stress. ratings are provided using likert scales ranging from 0 (“did not apply to me at all”) to 3 (``applied to me very much or most of the time”). the instructions on the dass-21 were aligned with the timeline of the study; participants were asked to rate their symptoms ‘in the past week.’ the subscales and total score have good reliability and construct validity in both clinical and nonclinical samples (antony, bieling, cox, enns, & swinson, 1998; henry & crawford, 2005). dass-21 scores are highly correlated with other measures of depression and anxiety (osman et al., 2012) and perfectionism (aldahadha, 2018). additional questions about perfectionism and the intervention. to assess the intervention’s ability to alter metacognitive self-appraisals about perfectionism, the following three questions were asked at baseline: “do you consider yourself to be a perfectionist?,” “does perfectionism get in the way of your happiness,” and “does perfectionism slow progress toward your goals?” participants also completed several questions about the acceptability, likability, and perceived helpfulness of the intervention, which were partially derived from the program feedback scale (pfs), a valid and reliable measure used to assess acceptability and perceptions of internet based ssis (sung, mumper, & schleider, 2021). they were asked, “how much did you like the intervention?,” “how much do you feel like the intervention helped you understand perfectionism?,” and “how helpful do you think the intervention was in teaching you to combat your perfectionism?” in addition, perceived changes in perfectionism were assessed at 1-week follow-up with the question: “do you think that completing the program helped you with your perfectionism in the past week?” procedure approval for this study was received from the institutional review board (irb) at barnard college. upon signing up for the study, participants were directed to a qualtrics form, where they completed a consent form and agreed to study duties. study duties required ƞǧǔ� ȓƺȗƞǩljǩȓƺǿƞ� ƞȅ� йǹǹ� ȅȣƞ� ȓȗǔॹ� ȓȅșƞॹ� ƺǿǐ� �েλǔǔƿࢲ ǟȅǹlow-up measures, in addition to actively engaging with the intervention. after providing consent, participants responded to a series of demographic questions and measures assessing perfectionism, depression, anxiety, and stress. immediately following the completion of the measures, participants were randomly assigned to either the experimental or stress-management control condition through the qualtrics randomizer element. the experimental intervention took approximately 40 minutes and required participants to maintain active participation through video and open-ended responding, while the stress-management condition lasted for a similar amount of time and consisted of a video and articles about stress. attention checks were included to ensure participants were paying attention, along with a direct question following the intervention which asks participants if they did their best. following the completion of the intervention, participants ǩǿǿǔǐǩƺƞǔǹρ�йǹǹǔǐ�ȅȣƞ�ƞǧǔ�ǿǔƺșȣȗǔș�ǟȅȗ�ƺ�șǔljȅǿǐ�ƞǩǿǔॹ� except for the depression, anxiety, and stress scales. participants had access to the follow-up assessment ��ǧȅȣȗș�শșǔκǔǿ�ǐƺρșষ�ƺǟƞǔȗ�ƞǧǔρ�ljȅǿȓǹǔƞǔǐ�ƞǧǔǩȗ�йȗșƞࢹࢷࢲ assessment and received a reminder email to take the assessment. if they did not take the assessment within 24 hours of receiving the email, they were sent additional reminders. the follow-up assessment consisted of questions about perceived changes in perfectionism in addition to the same measures used at baseline. participants were debriefed at the end of the study. statistical analyses were conducted in spss. indepenǐǔǿƞ�șƺǿȓǹǔș�ƞেƞǔșƞș�λǔȗǔ�ȗȣǿ�ƞȅ�ƺșșǔșș�ǟȅȗ�ǐǩаǔȗǔǿljǔș� between groups at baseline and a series of repeated measures, anovas, were utilized to examine the effect of the perfectionism intervention compared to the stress-management control on the various outcome measures. descriptive statistics on the likability and acceptability of the intervention were also analyzed. perfectionism intervention: the intervention was based on a treatment guide for clinical perfectionism (egan et al., 2016), which has been used to develop prior perfectionism interventions (e.g. rozental et al., 2017; shafran et al., 2017). the intervention was delivered through qualtrics and consists of colorful text, images, and video clips. participants can easily follow the intervention by clicking the arrows to the next page when they appear and writing in the text boxes ȓȗȅκǩǐǔǐঀ�eȅȗǔ�șȓǔljǩйljƺǹǹρॹ�ƞǧǔ�ǩǿƞǔȗκǔǿƞǩȅǿ�ǩǿljǹȣǐǔǐ� 4 major modules that take around 40 minutes total to complete and last for approximately 10 minutes each: 1) psychoeducation about perfectionism and its negative consequences, 2) cognitive restructuring of self-critical perfectionistic thoughts, 3) self-compassion techniques, and 4) generalization and mainte103 ssi targeting perfectionism nance of information learned in the intervention. psychoeducation and consequences of perে fectionism: given that perfectionism is considered ego-syntonic and perfectionists believe their high standards improve their functioning, it is important educate participants about the counterproductive nature ƺǿǐ� ǿǔǡƺƞǩκǔ� ǔаǔljƞș� ȅǟ� ȓǔȗǟǔljƞǩȅǿǩșǿ� শkκǔȗǧȅǹșǔȗ� ૭� dimaggio, 2020). by increasing awareness about the problems associated with perfectionism, clients may feel more motivated (yeh et al., 2017) and be able to more easily change the thoughts and behaviors contributing to these outcomes (kutlesa & arthur, 2008). eǧǔȗǔǟȅȗǔॹ�ƞǧǔ�ȓȗȅǡȗƺǿ�ǐǔйǿǔș�ȓǔȗǟǔljƞǩȅǿǩșǿ�ƺǿǐ�ǐǩșljȣșșǔș�ǩƞș�ljȅǿșǔȕȣǔǿljǔș�ǩǿ�ƞǧǔ�ǟȅȗǿ�ȅǟ�ƞǔǹǹǩǿǡ�йljƞǩȅǿƺǹ� stories about characters who are perfectionists. after learning what perfectionism is, participants learn the various ways perfectionism can manifest in life and its multidimensional nature. throughout the psychoeducation module, they apply this information to their own lives. cognitive restructuring and automatic thoughts. cognitive-behavioral therapy can reduce the tendency for unconstructive automatic thoughts about the self (overholser & dimaggio, 2020). interventions can help perfectionists become aware of, challenge, and change their automatic self-critical thought processes (besser et al., 2004; overholser & dimaggio, 2020). therefore, this section of the intervention explains how to combat the self-critical thoughts related to perfectionism through utilizing the three-step process (catch, challenge, and change) of cbt. challenging and changing is explained in the context of self-compassion. the primary way participants are instructed to challenge their thoughts is by thinking about what a loving friend would say about their thoughts. participants will practice catching, challenging, and changing self-critical thoughts that both ƺ� йljƞǩȅǿƺǹ� ljǧƺȗƺljƞǔȗ� ƺǿǐ� ƞǧǔρ� ƞǧǔǿșǔǹκǔș� ǔπȓǔȗǩǔǿljǔঀ ^ǔǹǟে�ȅǿȓƺșșǩȅǿॸ� because low self-compassion is often characteristic of perfectionism (brown, 2008), and interventions rooted in self-compassion ƺȗǔ� ǔаǔljƞǩκǔ� ǩǿ� ȗǔǐȣljǩǿǡ� ȓǔȗǟǔljƞǩȅǿǩșǿ� শfƺǐǔƺȣॹ� 2020), participants will be taught how to be more compassionate, forgiving, and kind to themselves. self-compassion principles (raes et al., 2011) are fused throughout the cbt section (e.g., mindfulǿǔșș�κǔȗșȣș�ȅκǔȗেǩǐǔǿƞǩйljƺƞǩȅǿষ�ƺǿǐ�ƺȗǔ�ƺǹșȅ�ǔπȓǹƺǩǿǔǐ� in the self-compassion module. self-kindness over self-judgement is taught by explaining the tendency to focus on mistakes in perfectionism, the imȓȅȗƞƺǿljǔ� ȅǟ� ǟȅȗǡǩκǔǿǔșșॹ� ƺǿǐ� ƺгȗǿƺƞǩȅǿ� ǔπǔȗljǩșǔșঀ� next, common humanity versus isolation is taught through a discussion and exercise on how everybody ǿƺƿǔș�ǿǩșƞƺƿǔș�ƺǿǐ�ǿȅ�ȅǿǔ�ǩș�ƺǹȅǿǔ�ǩǿ�ƞǧǔǩȗ�șȣаǔȗǩǿǡঀ concluding components: the intervention ends by discussing how reducing perfectionism can improve one’s life. neurogenesis is explained to show that change is possible, although change requires commitment. participants are encouraged to apply the cognitive distortion and self-compassion practices to everyday life. stress management program: the stress-management program was designed as an active control, for comparison with the perfectionism intervention, and did not contain any perfectionism components. �ǹƞǧȅȣǡǧ� ǐǩаǔȗǔǿƞ� ǩǿ� șƞȗȣljƞȣȗǔॹ� ƞǧǔ� ljȅȣȗșǔ� ljȅǿƞǔǿƞ� was similar to stress management conditions used in prior studies (hoge et al., 2013). like the perfectionism intervention, the stress-management program lasted for around 40 minutes and was delivered through qualtrics. participants were instructed to watch a κǩǐǔȅ�ƺǿǐ�ȗǔƺǐ�ǔπljǔȗȓƞș�ǐǔșljȗǩljǩǿǡ�ƞǧǔ�ǔаǔljƞș�ȅǟ�șƞȗǔșș� and the various ways to manage stress.. the content ǩǿljǹȣǐǔǐ�ǐǔƞƺǩǹș� ƺljȅȣƞ�ǧȅλ� ljǧȗȅǿǩlj� șƞȗǔșș� ƺаǔljƞș� ƞǧǔ� mind, body, and performance, and explored ways to reduce stress, including exercise, nutrition, mindfulness, positive experiences, time management, and sleep. results baseline scores and group comparisons table 1 shows the demographic characteristics for each group and the group mean scores of each of the outcome measures. according to independent șƺǿȓǹǔș� ƞেƞǔșƞșॹ� ƞǧǔȗǔ� λǔȗǔ� ǿȅ� șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔș� between the groups on any demographic or clinical variables at baseline. scores on the big three perfectionism scale and the dysfunctional attitudes perfectionism scale were elevated in both groups (m=55.7 on the das-pa; see table 1) compared to previously studied populations, including a clinically depressed adolescent sample (m=53.7 on the das-pa; jacobs et al., 2009). total scores on the dass-21 indicated mild to moderate levels of depression, anxiety, and stress (lovibond & lovibond, 1995) (see table 1). the majority of the sample (95.3%) considered themselves to be a perfectionist to some degree, to a considerable degree, or very much, while 74.7% ac104 ward, wheation knowledged that perfectionism sometimes gets in the way of their happiness, and 72.9% said that perfectionism sometimes slows progress towards goals. intervention acceptability and likability participants reported liking the intervention; 22.2% liked it “a little bit,” 42.2% liked it “somewhat.” and 35.6% liked it “very much,” while no one reported disliking the intervention. participants also indicated that the intervention was helpful in increasing their understanding of perfectionism; in terms of how helpful it was, 2.2% said “not at all,” 6.7% said “a little bit,” 42.2% reported “somewhat,” and 48.9% selected “very.” perceived helpfulness in teaching participants to combat their perfectionism was also assessed, with 4.4% of participants saying it was not at all helpful, 8.9% saying it was a little bit helpful, 60% saying it was somewhat helpful, and 26.7% saying it was very helpful. at the 1-week follow-up, participants were asked, “do you think that completing the program helped you with your perfectionism in the past week?” and 18.2% said “not at all,” 25% selected “very little,” 52.3% said “somewhat,” and 4.5% said “very much.” when asked “how much did you try to implement the techniques learned into your ǐƺǩǹρ�ǹǩǟǔঁॹ৛�ǿȅșƞ�ȓǔȅȓǹǔ�ȗǔȓȅȗƞǔǐ�ȓȣƞƞǩǿǡ�șȅǿǔ�ǔаȅȗƞ� in; 6.8% said “not at all,” 22.7% selected “very little,” 65.9% said “somewhat,” and 4.5% said “very much.” twenty-two participants left open-ended feedback, and 19 of these comments were positive and emphasized the utility or likable features of the intervention. change in outcome measures repeated measures anovas were utilized to test the hypothesis that the perfectionism intervention would reduce perfectionistic attitudes and depression, anxiety, and stress more than the stress-manageǿǔǿƞ� ljȅǿƞȗȅǹঀ� �ǩаǔȗǔǿljǔș� λǔȗǔ� ƺșșǔșșǔǐ� ƺƞ� ljƺșǔǹǩǿǔॹ� immediate post-test, and 1-week follow-up, except for dass-21, which was only assessed at baseline and �েλǔǔƿࢲ ǟȅǹǹȅλেȣȓঀ�eǧǔ�йȗșƞ��fkt��λƺș� ljȅǿǐȣljƞǔǐ� on the dysfunctional attitudes perfectionism subscale, which violated mauchly’s test of sphericity x2 (2)=25.924, p<.05, thus the degrees of freedom was adjusted for by reporting the greenhouse-geissǔȗ�ȗǔșȣǹƞșঀ�eǧǔ�ǔаǔljƞ�ȅǟ�ƞǩǿǔ�λƺș�șǩǡǿǩйljƺǿƞ�শ'�শࢲঀࢵࢶॹ� 115.782) = 6.145, p<.05, n2= .076); however, the ƞǩǿǔॴljȅǿǐǩƞǩȅǿ� ǩǿƞǔȗƺljƞǩȅǿ� ǔаǔljƞ� λƺș� ǿȅƞ� শ'ॹ� �ॹࢵࢶঀࢲ 115.782) = 1.935, p>.05, n2=.025) (see figure 1). similarly, mauchly’s test of sphericity indicated that the assumption of sphericity was violated for the changes in the big three perfectionism scale (x2 (2)=38.864, p<.05. after using the greenhouse-geiser ljȅȗȗǔljƞǩȅǿॹ�ƞǧǔ�ǔаǔljƞ�λƺș�șǩǡǿǩйljƺǿƞ�ǟȅȗ�ƞǩǿǔ�'শࢲঀࢸࢳࢴॹ� 74.335)=4.685, p<.05, n2=.077, but not for time*condition f(1.327, 74.335)=.072, p>.05, n2=.001) (see figure 2). finally a repeated measures anova of dass total scores at baseline and at the 1-week folǹȅλেȣȓ� ȗǔκǔƺǹǔǐ� ƞǧƺƞ� ƞǧǔȗǔ�λǔȗǔ� șǩǡǿǩйljƺǿƞ�ǐǩаǔȗǔǿljes for time (f (1, 74) =185.872, p<.05, n2=.715), ljȣƞ� ǿȅ� ǔаǔljƞ� ǟȅȗ� ljȅǿǐǩƞǩȅǿ� শ'� শࢲॹࢵࢸষ઀ࢹࢹࢲঀࢴࢵࢺॹ� p>.05, n2=.011). subscale scores were not analyzed ǐȣǔ� ƞȅ� ƞǧǔ� ǹƺljƿ� ȅǟ� șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔș� ǟȅȣǿǐ� ǟȅȗ� time and time*condition on the dass total scores. discussion the present study sought to examine the effectiveness of a single-session intervention in improving perfectionism and associated mental health characteristics in a college-student population. although symptoms improved for all clinical measures following the perfectionism intervention, they similarly improved in the control conǐǩƞǩȅǿঀ� eǧǔșǔ� йǿǐǩǿǡș� ƺȗǔ� ǐǩșljȣșșǔǐ� ǩǿ� ǐǔƞƺǩǹ� ljǔǹȅλঀ��� there are several potential reasons for the lack ȅǟ� șǩǡǿǩйljƺǿƞ� ǐǩаǔȗǔǿljǔș� ljǔƞλǔǔǿ� ƞǧǔ� ǩǿƞǔȗκǔǿƞǩȅǿ� and control conditions in the study. small sample șǩφǔ�ǿƺρ� ǧƺκǔ� ljȅǿƞȗǩljȣƞǔǐ� ƞȅ� ƞǧǔ� ǿȣǹǹ� йǿǐǩǿǡșঀ� eǧǔ� decreases were fairly large for some measures, yet staƞǩșƞǩljƺǹ�șǩǡǿǩйljƺǿljǔ�λƺș�ǿȅƞ�ƺljǧǩǔκǔǐঀ�'ȅȗ�ǩǿșƞƺǿljǔॹ�ƞǧǔ� mean score dropped from 55.31 at baseline to 48.01 at 1-week follow-up on the dysfunctional attitudes perfectionism scale in the experimental group, which is almost a seven-point decrease and a decline of three points greater than the stress-management control. a post-hoc sensitivity analysis with the study’s sample size (n=79) suggested we had adequate power (.80) to ǐǔƞǔljƞ�ƺǿ�ǔаǔljƞ� șǩφǔ�ȅǟ� ঀࢱࢲ�ȅȗ� ǹƺȗǡǔȗॹ�λǧǩljǧ� ǩș� șǹǩǡǧƞǹρ� ǹƺȗǡǔȗ�ƞǧƺǿ�ƺ�ǿǔǐǩȣǿ�ǔаǔljƞ�শȓƺȗƞǩƺǹ�ǔƞƺ�șȕȣƺȗǔǐ�઀�ঀࢺষঀ� therefore, our sample size was likely underpowered ǩǟ� ƞǧǔ� ǩǿƞǔȗκǔǿƞǩȅǿ�ǧƺǐ�ƺ� șǿƺǹǹ� ƞȅ�ǿǔǐǩȣǿ�ǔаǔljƞঀ��ǹthough traditional 8-week perfectionism interventions ǧƺκǔ�ǿǔǐǩȣǿ�ƞȅ� ǹƺȗǡǔ�ǔаǔljƞ�șǩφǔșॹ� ƞǧǔ�ǔπƞȗǔǿǔǹρ�ljȗǩǔǟ� ǿƺƞȣȗǔ�ȅǟ�ƞǧǔ�ǩǿƞǔȗκǔǿƞǩȅǿ�ǿƺƿǔș�ƺ�ǹƺȗǡǔȗ�ǔаǔljƞ�șǩφǔ�ǹǔșș� probable. additionally, although there were 79 participants who passed attention checks and submitted each assessment, many participants skipped questions. this led to fewer participants’ scores being analyzed in each 105 ssi targeting perfectionism anova; for example, only 58 participants’ scores were analyzed for the repeated measures anova for the btps. the majority of randomized controlled trials conducted on online single-session interventions have included hundreds of participants (e.g., schleider & weisz, 2017), and the in-person ssi conducted on perfectionism included 105 participants in their data analysis with no control group (lasota et al., 2017). future work with larger samples is needed to further compare these conditions. in addition, it is possible that the single dose of perfectionism intervention was ǿȅƞ� șȣгljǩǔǿƞ� ƞȅ� ǐǔǿȅǿșƞȗƺƞǔ� șȣȓǔȗǩȅȗǩƞρ� ȅκǔȗ� șƞȗǔșș� management. most trials conducted on treatments for perfectionism have ranged from 8-16 sessions in length (lasota et al., 2017), thus more practice and intervention time may be necessary to create score decreases greater than what the stress-management control produced. relatedly, although one-week follow-ups have been used in studies of single session interventions in the past (e.g., davidson, malloch, & humphris, 2018; duan & bu, 2019), a longer follow-up after the intervention would have provided participants with more time to implement practices they learned in their lives and utilize strategies more frequently. therefore, future studies could include 3-, 6-, or 12-month follow-ups and also explore whether repeated sessions and practice post-treatment contribute to reductions in perfectionism symptoms. although there is nothing in the student timeline or a widespread stressful event that would have accounted for a decline in perfectionism, depression, anxiety, and stress from baseline to one-week follow-up, including follow-up assessments at various time points in future research would allow for a more comprehensive understanding of changes in perfectionism over time. it is also plausible that the stress-management control condition represented an active intervention, suggesting that it was not necessarily an appropriate placebo control, but may provide information about ƞǧǔ�ȗǔȕȣǩȗǔǐ�șȓǔljǩйljǩƞρ�ȅǟ�ȓǔȗǟǔljƞǩȅǿǩșǿ�ǩǿƞǔȗκǔǿƞǩȅǿșঀ� perfectionistic behavior is thought to be associated with psychopathology, in part due to its association with stress.. perfectionists have higher levels of stress exposure and stress reactivity (i.e.i.e., maladaptive ways of reacting to stressors), and they may generate or exacerbate stress for themselves by engaging in self-critical thinking in response to daily stressors and failing to reach high standards. if stressful events are reduced, it is likely that perfectionistic behavior and automatic perfectionistic thoughts will subsequently decrease, and when perfectionistic attitudes decrease, stress levels will fall, indicating a bidirectional relationship (hewitt & flett, 2002). the results of the present study are similar to a study that had compared faceto-face cbt for perfectionism to a stress-management ljȅǿǐǩƞǩȅǿআ� ƞǧǩș� șƞȣǐρ� ǩǿκǔșƞǩǡƺƞǔǐ� ƞǧǔ� ǔаǔljƞǩκǔǿǔșș�ȅǟ� an online 10-week cbt intervention for perfectionǩșǿ� ǩǿ� йȗșƞেρǔƺȗ� ȓșρljǧȅǹȅǡρ� șƞȣǐǔǿƞș� ƺǿǐ� ȗƺǿǐȅǿǹρ� assigned participants to either stress management, stress-management + cbt, or a control condition (arpin-cribbie et al., 2008). the techniques taught in their stress-management condition overlapped with some of the techniques presented in the stress-management control of the current intervention. in line with our results, participants in the stress-management ljȅǿǐǩƞǩȅǿ� ǧƺǐ� șǩǡǿǩйljƺǿƞ� ǐǔljȗǔƺșǔș� ǩǿ� șǔǹǟেȅȗǩǔǿƞǔǐ� perfectionism and concern over mistakes, although the perfectionism intervention and stress-management combined led to greater decreases in the perfectionism construct. the results from arpin-cribbie (2008) and the present study may indicate that stress management represents an active treatment for perfectionism and works well in combination with more targeted content. thus, future research should further explore the complex relationship between perfectionism and stress, compare perfectionism interventions to other types of active controls, and work to elucidate the imȓȅȗƞƺǿljǔ�ȅǟ�șȓǔljǩйljǩƞρ�ǩǿ�ȓǔȗǟǔljƞǩȅǿǩșǿ�ǩǿƞǔȗκǔǿƞǩȅǿșঀ � eǧǔ�ǩǿƞǔȗκǔǿƞǩȅǿ�șǧȅȣǹǐ�ƺǹșȅ�ljǔ�ƞǔșƞǔǐ�ǩǿ�ǐǩаǔȗǔǿƞ� populations; one of the main limitations to the study is that the perfectionism intervention was designed for high levels of maladaptive perfectionism, yet it was tested in a typical nonclinical college-student population. although participants had higher than average levels of perfectionism, prior research indicates that perfectionism interventions, including single-session ǩǿƞǔȗκǔǿƞǩȅǿș�ǿƺρ�ǿȅƞ�ljǔ�ǔаǔljƞǩκǔ�ǟȅȗ�ƞǧȅșǔ�λǩƞǧ�ǹȅλ� perfectionism. lasota and colleagues (2017) focused on psychoeducation, setting high standards, fear over mistakes, and reducing stress in their in-person single-session intervention, dividing participants into high, medium, and low perfectionists. they found that participants with low perfectionism showed ǿȅ� șǩǡǿǩйljƺǿƞ� ljǧƺǿǡǔ�ȅκǔȗ� ƞǩǿǔॹ�λǧǩǹǔ� ƞǧǔ�ȅƞǧǔȗ� ƞλȅ� groups did. many perfectionism treatment studies have also utilized clinical samples (e.g., eating disorder 106 ward, wheation or depressed populations) with high levels of maladaptive perfectionism (e.g., kearns, forbes, & gardiner, 2007). additionally, most single-session interventions have been tested in adolescents (schleider et al., 2020) and previous experience with psychoeducation about perfectionism or cbt for perfectionism could ȓȅƞǔǿƞǩƺǹǹρ� ǹǩǿǩƞ� ǩƞș� ǔаǔljƞǩκǔǿǔșșঀ�eǧǩș�λƺș�ǧǩǡǧǹǩǡǧƞed by one participant who wrote, “the intervention was likely not a good match for me as i have undergone cbt in the past for anxiety and perfectionism and already knew a lot of these techniques;” thus, those who have not undergone therapy in the past are younger and more capable of change—potentially making themselves better candidates. in addition to age, other demographic factors, such as gender, may interact with perfectionism (gnilka & novakovic, 2017) and impact treatment response. considering that the present sample was almost 90% female and previous literature on perfectionism consists of majority female participants (stoeber & stoeber, 2009), future research could aim to recruit more males to ljǔƞƞǔȗ�ǔǹȣljǩǐƺƞǔ�ƞǧǔ�ǩǿȓƺljƞ�ȅǟ�ǡǔǿǐǔȗ�ȅǿ�ǔаǔljƞǩκǔǿǔșș� of perfectionism treatments. further research with larger sample sizes, especially research that includes populations with clinical perfectionism, is warranted. despite the study’s limitations, many particiȓƺǿƞș�ƺȓȓǔƺȗ�ƞȅ�ǧƺκǔ�ljǔǿǔйƞǔǐ�ǟȗȅǿ�ƞǧǔ�ǩǿƞǔȗκǔǿƞǩȅǿॹ� as respondents reported that the intervention was highly acceptable, engaging, and useful. all participants reported liking the intervention “at least a little bit” and 86.7% of participants thought the program was somewhat or very helpful. additionally, 57% of students thought it was somewhat or very helpful in combating their perfectionism in the week following the intervention and 93% of respondents attempted to implement the learned skills into their daily lives. to ljȅǿljǹȣǐǔॹ� ƞǧǩș� șƞȣǐρ� ǩș� ƞǧǔ�йȗșƞ� ƞȅ� ǔπƺǿǩǿǔ� ƞǧǔ� ǔаǔljtiveness of an online single-session intervention in reducing perfectionism, depression, anxiety, and stress. although prior literature was utilized to formulate hypotheses that the perfectionism intervention would ljǔ�ǿȅȗǔ� ǔаǔljƞǩκǔ� ƞǧƺǿ� ƺ� șƞȗǔșșেǿƺǿƺǡǔǿǔǿƞ� ljȅǿƞȗȅǹॹ� ƞǧǔ� ȗǔșȣǹƞș� ȅǿǹρ� ȗǔκǔƺǹǔǐ� ƺ� șǩǡǿǩйljƺǿƞ� ǔаǔljƞ� ǟȅȗ� ƞǩǿǔঀ� eǧǔ� șƞȣǐρ�λƺș� ǹǩƿǔǹρ� ȣǿǐǔȗȓȅλǔȗǔǐ� ƞȅ� ǐǔƞǔljƞ� ǐǩаǔȗences between conditions, had limitations in that the sample contained many individuals with low perfectionism, and the stress-management condition was ȓǔȗǧƺȓș� ǔаǔljƞǩκǔ� ƺƞ� ȗǔǐȣljǩǿǡ� șƞȗǔșșॹ� ƞǧȣș� ǩǿǐǩȗǔljƞǹρ� impacting perfectionism. future research with larger sample sizes, various types of control groups, and clinical populations is needed to more extensively ƞǔșƞ� ƞǧǔ�ǔаǔljƞș�ȅǟ� ƞǧǔ� ǩǿƞǔȗκǔǿƞǩȅǿঀ�fǔκǔȗƞǧǔǹǔșșॹ� ƞǧǩș� șƞȣǐρ�ƺǐǐș�ǩǿȓȅȗƞƺǿƞ�ǩǿǟȅȗǿƺƞǩȅǿ�ƺljȅȣƞ�ƞǧǔ�ǔаǔljƞǩκǔness of a perfectionism 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(2016). conducting psychopathology prevention research in the rdoc era. clinical psychology: science and practice, 23(1), 94-104. doi: 10.1111/cpsp.12144 112 ward, wheation 113 ssi targeting perfectionism 99 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university autism spectrum disorder and face identity recognition deficit across ages autism spectrum disorder, or asd, is a neurodevelopmental disorder with symptoms such as difficulties in social communication and social interaction, and restricted patterns in behaviors, interests, and activities (apa, 2022). according to the centers for disease control and prevention, around one in 44 children has a diagnosis of asd, and the prevalence has been continuously increasing (cdc, 2022). when the concept of autism was first brought up in 1908 by swiss psychiatrist eugen bleuler, it was considered a cognition and behavior style that occurs in patients with schizophrenia (evans, 2013), and was recognized as childhood-type schizophrenia in the second version of diagnostic and statistical manual of mental disorders, dsm-ii (kendhari et al., 2016). in dsm-iii, published in 1980, autism was officially recognized and introduced as an isolated disorder of pervasive developmental disorders. the diagnostic criteria were further specified in the later revised version of dsm-iii, dsmiii-r (volkmar et al., 1988). in 1994, the fourth version of dsm specified autism as autistic disorder, asperger’s disorder, and pervasive developmental disorder, not otherwise specified (pdd-nos), which were then all classified as autism spectrum disorders, asd, in the current version of dsm (harker & stone, 2014). although diagnostic labels and criteria change drastically for asd, the core deficit presented in the disorder remains the same. impaired social cognition, debilitated communication skills, and ritualized behavior patterns are core deficits commonly occurring in asd (faras et al., 2010). these deficits are included in the diagnostic manual for asd, for their potentially discriminative characteristics from other disorders, and can significantly impact daily functioning. many aspects of manifestation of these deficits, including facial emotion recognition deficit (uljarevic & hamilton, 2013; lozier et al., 2014; keung, 2022), delay in language development (mitchell et al., 2006; landa & mayer, 206; eigsti et al., 2010), reading comprehension deficit (norbury & nation, 2010; ricketts, 2013) and other impairment have been extensively studied. they have shown different underlying mechanisms and developmental trajectories for these shortfalls, but all contributed to the dysfunction of the disorder. face perception, which is an essential part of social interaction and communication, is an innate ability that occurs as early as 9 minutes after birth. it is defined as the ability to recognize, process, and integrate information from faces, which include direction of gazing, expression, identity, hostility, etc. (ward & bernier, 2013; palermo & rhodes, 2006). disruption in the systems, or unsuccessful face processing, can elicit prominent changes in social behaviors in some psychiatric disorders including asd (lopatina et al., 2018). the social functioning deficit in people with diagnosed asd may partially be explained by the impairment in face perception, which manifested as unsuccessful extraction of identification, emotion, and psychological information from faces during interpersonal interaction (todorv et al., 2012). the manifestation of the deficit in face perception in the early stage of the face perception in asd is the tendency of avoiding eye contact. this is also an early indication of children presenting symptoms of asd, if they present an aversion to direct eye contact from caregivers and others. the avoidance of eye contact is also directly linked to socioemotional dysfunction in asd (kliemann et al., 2010). two general models were proposed the purpose of this review was to assess the face identity recognition deficit and the developmental difference that manifested in autism spectrum disorder (asd) compared to their typically developing (td) peers. based on the meta-analysis using a random-effect model of 94 studies, with 144 effect sizes, for both adult and pediatric subjects with simultaneous and delayed face identity recognition paradigms, the underperformance in asd was significant and persistent across ages. in addition, a higher level of deficit was found in adult asd when performing simultaneous face-matching tasks while other subgroups showed homogenous effect sizes. this suggested a dissociation between the difficulties of the two mechanisms of face recognition: face perception (perceiving identity from the face with minimal memory load required) and face memory (recall of identity from the face that requires memory load), which was only shown in adults but not in children. the result indicated the possibility of using face identity recognition deficit as a diagnostic trait for asd. ye song teachers college, columbia university, department of clinical and counseling psychology 100 data on the face identity process. after duplicates were removed, full-text articles were screened for eligibility. inclusion criteria the inclusion for the final meta-analysis: a) is an empirical study published in english. b) included an asd group with diagnosed asd, autism, asperger, or pdd-nos. c) include a typically developing, chronological age-matched, comparison group. d) include data on participants’ age. e) include a homogenous adult or pediatric group of participants or have separate data for different age groups (categorization of adult and pediatric groups used an age cutoff of 18 years of ages). f) used static images with real human faces that are not the participants’ own faces. g) include data on the types of tests performed, face identity recognition tasks or face identity discrimination tasks. h) reported accuracy data of participants’ performance on the tasks. data extraction data was extracted from every paper that satisfied the inclusion criteria, and all data were input onto microsoft excel sheets. results for studies with adult or pediatric participants were recorded separately, but the categories of data extracted were the same as follows: a) authors and year the article was published. b) demographic data of asd and td control groups, including sample size, gender distribution, mean age, and the standard deviation of age, intelligence quotient, the standard deviation of iq, and the diagnostic tool implemented. for studies that were carried out with multiple groups of participants, data were recorded independently and classified in accordance with their characteristics. c) type of task implemented on face identity recognition or discrimination ability. the tasks implemented for each study were categorized into simultaneous or delayed categories. the simultaneous face identity recognition test, which is also categorized as the simultaneous face identity discrimination test, was a simultaneous match-to-sample test, in which, the target stimuli and test stimuli were presented simultaneously. this type of task was adopted in the widely used face identification task, benton facial recognition test. the simultaneous match-to-sample task did not require memory load to perform an accurate matching of faces (duchaine & weidenfeld, 2002; duchaine & nakayama, 2004). on the other hand, a delayed match-to-sample task, which in weigelt et al. (2013) and griffin et al. (2021) was also identified as face discrimination, did require memory load and the amount of memory load required was directly related to the length of time delayed between the presentation of the stimulus (anderson & colombo, 2019). therefore, the rationale behind the categorization was the requirement of memory load. the simultaneous task demanded no memory load and the delayed task required at least some memory load to perform. studies that used both types of tests were recorded individually in each section. d) effect size of the difference in accuracy performance between asd and td groups. if effect sizes were not provided, statistical data required to calculate the standardized mean difference were extracted. sample sizes, means, and standard deviations of behavioral results for both groups were extracted for calculating the effect sizes. if these data were not provided, inferential statistics of comparison between groups were collected to estimate effect size. for studies that performed multiple experiments, the data for each experiment was recorded separately based on their participants’ characteristics or the type of task performed. for studies that reported demographic information and performance results individually for each participant, the mean and standard deviation data were calculated manually for pediatric and adult participants groups. in some cases where neither the effect size nor specific data of results were textually available, but graphic representations of data were presented, the online application, webplotdigitizer was used to extract the necessary data. numerous studies had shown consistent validity and reliability of numerical results extracted from graphic inputs using webplotdigitizer (drevon et al., 2016; aydin & yassikaya, 2022). the calculation of standardized mean differences was done manually by inputting equations with excel functions. most of the studies provided effect sizes in cohen’s d value as the standardized effect size. it has been noticed that cohen’s d values tend to overestimate the actual effect sizes when sample sizes are small. on the other hand, hedges’ g removes the bias with a correction factor. (lin & aloe, 2021; durlak, 2009) most studies included in the current meta-analysis did not have large sample sizes. therefore, it might be prone to an upward bias if using cohen’s d for calculating the effect sizes. on the other hand, hedges’s g, which can easily be transformed from cohen’s d, was more reliable in the current meta-analysis. therefore, for other studies that require manual calculation, cohen’s d values were first calcu song 101 asd and face identity recognition deficit lated and then transformed into hedge’s g together. the formula for calculating the cohen’s d was (cohen, 1998; lipsey, 2001): where and were mean values and the pooled standard deviation, σpooled is calculated as: where n1 and n2 are sample sizes, and σ1 and σ2 are standard deviations for each group. for studies that did not provide sample size, mean, or standard deviation, the equation used to convert values from f-test (3) or t-test (4) value to cohen’s d were (thalheimer & cook, 2002; lipsey, 2001): after all cohen’s d were calculated, the calculated effect sizes were then converted into hedges’ g value, along with the provided cohen’s d effect sizes. the conversion formula used was (hedges, 1981; borenstein et al., 2011): where df = n1 + n2 2. the standard errors of hedges’ g (6; hedges, 1981; nist, 2018) were calculated for further analysis: risk of bias evaluation and quality assessment an evaluation matrix of the studies’ design and methodology was adapted from previous meta-analyses (griffin et al., 2021; yeung, 2022; tang et al., 2015). for every study, their evaluations were based on the quality of participants’ selection procedures and the characteristics of the instruments implemented. for assessing the reliability of the sample subjects representing the intended target population, the demographic characteristics were assessed and compared to ensure the result performance data extracted were a representation of the group difference with minimal mediation from other properties. whether data on participants’ age, gender, and iq were provided for both asd and td groups, and whether these characteristics are matched to control for effects that can potentially bias the result, were significant determinants of the studies’ quality. on the other hand, aside from many established tests targeting face identity recognition measurement: cfmt (cambridge face memory test), benton facial recognition test, nepsy-ii (developmental neuropsychological assessment, second edition), face subtest, etc., many studies developed their own testing procedures evaluating the performance. within established tests, the materials used and courses of action varied largely from each other. there was not a general consensus on which test was best in reliability and validity in rating the identity recognition ability specified in the asd population (duchaine & weidenfeld, 2002; albonico et al., 2017). however, some material characteristics were preferred that tend to be more consistent in conveying reliable results. compared to black-and-white, or grayscale photos of faces, colored photos had been shown to carry more information that was not related to faces. for instance, when photos of faces were presented in color, chunking areas of faces according to different tones or shades became possible. instead of remembering and recognizing a person’s face from their facial features, the mechanism then became remembering patterns of color segments (bindemann & burton, 2009; yip & sinha, 2010; bobak et al., 2019). similarly, photos of full faces, including hair and clothing, provided excessive information that was not related to facial features when testing the identification ability. more significantly, when subjects were not able to extract sufficient information from facial features alone, they were more likely to rely on external information, hairstyle, brow shapes, etc (duchaine & weidenfeld, 2003). in addition, different facial expressions also were shown to impact identity recognition (chen et al., 2015). with the asd population, whose recognition of facial affect is impaired, the ambivalent effect can lead to biased results. therefore, for achieving consistent reliable results, the method implemented with grayscale photos of inner face features alone with neutral expression was preferred. the evaluation is done in rating format. each criterion is marked as one point for each study on whether it provides the necessary information for each criterion. the study’s quality is the sum of scores on each criterion and the maximum quality score is 12 points. statistical analysis with the calculated hedges’s g and standard error of hedges’s g value, the data were input into spss v. 28 for meta-analysis. analysis was performed using a random effect model with the hunter-schmidt method (hunter & schmidt, 1990). fixed-effect model 102 hypothesized a universal effect size for all studies and proposed a similar methodology across studies in the meta-analysis (field & gillett, 2010). on the other hand, the random-effect model assumed that every study estimated a different inherent relation and appraised both between-study and within-study variability (kock, 2009; tufanaru, 2015). the hunter-schmidt method is a method using a random-effect model and it was shown to produce the most accurate and reliable estimates when heterogeneity exists in effect sizes (cornwell & ladd, 1993; field, 2001). in addition, forest plots and funnel plots were produced with spss plotting functions for meta-analysis. forest plots provide a vivid visual representation of the overall effect of the meta-analysis and effect size of individual studies used to generate the results. the meta-analyses were performed in accordance with these procedures. first, an overall meta-analysis of every study was performed to estimate the difference in accuracy performance on face identity recognition between asd and td populations. random-effect meta-analysis was performed with all data included and forest plots were produced. in addition, evaluation of heterogeneity and homogeneity were carried out to inspect the variability across studies. furthermore, an assessment of publication bias was also implemented to further specify and solidify the results. then, a meta-analysis of studies within each age group and a comparison of results across ages were inspected. similar procedures that were executed for evaluating the overall effect size were performed for the pediatric group and the adult group. the comparison between groups was assessed with an estimation of the homogeneity of the two groups as a subgroup analysis of the overall effect. additionally, subgroup analyses of methodology effects within each age group were performed. this analysis examines whether the two kinds of face perception, with and without memory load, show different performance between asd and td at different age stages. on the other hand, a hypothesis by weigelt et al. (2013) was tested. weigelt et al. (2013) proposed that face identity recognition deficit in asd was specific to face memory deficit, in which the higher demands in memory load would lead to worse performance in asd. for tests that did not require face memory, the performance between asd and td should be the same. even though griffin et al. (2021) had shown results opposite to this hypothesis, griffin et al. (2021) studies examined the difference between face identity recognition and face identity discrimination tasks. the divergence between these two tasks was not clearly defined in either the weigelt et al. (2012) or griffin et al. (2021) study. as mentioned in tang et al. (2015), the definition of face discrimination was ambiguous. therefore, a dichotomy classification was used to be more robust and specific. evaluation of publication bias to evaluate potential publication bias, a funnel plot and egger’s regression were used. a funnel plot is a visual representation of comparing the sizes of trials to their effect size. usually, studies without publication biases would produce a plot that is symmetric and shaped like a funnel. if the resulting plot was significantly asymmetric, this indicated a potential publication bias (lee & hotopf, 2012; simmonds, 2015). interpretation from graphics alone can be unreliable so egger’s test is also used. egger’s regression test is a test based on a linear regression model comparing the intercept, which evaluates the asymmetricity of the funnel plot. egger’s test examines the hypothesis of zero linear intercept, which represents a symmetric funnel plot with no publication biases (egger et al., 1997). results study selection the literature selection and screening process was shown in the flow diagram, figure 1. an initial database and references search gave 7,432 results, including 1,975 from pubmed, 5,345 from psycinfo, and 112 from griffin et al. (2021) references list. with the psycinfo filter, 299 articles that were not written in english and 1,151 articles that were not empirical research studies were removed. then, a total of 5,602 studies were eliminated because they did not include information on asd or face processing. after removing 82 duplicate papers, 298 unique papers related to autism spectrum disorder and face processing were reviewed in full-text screening. 204 papers, in total, were eliminated based on inclusion and exclusion criteria: a) 15 articles were not empirical research papers. b) 30 papers were not studying face processing in the asd population or did not include participants with diagnosed asd. c) 13 studies did not have a comparison group or did not compare to the typically developing population. d) seven papers did not provide informa song 103 asd and face identity recognition deficit tion on participants’ age range, and e) 19 papers have a heterogenous age that include a mix of adult and pediatric participants. f) six studies did not use static real human faces, whereas three studies studied self-recognition. i) 114 studies involved face processing in asd but did not include behavioral results concerning their face identity recognition or discrimination ability. a total of 94 studies satisfied all the inclusion criterias and were included in current meta-analysis, with 4,849 total number of individual participants, 2,351 with asd and 2,498 td comparisons. the general characteristics of participants in the 94 studies are shown in table 1. the overall average age of pediatric asd participants was 10.99 (sd=2.51), and pediatric td participants with mean age of 10.64 (2.93). the mean age between the asd and td groups did not differ significantly; t(144)=0.768, p=.444. the overall mean age of adult asd participants was 28.48 (sd=4.6) , ranging from 20.60 to 43.2; the mean age for adult td subjects was 28.19 (sd=4.52), with a range of 21.6 to 44. the mean ages between the two groups did not differ significantly; t(58)=0.249, p=.8041. studies were also categorized based on the test characteristics, either a delayed design or a simultaneous presentation design. the number of studies with different characteristics is shown in table 2. overall face identity recognition ability first, the overall difference in face identity recognition was evaluated. meta-analysis was performed with a total of 94 papers and 144 pairs of results of effect size between asd and td. all results were included to assess the overall difference in facial identity recognition ability between the asd and td groups. of the 144 effect sizes from studies, 17 reported a positive effect size, which indicates a comparatively higher performance in asd than the td control group. in addition, three studies reported an effect size of 0, which indicated an equal level of performance between the two subject groups. all other 124 results showed a lower level of performance in asd subjects than in td control subjects. figure 3 shows the forest plot representing the result of a random-effect meta-analysis on overall face identity recognition ability in asd. the results show a large overall effect size, hedges’s g = -.716, 95% ci [.835, .597], p<.0001. indicating a significant overall deficit in asd population on face identity recognition. on the other hand, the heterogeneity measures of all 144 effect sizes from the studies show a significant heterogeneity, τ2= .405, i2 = .803. the homogeneity test also confirmed the variances between the studies’ effect sizes, q(143) = 731.35, p = .00. these results show a large heterogeneity in effect sizes. in addition, the i2 result confirmed that 80.3% of variances can be attributed to the heterogeneity of studies. the funnel plot in figure 2 shows the studies are roughly symmetrical, which indicates no potential publication bias. in addition, egger’s regression-based test also confirmed the absence of biases with an intercept of 0.325, 95% ci [-0.151, 0.8], t = 1.348, p=.180. face identity recognition in adult samples a total of 39 studies from 30 papers, with statistics from total sample sizes of 1316 participants, were included in the random effect meta-analysis on the adult group. the resulting overall negative effect size on face identity recognition performance between asd and td, hedges’ g = -.753, showed a significant deficit in the identification ability in asd subjects. figure 4 showed the forest plot displaying the effect sizes of each study, which presented an overall lower performance in asd than in td. furthermore, subgroup analysis on the type of test performed were also included. the statistics and visual representations in the forest plot both indicated an outstanding negative effect size. hedges’ g= -.753, 95% ci [-.931, -.575], p<.0001. heterogeneity tests indicated a substantial variation in effect sizes between studies. τ2 = .211, i2 = .682. the test of homogeneity also confirmed the disparity. q(38)= 123.499, p<.001. the i2 connoting 68.2% of heterogeneity explained by studies’ differences was lower than the overall heterogeneity in data with both children and adult data. egger’s regression test of intercept = 0.070, 95% ci [-0.774, 0.915], p=.867, which suggested a high level of robustness. in addition, consistent results were shown in subgroup analysis for both delayed and simultaneous tests. of the 39 studies’ results, 29 studies were performed with delayed recognition tasks, and 10 studies were implemented with simultaneous designs. heterogeneity testing indicated that for both categories classified based on test procedure, the heterogeneity between studies was on a similar level. for delayed tests, τ2 = .185, i2 = .678; for simultaneous design, τ2 = .308, i2 = .674, which both indicated a high level, 67.8% and 67.4% of heterogeneity from variation between studies. however, publication biases were not significant in either design. for delayed tests, in 104 tercept = -0.451, 95% ci [-1.457, 0.555], p=.366; for the simultaneous test, intercept = 2.036, 95% ci [ -0.591, 4.664], p=.112. therefore, no studies were excluded from the analysis. figure 5 presented a funnel plot image for all studied among adult participants, and different methodologies used were labeled with different colored dots. for studies with adult samples and implemented delayed identity recognition tests, the overall hedge’s g effect size was -.697, 95% ci [-.891, -.504], p<.001. for studies with simultaneous design methods, the overall effect size was hedges’ g = -.954, 95% ci [-1.377, -.531], p<.001. although the overall effect size for the simultaneous test, g=-.954, was larger than the delayed test, g=-.697, the homogeneity test between these two subgroups shows an insignificant effect, q(1)=1.17, p=0.28. on the other hand, both significantly negative effect sizes results suggested a deficit in both delayed and simultaneous face identity recognition ability in adult asd compared to typically developing controls. face identity recognition in children samples a total of 66 papers with 104 studies of children were included in the random-effect meta-analysis for identity recognition performance difference between asd and td. the overall result showed a similar level of effect sizes to the overall effect size with adult subjects. hedges’ g= -.701, 95% ci [-.851, -.551], p=.000. a subgroup analysis comparing homogeneity of overall effect sizes between asd and td for adult and children subjects showed q(1)=.187, p=.666. this result indicated no significant difference between the distribution of the two subgroups, children and adults. in addition, egger’s regression test showed a large but insignificant publication bias. intercept = 0.43, 95% ci [-0.15, 1.011], p=.144. on the other hand, similar to prior results, the heterogeneity across studies included in the analysis was still pronounced. the resulting funnel plot is also shown in figure 7. heterogeneity measures show an overall 82.6% of heterogeneity from variation between studies. τ2 = .482, i2 = .826. the homogeneity measure also confirmed the significance. q(103)=601.67, p=.000. figure 6 displayed all effect sizes included in the analysis for the children subject group. although publication was not significant in the overall analysis of studies, when subgroup analyses were performed for studies implementing delayed and simultaneous design within the children group, the publication bias estimated by egger’s regression test predicted a high likelihood of publication bias in the delayed condition, intercept=0.598, 95% ci [-0.067, 1.263], p=.07. the result is not statistically significant with p=.05, but the borderline significant result indicated a high likelihood of effect of biases from extreme data. after eliminating five sets of data with extreme effect sizes, the possibility of publication bias became minimal and thus the results were more robust and funnel plots are symmetric. figure 8 displayed the funnel plots before and after extreme data were removed. for delayed groups, intercept = 0.141, p=.65; for simultaneous group, intercept = -0.349, p=.55; and for all studies with children, intercept = 0.005, p= .987. the resulting heterogeneity measures were smaller but still significant. for overall effect: τ2 = .281, i2 = .742; delayed condition: τ2 = .283, i2 = .75; simultaneous condition: τ2 = .273, i2 = .715. the estimated effect sizes for both conditions are similar and all negatively significant. for the delayed face recognition condition, the effect size was hedges’ g = -.628, 95% ci [-.776, -.48], p=.000. for the simultaneous condition, the hedge’s g effect size was -.607, 95% ci [-.837, -.377], p<.001. the results indicated a noticeable shortfall in face identity recognition in children with asd compared to td regardless of memory load requirement of tests, delayed or simultaneous. the subgroup homogeneity test also provided the result that the distribution of performance for delayed and simultaneous conditions was highly similar. q(1)=0.022, p=.881. furthermore, after removing extreme effect sizes, the evaluated effect size of overall performance for children became slightly less negative. hedges’ g = -.622, 95%ci [-.746, -.498], p=0.000. additionally, the result for subgroup homogeneity tests between children and adult subgroups, although still insignificant, decreases, indicating a lower level of similarity of distribution across the two groups. q(1) = 1.393, p=.238. therefore, although removing outlier data increased the robustness of studies data included in the analysis, it did not change the overall underperformance in children with asd, or the homogeneity in results between children and adult subgroups. additional analysis meta-regression analysis weighting the mean age of each study on the heterogeneity of performance for overall result data, and for delayed and simultaneous identity recognition tasks showed song asd and face identity recognition deficit 105 small mediating effects. the largest mediating effect observed was in simultaneous design where of the 71% of heterogeneity, the mean age of participants could account for 3.2% of the variation. in addition, subgroup analysis was performed on assessing the difference of age groups in different methodology groups. the homogeneity test of studies with children and adult subjects on simultaneous face identity recognition test gave the result, q(1)=1.998, p=.157. the test on the homogeneity of studies for both groups on the delayed face identity recognition test resulted in, q(1)=0.100, p=.752. discussion the current study examined facial identity recognition ability in autism spectrum disorder, asd, whether there were changes across developmental stages, and whether there was a difference depending on specific aspects of face recognition. the result from the meta-analysis indicated an overall underperformance in face identity recognition in asd compared to typically developing control and the deficit was significant. the overall effect size (hedges’ g = -.716) presented a significantly lower performance in the asd group on identifying faces. for studies that were performed with adult subjects or children participants, the deficits were consistent in both groups. the effect sizes for adult and children groups respectively were hedges’ g = -.753, and hedges’ g = -.622. both indicate a significant underperformance in asd children and adults compared to their td control. although the effect size for adults was larger than the effect size for the children’s group, which represented a higher level of deficit in the adult population than in children, the homogeneity test shows insignificant results. therefore, the difference between the results cannot be statistically interpreted as a noticeable change across ages. additional subgroup analysis on the interaction between age group and type of test showed a variation in effect size between delayed and simultaneous tests in adult samples but not in children. in addition, only the effect size of performance on simultaneous identity-matching tasks in adults was considered to present a large effect size with hedges’ g = -.954 (cohen, 1998). the effect sizes showing underperformance in other interactive groups showed similar results, which indicates an indistinguishable level of deficits. the general result of an overall deficit in asd compared to td was consistent with results found in most research studies and concluding remarks from the prior meta-analysis (weigelt et al., 2012; tang et al., 2015; griffin et al., 2021). of the 144 pairs of effect sizes data extracted from 94 studies for the current meta-analysis, 20 results found either no difference or slightly better results in performance in the asd group. the differences in findings can be a mixed effect from the differences in the subject’s selections and disparity in the quality of the experimental paradigm adopted by the studies. on the other hand, majorities of the studies concluded a deficit in asd face recognition performance, which is also aligned with results from the current meta-analysis. the consistent deficit suggested a case of developmental prosopagnosia that can potentially be considered as an endophenotype of asd. there have been continual reports of cases of patients with asd having difficulties in face recognition (kracke, 2008; pietz et al., 2007). in addition, subsets of patients with developmental prosopagnosia also present significant levels of autistic traits (minio-paluello et al., 2020; cook et al., 2015). therefore, research may need to consider this co-occurrence of the two disorders and potentially the face recognition deficit as an intermediate phenotype of asd. subgroup analysis revealed subtle development changes in performance, which suggested a persistent deficit in face recognition in asd across ages. the difference in effect sizes occurred only in adults on simultaneous facematching tasks rather than delayed face recognition tasks, but was not found in children samples, which implied an isolated face perception and face recognition in adults but not in children. this difference could potentially explain the contraction found in the results for weigelt et al. (2013) and griffin et al. (2021). weigelt et al. (2013) initially proposed the deficit depended on memory demand, and griffin et al. (2021) challenged the hypothesis by showing a significant deficit in both face discrimination and face recognition tasks. since most studies investigating asd deficits were performed in children, the overall results with systematic studies would likely present persistent results since asd children showed constituent deficits across tasks. although the deficit persists on average, the underlying mechanism of performance differs across ages. similar results were presented in studies on developmental prosopagnosia, which presented a dissociation in performance 106 between face perception and face memory in adults but not in children (dalrymple et al., 2014). in addition, studies in typically developing populations on simultaneous face identity match-to-sample tasks also indicate a decrease in accuracy performance as age increases (megreya et al., 2015; schretlen et al., 2001). on the other hand, the limitations of the accuracy of results for the current meta-analysis also need to be considered. the majority of studies on asd were conducted with children for it is a neurodevelopmental disorder. the drastic modification of diagnostic criteria of asd also made the selection and classification of asd participation complicated. of the 144 studies included, only 39 studies data were performed on adult participants, and only 10 pairs of data were assessing the simultaneous face-matching ability in adult asd. with a limited number of studies, the high effect size for adults on simultaneous tasks may be biased. in addition, the difference in studies results can also contribute to heterogeneities in studies results. for future studies, the implementation of a random-effect size model is necessary since the heterogeneity in studies was substantial. a possible resolution can be the inclusion of single design studies in the inclusion criteria, for instance, using only cfmt or benton for assessing face memory and face perception. however, these limiting criteria would be prone to having a minimal sample size. therefore, for future research studies, there should be a consideration of the material and procedure used to perform the studies to have reliability and validity across studies and populations. another limitation of this study was that the study process, including literature search, review, and meta-analysis, was done by the author alone so the inter-reviewer reliability was not assessed for the current study. conclusion overall the result was significant in that asd presented a significantly lower level of accuracy in face identity recognition than their typically developing peers. in addition, the deficit persists across age, which may imply potential comorbidity of asd and developmental prosopagnosia. nevertheless, the difference in results from the subgroups analysis showing a difference in performance on simultaneous face matching tasks and delayed face recognition tasks indicated a dissociation between face perception and face memory that was only manifested in adults but not children with asd. however, more studies focusing on the adult asd population is necessary to specify the mechanism of this divergence. in general, studies on face identity recognition ability in asd should consider these factors when deciding on the studies’ participants and materials. references references marked with an asterisk indicate studies included in the meta-analysis anderson, c., & colombo, m. 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(2011). brief report: developing spatial frequency biases for face recognition in autism and williams syndrome. journal of autism and developmental disorders, 41(7), 968– 973. https://doi.org/10.1007/s10803-010-1115-7 *li, t., wang, x., pan, j., feng, s., gong, m., wu, y., li, g., li, s., & yi, l. (2017). reward learning modulates the attentional processing of faces in children with and without autism spectrum disorder: reward learning in autism. autism research, 10(11), 1797–1807. https://doi. org/10.1002/aur.1823 lin, t., fischer, h., johnson, m. k., & ebner, n. c. (2020). the effects of face attractiveness on face memory depend on both age of perceiver and age of face. cognition and emotion, 34(5), 875–889. https://doi.org/10.1080/02699931.2019.169449 1 lopatina, o. l., komleva, y. k., gorina, y. v., higashida, h., & salmina, a. b. 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(2013). the role of gaze direction in face memory in autism spectrum disorder: eye gaze in autism. autism research, 6(4), 280–287. https://doi.org/10.1002/aur.1292 115 asd and face identity recognition deficit table 1 demographic characteristics of the studies included in the current meta-analysis note. asd = autism spectrum disorder; td = typically developing; n = number; std = standard deviation. * = two studies had both adult and children participation groups and were included in both categories. 116 table 2 design characteristics of studies included in the current meta-analysis note. the number indicates the number of studies in each category. song 117 asd and face identity recognition deficit figure 1 prisma 2020 flow diagram showing the literature identification and screening process note. asd = autism spectrum disorder; td = typically developing. 118 figure 2 funnel plot of effect sizes of all studies over standard errors for overall face identity recognition note. egger’s linear regression test result of t = 1.348, p = .180 indicated overall symmetricity of all studies used in the current meta-analysis. song 119 asd and face identity recognition deficit figure 3 forest plot of the overall effect size of face identity recognition ability difference between asd and td groups 120 song 121 asd and face identity recognition deficit figure 4 forest plot of overall face identity recognition performance in adult asd and td groups note. forest plot from the meta-analysis using a random-effect model on all studies with adult participants. overall hedge’s g value= -.76; delayed subgroup, hedges’ g = -.70; simultaneous subgroup, hedges’ g = -.95. 122 figure 5 funnel plot of overall studies with adult participants note. egger’s regression-based test with an overall result of t=0.169, p=.867, indicated an overall symmetric funnel plot. song 123 asd and face identity recognition deficit figure 6 forest plot of overall identity recognition performance in children with asd and td 124 song 125 asd and face identity recognition deficit figure 7 funnel plot of overall studies with children participants 126 figure 8 funnel plot of studies on children with delayed face identity recognition test before and after (extreme data were removed) note. the plot on the left showed the funnel plot prior to modification. the plot on the right showed the funnel plot after five studies’ data with extreme effect sizes removed. song microsoft word layout_draft_merged_sbw12.12.2012 (1).doc t e a c h e r s c o l l e g e c o l u m b i a u n i v e r s i t y department of counseling and clinical psychology 2 letter from the editors: it gives us great pleasure to present volume 14 of the graduate student journal of psychology (gsjp), which has been the result of another fruitful and productive year. we were honored to have worked with a diverse and accomplished team of peer reviewers and editors, each of whom worked diligently to ensure that this year’s volume would be of the highest quality. we’re sure you’ll agree that the journal this year is indeed a product to be proud of. gsjp is a cause and an enterprise which we believe in deeply, one whose primary aim is to foster career development opportunities for graduate students. despite the training that graduate students receive in research design, we are often left with a disconnect between theory and application, and opportunities to publish can be hard to come by. gsjp seeks to bridge this divide by providing an opportunity to learn about the publishing process firsthand. we aim for the journal to be a unique platform for beginning researchers to disseminate their work and to act as a steppingstone for future involvements in publishing. despite being a student-run journal, gsjp follows rigorous standards. each manuscript submitted goes through two rounds of in-depth peer-review, exposing students to multiple stages of revision and challenging them to improve their work at each stage. this peer-mentoring process—itself a rare opportunity in the early stages of one’s career— enables students and trainees to offer each other invaluable feedback and guidance. the result is a volume this year that represents a diverse cross-section of subfields in clinical psychology, including exciting new directions in psychotherapy research. we were also delighted to receive a diverse range of submissions from across the globe this year, including research conducted in india, pakistan, ghana, and hong kong. the journal saw a number of accomplishments this year, including our registration in journalseek (an online database of academic journals) and our acquisition of an issn number through the library of congress. we also broadened the journal’s staff membership to include an undergraduate intern from barnard college, whose assistance in preparing this volume was invaluable. looking toward the next volume, we hope to continue expanding training opportunities to undergraduate and predoctoral graduate students in psychology. in addition, we maintain an active web presence on facebook and twitter (@gsjp_journal) and we hope to launch a gsjp blog which will offer publishing resources and guidance to graduate students. we would like to thank the exceptional group of authors, reviewers, and editors who contributed to the journal this year for their unwavering commitment to excellence in their work. we are very proud to have published a volume of innovative original research that is thought-provoking and represents such a high level of scholarship. last but certainly not least, we would like to offer our sincere thanks to professor barry a. farber, whose guidance, support, and mentorship of gsjp these many years has left an indelible impact on the journal and its members. please feel free to share your thoughts and comments with us at gsjp@tc.columbia.edu. we hope you enjoy the volume! sarah bellovin-weiss eleni vousoura microsoft word gsjp vol 10 instructions-1.doc 70 instructions to authors graduate student journal of psychology submission guidelines. three (3) printed copies of the manuscript via postal mail to the gsjp office at teachers college, columbia university and a complete electronic copy (including text and tables, and figures if applicable) via email to gsjp@tc.edu must be submitted. all printed copies should be clear, readable, and on paper of good quality. in addition to addresses and phone numbers, authors should supply electronic mail addresses for use by the editorial office and later by the production office. the majority of correspondence between the editorial office and authors is handled by e-mail, so a valid email address is important for the timely flow of communication during the editorial process. authors should provide electronic mail addresses in their cover letters and should keep a copy of the manuscript to guard against loss. manuscripts are not returned. manuscripts for gsjp can vary in length; typically they will range from 15 to 30 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theoretical articles. gsjp publishes articles that make important theoretical contributions to research and practice that are of major importance for the study and practice of clinical and counseling psychology. preference is given to manuscripts that advance theory by integrating prior work. manuscripts devoted to surveys of the literature are acceptable only if they can be considered as a major contribution to the field, documenting cumulative evidence and highlighting central theoretical and/or methodological issues. masked reviews are optional, and authors who wish masked reviews must specifically request them when they submit their manuscripts. for masked reviews, each copy of the manuscript must include a separate title page with the authors' names and affiliations, and these ought not to appear anywhere else in the manuscript. footnotes that identify the authors must be typed on a separate page. authors are to make every effort to see that the manuscript itself contains no clues to their identities. for more information regarding submission guidelines, or to view previous volumes of the journal, please visit our website: www.tc.columbia.edu/publications/gsjp ethical considerations. apa policy prohibits an author from submitting the same manuscript for concurrent consideration by two or more publications. in addition, it is a violation of apa ethical principles to publish "as original data, data that have been previously published" (standard 8.13). as this journal is a primary journal that publishes original material only, apa policy prohibits as well publication of any manuscript that has already been published in whole or substantial part elsewhere. authors have an obligation to inform journal editors in their cover letter that the manuscript is not under review elsewhere, that the primary data have not been published previously or accepted for publication, and that the appropriate ethical guidelines were followed in the conduct of the research. however, the editors of gsjp will make an exception for brief reports submitted regarding empirical research articles that are under review for publication elsewhere. in addition, apa ethical principles specify that "after research results are published, psychologists do not withhold the data on which their conclusions are based from other competent professionals who seek to verify the substantive claims through reanalysis and who intend to use such data only for that purpose, provided that the confidentiality of the participants can be protected and unless legal rights concerning proprietary data preclude their release" (standard 8.14). apa expects authors submitting to this journal to adhere to these standards. specifically, authors are expected to have available their data throughout the editorial review process and for at least 5 years after the date of publication. authors will be required to state in writing that they have complied with apa ethical standards in the treatment of their sample, human or animal, or to describe the details of treatment. a copy of the apa ethical principles may be obtained electronically or by writing the apa ethics office, 750 first street, ne, washington, dc 20002-4242. in addition, gsjp requires authors to reveal any possible conflict of interest in the conduct and reporting of research (e.g., financial interests in a test or procedure, funding by pharmaceutical companies for drug research). t e a c h e r s c o l l e g e c o l u m b i a u n i v e r s i t y department of counseling and clinical psychology letter from the editors: we are excited to present volume 15 of the graduate student journal of psychology (gsjp), a peer-reviewed journal for graduate students in the field of psychology. as we move forward, the core principles of the journal will continue to be the guiding force of this project. gsjp provides an important space for student learning and covers all factors pertinent to publishing a scientific manuscript, such as writing and preparation for submission, editing, and reviewing. our primary aim is to foster professional development and to provide support in this process. our continued commitment to the publication of underrepresented works in the major journals makes gsjp truly unique. the emphasis of the journal will continue to focus on providing an outlet for quality graduate student work and on creating a space for both students and practicing psychologists to participate in all aspects of the publication process. the present issue marks the sustained effort to adhere to our goals. this issue represents a small sample of the diversity of material submitted for publication. the reader will find articles examining changes taking place in the realm of psychotherapy practice, such as psychologists’ potential to prescribe psychiatric medications as well as the use of technology and social media in clinical work. additionally, the reader will be exposed to a new understanding of addiction and substance use which mirrors recent advances in dsm-5. the present issue is representative of the dedication on behalf of the authors, the peer reviewers, the editorial board, the layout editor, and all others who have been involved in creating this volume and we are very grateful to all of them. we would especially like to thank our faculty sponsor, professor barry a. farber, whose guidance and support in this publication process has been irreplaceable. please feel free to share your thoughts and comments with us at gsjp@tc.columbia.edu. marina mazur sarah bellovin-weiss interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 12 interpreter-mediated therapy for refugees: a need for awareness and training stacy j. cecchet and dena calabrese seattle pacific university this brief report discusses the challenges arising from interpreter-mediated therapy in the treatment of refugees with post traumatic stress disorder (ptsd). although the refugee population continues to grow in the united states, the treatment competency of mental health professionals working with this population has not adequately responded to this growth. as a result of the trauma often experienced by refugees many present with ptsd symptomatology and require trauma-focused mental health care. language disparities between clinical psychologists and refugees often result in the need for interpreter-mediated therapy, yet psychologists lack awareness and relevant training in working collaboratively with interpreters to provide competent care. the complex reality of interpreter-mediated therapy can involve substantial deviations from the refugee’s original message and deprive refugees from receiving adequate treatment. of the estimated 16 million refugees globally, over 2.5 million have been relocated to the united states (united nations high commissioner for refugees; unhcr, 2009). in addition to not speaking english (united states department of state, bureau of population, refugees, and migration, 2001), many refugees experience forced separation from loved ones, a lack of formal education, restricted employment and housing opportunities, and discrimination from both the general population and other ethnic minorities (iwamasa, hsia, & hinton, 2006). according to the united nations high commissioner for refugees (1951): a refugee is defined as anyone fearing of being persecuted for reasons of race, religion, nationality, or political opinion who is outside of the country of his or her nationality and is unable or, owing to such fear, is unwilling to avail himor herself of the protection of that country; or who, not having a nationality and being outside the country of his or her former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it. (p. 16) given their traumatic history and the hardships they face upon arrival in the u.s., many refugees suffer extreme distress and require trauma-focused mental health care. however, the reality is that the refugee population continues to grow in the u.s., and the psychological community has not adapted to meet the needs of this community.  a rationale for interpreter-mediated therapy there is currently a gap in the implementation of culturally relevant psychotherapy interventions for ethnic minorities. although approximately 25% of the u.s. correspondence concerning this article should be addressed to stacy j. cecchet, department of clinical psychology, seattle pacific university, 3307 third avenue west, suite 107, seattle, wa 981191922. email: cecchet@spu.edu population is an ethnic minority, only 7% of clinical psychologists fall into this category (norcross, karpiak, & santoro, 2005). due to this disparity, non-english speaking clients may face several challenges in their communication with english-speaking therapists, who may misperceive cultural influences. even more, much of the language used in psychology, as well as in case conceptualization, is rooted in a western world view and can often lead to imposing western ideals of social convention and role expectation onto refugees (tribe, 2007). for refugees in particular, the inability to speak english and communicate fluently can be both frightening and disempowering (tribe, 2008). few refugees speak english and relatively few psychologists speak multiple languages. as such, therapists must rely on the use of interpreters to facilitate the therapeutic process (miller, martell, pazdirek, caruth, & lopez, 2005). using interpreters, many of whom are insufficiently trained in the field of psychology, contributes to an already complex endeavor (farooq, fear, & oyebode, 1997), including the erroneous interpretation of psychological symptoms and subsequent misdiagnoses. psychologists have rigorous standards that include an ethics code, state laws, and institutional mandates, yet none of these appear to sufficiently address how to work collaboratively with an interpreter to provide competent care. in addition to our ethical obligation to provide treatment to this population, the absence of interpreter-mediated treatment for refugees violates the standards put forth by the office of minority health (omh) for culturally and linguistically appropriate services (clas; omh, 2001). in an effort to improve the health of minority populations, the omh adopted 14 clas standards to address culturally competent care, language access services, and organizational support for cultural competence. while the clas standards have signaled an appropriate first step towards addressing the inequities of health care, the standards regarding access to language services are largely directed at policy makers and cecchet & calabrese 13 have, unfortunately, circumvented awareness in the field of psychology. this lack of awareness coupled with the substantial refugee population in the u.s. highlights our ethical responsibility to gain training and experience with this population. we believe that training standards for collaboration between psychologists and interpreters have yet to be established. this absence of training is a direct result of a lack of awareness and a gap in the literature, all of which deprive a large population of refugees from receiving adequate treatment. culturally competent treatment of refugees requires the training of both psychologists and interpreters in collaborative care. in order to generate greater awareness of this subject matter, and thereby influence the psychological community to take action, the current paper presents a brief report on interpreter-mediated therapy as it exists today. first, we seek to establish the need to provide competent care to the refugee population by illustrating their unique experiences of trauma. second, we will address the complex reality of interpreter-mediated therapy as it relates directly to the refugee population. finally, we provide suggestions for areas of future research and growth. understanding ptsd experiences among refugees although the symptom presentation of ptsd is largely cultural and dependent on race, gender, and the type of trauma experienced, many refugees exhibit enough symptoms to meet diagnostic criteria of ptsd as outlined in the diagnostic and statistical manual of mental disorders (american psychiatric association [dsm-iv-tr], 2000; keller, et al., 2006; regel & berliner, 2007). in addition to experiencing the intrusive, avoidant, and arousal symptoms characteristic of ptsd, other often multiculturally influenced characteristics include feelings of self-blame, guilt, shame (drozdek, 1997), poor coping strategies, negative selfconcept, and hyper-vigilance (silove, sinnerbrink, field, & manicavasagar, 1997). despite the universality of ptsd clinical features, the traumatic experiences of refugees are qualitatively different from the traumatic experiences of non-refugee clients (kinzie, 2001), even those from ethnic minority backgrounds. the traumatic experiences of refugees are typically extreme (i.e., torture), prolonged, and persistent (kinzie, 2001; nicholl & thompson, 2004). literature is abundant in describing the traumatic events experienced by refugees. one cambodian woman recounted the time she was forced to witness her husband being slaughtered while a knife was held to her throat and her life threatened if she spoke a word (kinzie, 2001). an iraqi kurdish man detained by iraq security forces was subjected to prolonged interrogations, frequent beatings, cold water dousing, suspensions off the floor for hours with his arms bent backwards, and genital mutilation for three months; he was taken to the hospital twice when his body gave way to the torment, only to be returned to the prison when he was revived (regel & berliner, 2007). a rwandan woman was raped by her son as soldiers held a knife to his neck. her husband was forced to watch and their young children were forced to hold open her legs (landesman, 2002). examples such as these illustrate the extreme, prolonged, and persistent traumas refugees experience, and unlike non-refugees, the environmental realities from which they seek asylum. for refugees, everyday life equates to a continuous threat to safety; trauma is a perpetual state of existence. as a result of severe trauma experienced by refugees, up to 86% of this population displays ptsd symptomatology (thulesius & hakansson, 1999). currently, trauma-focused cognitive behavioral therapy (tf-cbt) is recognized as a first line treatment for individuals who manifest symptoms of ptsd (bisson & andrew, 2005). tf-cbt is an adapted model of cbt that specifically addresses ptsd symptoms, depression, behavior problems, and other difficulties related to traumatic stress (cohen & mannarino, 2008; for a review, see child sexual abuse task force and research & practice core, national child traumatic stress network, 2004). tfcbt has been found to be efficacious in diverse cultural backgrounds and multiple languages, as well as in the treatment of multiple traumas, sexual abuse, and traumatic grief. despite the effectiveness of this treatment (cohen & mannarino, 2008; mendes, mello, ventura, de medeiros passarela, & de jesus mari, 2008), tf-cbt remains unutilized with refugees. the complex reality of interpreter-mediated therapy therapy would not be possible for many refugees without interpreters. the use of an interpreter allows the refugee to communicate in his or her native tongue and utilize culturally relevant linguistics to facilitate accurate communication and a comfortable working pace. yet, the presence of an interpreter adds new dimensions to the therapeutic process, including additional factors that need to be considered in therapy. interpreters imbue translations with corrected cultural meaning and may not interpret verbatim (farooq, fear, & oyebode, 1997). farooq and fear (2003) identify common interpretation errors while using an interpreter: (a) omission (a portion of the therapist’s question or the client’s answer is left out of the interpretation); (b) addition (the interpreter adds his or her own information into the client’s response); (c) condensation (the interpreter paraphrases a client’s response); (d) substitution (an interpreter replaces a concept that the therapist uses with another similar, but abstractly different concept); (e) role exchange (the interpreter asks his or her own question instead of the therapist’s); (f) closed-ended questioning (the interpreter tries to shorten or simplify the questioning process by shifting the questions to a closed format); and (g) normalization (the interpreter is unsure of how to interpret information from a client and thus will attempt to provide a rationalized version of the client’s response). in addition to interpretation errors, other factors may play a role in confounding the therapeutic process. interpreters often play multiple roles when working with clients; they are translators for language and culture, client advocates, co-workers, neighbors, social workers, and family interpreter-mediated therapy for refugees 14 members (farooq & fear, 2003; raval & smith, 2003). multiple roles can create complications for both the client and the interpreter. if the refugee and the interpreter share the same culture, the interpreter may feel that the client’s disclosure will bring shame to his or her country of origin. as a result, this is likely to lead to errors in interpretation. an additional complication arises when the interpreter has a close relationship with the client outside of therapy (i.e., family member, neighbor), which can contribute to the client withholding information for fear of embarrassment or lack of privacy. moreover, if the interpreter has experienced a trauma, the interpretation process may lead to a reexperiencing of trauma for the interpreter. regardless of the interpreter’s role, the task of translating communication from the refugee to the psychologist involves an unconscious act of gatekeeping (davidson, 2000; wadensjö, 1993). as a function of gatekeeping or coordinating communication, the message between the refugee and psychologist is altered, albeit unconsciously, by the interpreter. though the reasons for altering the message remain unconscious, this creates an unavoidable bias in communication that is beyond the purview of the psychologist. there appears to be intrinsic and extrinsic forms of gatekeeping. intrinsic gatekeeping reflects the interpreter’s personal belief system and may reflect attempts to “communicate more clearly, avoid conflict, or present a cultural perspective different from what is given in the intended message” (hwa-froelich & westby, 2003, p. 82). extrinsic gatekeeping reflects differences in linguistic systems and variations in comprehending sociocultural differences embedded within the context of communication (davidson, 2000). though interpretation errors, multiple roles, and gatekeeping are inevitabilities of interpreter-mediated therapy, many interpreters have little or no training in these areas. while these problems may always exist to some extent, it is likely that awareness and training in these areas may limit deviations in the original communication. hwa-froelich and westby (2003) acknowledge an overall lack of available educational opportunities for professional interpreters, highlighting that certification requirements are also not established. in fact, the role of the interpreter first came into play when translators were needed to facilitate political and diplomatic work. with over 300 languages spoken in the u.s. today, the role of the interpreter has since shifted to include providing services in education, medical, and community settings (avery, 2001). certainly, the training required for translating in a psychological setting differs from the skills required for translating in a diplomatic setting. unfortunately, training interpreters to work in psychological settings has not caught up with the growing demand for their service. gaining greater awareness and experience refugees face several problems when relocating to the united states. while they face normative problems of acculturation (i.e., cultural differences and language barriers), these problems are further exacerbated by the traumatic experiences that precipitated their relocation. the inability to meet the language and cultural demands of refugees leaves them with scant resources for treatment after relocation. the reality is that while a large refugee population suffers from ptsd, most do not receive adequate treatment. the role of the interpreter has only recently shifted to include providing services in professional arenas outside of diplomacy. currently, there are two forms of interpretation that appear to be consistently used in most settings: simultaneous interpretation and conservative interpretation (hwa-froelich & westby, 2003). simultaneous interpretation occurs when the interpreter translates at the same time as the client is speaking; this type of interpreting is often used for political or diplomatic work and is most common at the united nations (ohtake, santos, & fowler, 2000). consecutive interpretation occurs when the interpreter waits to translate until the client pauses, indicating to the interpreter that it is the appropriate time to translate; this method of translation is often used in medical and educational settings. at this time, no research has examined the effect of simultaneous versus consecutive interpretation in health care settings. research in this area could provide a strong foundation from which to develop guidelines for psychologists working with interpreters. psychologists as well as interpreters would certainly benefit from a standard and consistent approach to interpretation. outcome studies comparing the efficacy of tf-cbt to other trauma-focused therapies among refugee populations would also contribute to the implementation of adequate care for this population. if a best practice can be established for treating refugees, interpreter training can be tailored more effectively. although guidelines have been suggested for working with interpreters (see tribe, 2007 for a review), too often these suggestions represent conceptual considerations (e.g., creating a good atmosphere to ask for clarification), rather than concrete practices (e.g., allocating time to meet with the interpreter prior to meeting with the client), for managing the relations of the psychologist-interpreter-client triad (tribe, 2007). yet, there remains an absence of awareness, literature, and training to target the dyadic relationship between psychologist and interpreter. such guidelines might offer suggestions on how to effectively address issues of multiple roles, interpretation errors, and gatekeeping with the interpreter. awareness and advocacy serve as the foundation for new research and ultimately the clinical application of that research into training opportunities. as a new generation of emerging psychologists, we must hold ourselves to higher standards when providing treatment to refugees by bringing awareness to professionals in our field and through advocacy efforts. graduate students interested in developing clinical experience and competency in working with interpreters to treat refugees may want to first begin by becoming involved in local community outreach and advocacy efforts and by demanding training opportunities from professors, leaders in the field, american psychological association (apa) cecchet & calabrese 15 division representatives, and the american psychological association of graduate students (apags). while a seemingly daunting task, apa divisions have historically been formed in the same manner. it is our hope that this paper will inspire small efforts in each of its readers that, in turn, will launch future efforts in research and clinical training. references american psychiatric association. 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(1993). the double role of a dialogue interpreter. perspectives: studies in translatology, 1, 105–121. http://www.unhcr.org/4a2fd52412d.html http://www.unhcr.org/4a2fd52412d.html http://www.state.gov/g/prm/rls/fs/2001/5412pf.htm 46 graduate student journal of psychology copyright 2005 by the department of counseling & clinical psychology 2005, vol. 7 teachers college, columbia university issn 1088-4661 invited paper learning to live with fear: negotiating life after a tsunami disaster a first-person account of doing trauma work with the survivors shefali tsabary teachers college, columbia university 4,000 dead, another 2,000 missing. “no, no, that number is wrong,” the man in charge of unicef’s disaster management team insisted to me, his eyes begging me to understand the magnitude of what he had recently lived through, the remnants of the hell he was still living in—“there are at least 6,000 dead and at least 5,000 missing.” 6,000 dead, 12,000 dead, 9,000 missing—the numbers swirled in my consciousness, until they ceased to have significance anymore. everyone was giving me different numbers, tossing them like pennies into the sweltering, humid air. numbers that hung heavy on the weary shoulders of relief workers, doctors, and nurses, and that eventually came to lie like mortar across my own. and i shamefully admit that i began to embrace a fascination almost macabre for the exact number of people dead. the question “how many dead?” had, in an incomprehensible manner, become the first question i asked. and strangely, “a thousand here or a thousand there” became irrelevant after the first few days. soon, they were just that—numbers. numbers that because of their concreteness were somehow able to offer odd relief from the ineffable bewilderment brought upon by trauma, grief, and psychological shock. it was only late at night, when my eyes would refuse to rest and my mind simply would not stop, that i would realize the meaning of these numbers. these were numbers of human lives taken. numbers of human people missing. never to be found or recovered. ever. swallowed by fifteen minutes of the ocean’s incensed dysregulation. these were actual numbers of people dead. even today i labor to find a way to comprehend these irreversible facts. how on earth does one begin to understand the relevance of this event? how is one supposed to reconcile its meaning, to integrate a despair so catastrophic that recovery seems almost a naïve fantasy? who is to blame and to whom can the survivors turn their unprocessed depression and inevitable vengeance against? the ocean? the very ocean that once sustained and fed their children? the very waters that nurtured their existence before but that has now ravaged all they know to be familiar—how are they supposed to accept this? how does anyone begin to make sense of that which is beyond understanding? these were the questions that burned for answers and, most of all, for healing acceptance. “i left with the clothes on my back. i ran uphill as fast as i could go, but the water kept running after me. i didn’t look back, i didn’t stop running for two hours. i didn’t go back to the shore for three days. i was scared to. and when i did, i did not recognize anything. my house, my belongings—they were all gone.” —krishna, age 32 “my husband picked up his mother on his back—she is over eighty years old—and i grabbed my son’s hand and we ran up the mountain. my son was crying because his favorite toy was swimming away and he wanted to catch it. he began to run behind it. i had to slap him really hard.” —sunita, age 24 “we have nothing now. nothing. when i first came to the island in 1974 i at least had a few clothes and the utensils that my mother had given me. now i have nothing. i need to start all over. i don’t know what to do. should i go back or should i go to the mainland? what will become of my children?” —ramesh, age 47 “the wave was huge, it was black, as high as that tree over there. i have never seen anything like it in my life. i was screaming at my neighbor to run, run, run. she did not hear me. she did not even see the wave. i ran as fast as i could run. i do not know what happened to her. she was never found.” —anand, age 38 invited paper 47 “all the water went back. there, as far as the road over there. no, even further than that i think. i could see fish dead, lying there, so many fish. we did not understand what was happening. but my husband told me to get far away from the water. so we did. and i am so glad we did. we went uphill and kept going. i never went back to the shore. only my husband went. i was too scared to go there. i have not gone to the shore again since that day. i never saw what happened to my house or my things. my husband says that everything was wiped out. everything. my daughter is young, only three. she doesn’t know what happened. all she keeps saying is, ‘let me play in the water, let me play in the water.’ how do i tell her that we can never play in the water again? i get angry with her. i hope she will forget about the water forever.” —suman, age 23 as i wandered through the narrow, winding streets of port blair, the capital of the andaman and nicobar islands, i wondered how it used to be before december 26th. i imagined the streets bustling with loud music that blared from tiny transistor radios, kiosk stands busy selling the hot oily snacks so enjoyed by most indians, and the boardwalk alongside the calm, blue waters, crowded with families enjoying the ocean’s resplendence. on this day however, the boardwalk was barren, and the streets were muted with a silence completely uncharacteristic of an indian city. the doctor who was giving me a tour shook his head as he looked out into the ocean. “no one comes out any more. children are afraid to come near the water.” he then told me how the entire tide system had changed since the tsunami. while the locals could predict the change of tides accurately before, now they were left befuddled by its unpredictable nature. the tides, he said, changed every few hours now. “very strange,” he muttered to himself. later, when i walked along the beach, my feet constantly bumped into twigs, branches, rubber, and other debris. “none of this was here before,” the doctor said. “it was clean, clear water. no rubble then.” and then he told me how on jan 2nd there had been a rumor that another tsunami was going to strike. “the entire city was terrorized,” he said. “two people died in the chaos that day. everyone was running like mad. no one knew what was going on; all they knew was that they had to run as far from the water as possible.” i later discovered that rumors of more tsunamis had become a rampant and almost weekly occurrence, constantly barraging any hope for a secure psychological recovery for the inhabitants of these islands. “even without the rumors,” the doctor wisely told me, “the people would still be terrorized. whenever they hear the word ‘water,’ they run. they don’t even wait to hear the entire sentence, just the word ‘water,’ and there they go like crazy chickens,” he laughed nervously. and he, like many others i met, now lived a life overshadowed by a nervous tension painted with the timorous strokes of an unyielding agitation and a desperate uncertainty about the future. today, they dwell in new bodies, and live new lives. bodies that have changed, for some, in drastic ways reminiscent of classical ptsd; for others, in ways more subtle—so subtle as to be imperceptible. until one probes a little deeper. and then they reveal that their lives are no longer theirs to feel control over, their future no longer theirs to dream of. their nightmares are strange, and their dreams are filled with mental chaos. their relationships are skewed, forced, unnatural. their very selves seem to be split, part of them clutching to the lives they lived pre-tsunami, and part of them desperately searching for meaning in an unfamiliar world since. to laugh is toilsome, to cry terrifying. neither offers relief. no, nothing is the same anymore. simply put, their entire worlds have changed. irrevocably. the tsunami disaster has been the worst natural disaster in over a hundred years. entire communities have been wiped from existence. they have been shaken from their foundation. they have been uprooted with nowhere to turn. there is no one to blame here, no evil “other” person or race. here, it is nature that turned against humans. is nature then evil or benevolent, or both? how do the survivors integrate this tragedy into their lives and learn to live with, not run from, the fear that has now enshrouded their psyches? and while we all say that one should ‘move forward,’ can you tell me how it is that they should move forward with their lives? i ask you this, because this is what i was asked. “you tell me,” they would demand, “how am i supposed to understand this?” “please explain to me what i am supposed to tell my children,” they would implore. “faith! what faith should i have, in whom?” “hope, you say? tell me what hope can i have, when my sister lives each day with the memory of her children being swept into the ocean?” yes, these were the searing unknowns that i was presented with each day of my stay there. some of the eyes that searched deep within me were filled with resignment; others, with confusion, even anger. yet most faced me with hope—hope that i would actually be able to put this tragedy into perspective for them. that i, fresh-faced and full of optimism, would somehow tell them that it would all be over soon, that the fear they lived with would soon fade, and that the tsunami would never dare to touch their pristine island again. yet when i looked back at them, i knew that i couldn’t give them any of this. i couldn’t assure them anything. all i could do was look back into their eyes as deeply as i could. and tell them that i understood. i understood their helplessness, fully felt their fears, and equally longed for their lost sense of security. to this day i marvel at the synergy of events that led to my going to these islands. i first heard about the possibility three weeks before i actually went there, giving me little time to change my mind or succumb to the endless doubts i had about my capacity to actually do such a training. i remember oddly wishing for the flights to be full, or for something drastic to happen—anything that would relieve me of this awesome responsibility, yet not make me look like the coward i really felt like. “i shefali tsabary 48 am not a trauma expert,” i told myself repeatedly, and then, to provide the illusion of solace, i would look up the portfolios of “trauma experts” on the internet and feel relieved when they had pictures attached to the resumes. “ah, perhaps i look more interesting than that man there,” i would think, or, “this person doesn’t look like fun,” i would say. unhealthy compensatory tactics, admittedly. but they helped momentarily. i remember feeling nauseous for most of the time prior to my workshop. i couldn’t sleep and was wired. i just wanted to go and be back in the safety of my family and home. i had no idea what i was going to do. i felt despair and much sadness just thinking about all that i would witness. i was nervous as hell. and then one day it shifted. it shifted when i realized that here i was merrily, vicariously traumatizing myself, transfusing my silly mind with all sorts of depressing energy. i had, in effect, forgotten to give myself the permission to enjoy this endeavor. i had mistakenly assumed that i needed to be all serious or sad. and then i got it: this is what i would bring to the people there—the permission to be joyful. the permission to laugh again, to love life again and to “be” again. we would dance and sing. we would write poetry and play games. we would build sand castles and write letters. or we would cry together. but most of all, we would simply be. it was then that i relaxed into my own being and allowed myself to be organically oriented to this journey. it was only then that i let go of my need to be an “expert” or “a very serious person,” and instead simply be me. but be fully me. open and ready to be transformed. more than any of my egotistical insecurities being quelled however was, i think, my unshakable conviction that i simply could not pass up an opportunity to be part of this event. this gave me the courage to go. i knew in my heart that i would learn so much, that i would grow, and that i would so push my internal envelope of comfort that it was worth the consequent agony and moments of illogical anxieties. and it was. i truly did receive far more than i could have ever given. so much so that i do not even look at what i did as anything but a truly self-fulfilling endeavor. helping others was an unspoken and organic concomitant of my agenda, not something i even paid heed to. i went there with one purpose: to show up. to be present. to take risks and to grow. i wasn’t going to change or heal anyone. i wasn’t on any such mission. i was going to ask questions, to share stories, and most of all, to listen. and in this process, it was i who was healed and i who was helped—the most. i had a two-fold task in training over 60 doctors, nurses, and counselors in two 4-day workshops. the first was to train them in the understanding and treatment of trauma, and the second—because they themselves were victims of the tragedy—was to actually conduct psychological processes with them. together we were to create our own framework of what this trauma meant to us, how we could process it, how we could integrate it, and, the most challenging, how we could transcend it. my goal was to provide the group with an educated understanding of trauma and to demonstrate psychological processes—both individual and group—that they could later implement in schools, health centers, and relief camps. my orientation to running this group was inspired not only by my psychodynamic training at teachers college, but also by my training in the creative arts. i received my masters in drama therapy from the california institute of integral studies in california, where i received training in how to run groups using the power of the arts as the primary mechanism of healing. the main premise behind the use of the creative arts in therapy is not to minimize verbal introspection, but to accelerate and often even deepen it through a constant focus on the here and now. the moment right now is of supreme importance, and the therapist’s task is to find a vehicle by which this moment can be best expressed by the client in an active and fully present manner. with its focus on spontaneous expression and the release of the creative spirit, this type of therapy helps clients enter a new realm of experience and feel the present moment in an entirely new way. as such, i utilized art, poetry, drama, and movement in this group to bring the clients into their bodies in as holistic a manner as possible, hoping to provide an experience of integration and to allow them to actively embrace that which was previously latent. as inexplicable as the use of the creative arts in healing work can be, it has an imitable sense and rhythm behind it, following the group’s beat and listening to the sounds of their experiences. every psychological intervention i used with the group, in some small way or another, utilized the arts, creating a circle of healing and creativity that most had never been exposed to in their lives thus far. when i first began to speak of trauma and traumatic symptoms, not once did i use the term ‘ptsd.’ not only because i didn’t want to use the word ‘disorder,’ but also because i simply wanted to refrain from jargon and diagnosis, at least in the beginning. because of all that they are newly experiencing, trauma survivors feel distant and strange, and it just didn’t feel right to label them with a term that could further perpetuate their sense of isolation. i also didn’t yet fully understand the meaning they would attribute to this diagnosis. so instead, i wanted to focus on process, and on group sharing and dynamics. i wanted to use the language of the group—the words they used to describe their experiences. in order to do this, i asked them to share their stories, through exercises such as automatic writing, sentence completions, and letters to themselves. from their sharings, i elicited the themes, metaphors, and analogies that would shape our understanding of the trauma each was experiencing. for example, when i asked them to think of their lives post-tsunami, i asked them to think about it in colors. most of them chose dark, dismal colors, bereft of warmth or energy. so we talked about trauma being like ice or ashes, freezing or burning up one’s inner resources, solidifying or crumbling habitual defenses and calcifying courage. all the symptoms we talked about came through their stories—and people had plenty of stories to tell. each one knew of someone who had lost someone. there were four members who had directly lost a loved one—one had lost her father, another, her two nieces, another, an uncle, and the fourth, her friend. in an automatic writing exercise, the very first day, a woman began to cry. she said, “i didn’t think i was traumatized. i didn’t even realize that i was feeling this way.” and this became a persistent theme—the understanding that all of them in the room invited paper 49 were traumatized in some way or another. many thought that they should be brave and deny their own feelings of trauma because they had not directly experienced loss. we quickly dispelled this myth. we soon came to accept that each in the room had experienced trauma, regardless of the level of impact. slowly, very slowly, the group began to give each other the permission to experience what had been previously split off. this became possible, first, through the poignant realization that “yes, i do experience trauma reactions, and i have every right to,” and second, through the understanding that this experience is normal. normalizing the trauma became a large part of the work we did together. however, it was only when i shared my own “abnormal” reactions to stress that the group finally opened up to sharing theirs. so i found myself, without meaning to, telling them very personal secrets of my own “dark side.” yet, when i saw the group relax and ease into their own sharings, i felt that perhaps my own dark side wasn’t so dark anymore. perhaps i learned to normalize my own abnormalities in this process as well. we saw trauma as constricted energy within the psyche and soma. consequently, the inter-relatedness of the psyche and soma was repeatedly emphasized, and releasing this pent-up energy became a focus. exercises from the creative arts were tailored to help them experience their bodies in new ways and begin to integrate their experiences. i asked the group to begin to honor what they were feeling in the moment, in the here and now. towards this end, we did many creative exercises that grounded them in the present moment. we meditated, we did breathing exercises. we did movement exercises that zoned emotions in the body. we played drama games that challenged them to hone in on what they were experiencing through visual representation. we drew images that centered their experiences in a very concrete, yet creative, manner. these exercises, all of which aimed to both center experience in the here and now and to free up the creative spirit, helped participants to share their experiences in a very free-flowing and natural manner. before they knew it, they were sharing very personal stories with each other, revealing their post-tsunami experiences—sometimes crying at all that had never been expressed, sometimes giggling uncontrollably as a way of release. because i view trauma as creating splinters within the self, much of the focus was on articulating this split as it represented itself within each participant’s psyche. the more ways i could help them visualize this split, the better. i asked them to choose objects from nature to represent themselves before the tsunami, at present, and in the future. then the group together made a collage of the objects from nature. in another task, i asked them to pair up and make sculptures of their partners representing their inner emotions during the tsunami and at present. this was again designed to provide a concrete and visual representation of their emotions at different time periods in connection to this event. and then i asked that we create a “group sculpture”—again, to give the participants a visual representation of their collective emotions. they were asked to write letters to the people they used to be before this event describing how they have now changed. here, they found themselves saying goodbye to parts of themselves, but also welcoming new parts of themselves, some fear-ridden, some full of new-born strength. again, each person in the group shared their writings with the others. so while the work was individual on many levels, it was always made collective, so that the individuals always felt a sense of connection to the larger group. these exercises are an example of how i used the arts to illuminate a self that, rather than being congealed—describable only in terms of the trauma—, was in actuality still multi-layered and complex. i found that many of the participants referred to themselves in unidimensional terms. as if all they were now were victims of this tragedy. piecing apart the many layers of their selves became an all-important focus that allowed them to see that yes, there are huge chunks of me that are paralyzed and rooted in trauma, but that there is that slightest possibility that there a part of me that is free from it, perhaps still hopeful, perhaps still available for growth. emphasis, in all of these exercises, was in expression and integration. recognition and awareness. and most importantly, acceptance and hope. while i cannot give enough details of what we actually did, what i hope to offer is a qualitative gist. what our eight days together was really about was the creation of a common language. this was perhaps the most empowering element of our time together. identifying emotions, while easy for us to do, is often particularly hard to do in the aftermath of a trauma. for the trauma survivor, emotions are often coagulated, foreign, and unidentifiable. much of the work then gets focused on creating a language to identify emotions. much like children with the “smiley chart,” here too, each emotion and behavioral correlate needs to be spelled out. just in the labeling of emotions—“you are feeling worthless, i know,” or “you are angry, this is so natural,” or “you feel your future is bleak”— helps in relieving the pressure of these scary emotions within the trauma victims. so it was through the creation of a common language that the participants began to give themselves the space to exist—emotional meltdowns and all. many of the participants said that they simply never went to the beach anymore. they missed it, yes, but their fear of even the possibility of another tsunami was just too overwhelming. as much of the work in trauma is on desensitization and integration, i thought to myself, “well, if they don’t go to the beach, i have to bring the beach to them.” so, on the last day, i went to the beach and hauled buckets of sand to the workshop. i then asked participants to take the sand in their hands, and i conducted a visual imagery exercise with them. they were asked to close their eyes and imagine their childhood again, a childhood where they were friends with the sand, the ocean. because the imagery of trauma as an “ice-like” experience was so consonant with many of their stories, i asked them to imagine “golden” and “warm” thoughts around their feelings. then participants were asked to write letters to the ocean, and it was here that the group came full-circle. they wrote about their feelings of betrayal and confusion. how they felt like they had lost one of their biggest allies, as most of them had spent their free time on the beaches. many felt like their children had been robbed of the opportunity to live without fear, and this angered them. yet, towards the end of shefali tsabary 50 most letters, they wrote of their deep love and appreciation for the ocean. their forgiveness towards it. and for some, their acceptance. in this space of openness and creativity, we also explored our role as “helpers.” many of the participants had never counseled before, so the basics of counseling were also talked about: how does one empathize, how does one be in-tune, how does one offer brief counseling? many of these “helpers” were feeling overburdened by their feelings of inadequacy in the counseling field. they were running out of solutions to offer. it was a great relief to them to hear that they didn’t in fact have to offer any solutions. yet, for many this was a cause of great resistance. they could not wrap their heads around the concept of “simply being with another.” only after four days of experiential work and “being” with the others in a very open manner were they able to glimpse what it meant to enter into another’s space and join. for many, this was the first time that they had ever allowed themselves to enter into their own inner space. participants struggled greatly with a dilemma researchers in this country grapple with—to repress or to express. in their own sophisticated manner, the group came up against this dilemma themselves. i asked that they hold off on the question until the very last day of the workshop. i never presented what my opinion was, because i can honestly say that i do not have a fixed one. and then, when i asked them on the last day what they thought of their initial dilemma of repression versus expression, one of them wisely summed up the group’s consensus: “i guess repression helped right at the beginning, because we just had to survive. we had no electricity, no water, for weeks, we just had to survive. but now, i needed to talk about my feelings. i needed to get it all off my chest. it was driving me crazy.” much of the work was also about shaking people’s level of complacency, or perhaps fear. much of our time was spent focusing on our own fears of confronting another’s pain, especially traumatic pain. many of the doctors and nurses there felt burned-out and unable to give of themselves anymore. many of the teachers there had come from affected areas and could not bear to go back. fear had kicked in old defenses—perhaps rightfully so—and they were extremely resistant to opening themselves to vulnerability again. in fact, many of them had not even gone to the relief camps, not even once—so great was their resistance, so desperate their need to shield themselves from pain. so while honoring where they were was important, so was reinforcing their courage and inspiration to serve. somehow, we needed to get to their core, beneath the logic or illogic of their defenses. i didn’t do this directly—that would have seemed too patronizing. instead, i had the group enact out their resistances. as one example, i divided the group into two. one group played out all the fears and resistances. they were asked to amplify these defenses. the other group had to motivate and inspire them. i made sure to put the more resistant folk in the group that was supposed to motivate the other group. once the “motivators” saw how difficult it was to “motivate,” and how frustrating it was to come up against well-formed defenses, they began to have insight into their own rigidity and unwillingness to confront their fears. one of my more resistant participants said to me, “they were so difficult to convince. i hope i am not like that.” my stance therefore was to refrain from being “the educator” or “the inspirer”—sure, i was a facilitator, and i was extremely active and directive in this role—but i really wanted the answers to come from the group members themselves. they were to together negotiate strategies and solutions, of course within the framework i provided. but that framework was loose—i simply provided the creative circle within which avenues for expression were paved. i still remember how one teacher said to me at the end of the workshop, “you know, i have always wanted to go and play volleyball with the children in the relief camps, but i have never gone. now this has given me the courage to go. i am going to go every sunday and play with them.” a nurse, while reading out her “personal commitment statement” (which each participant was asked to create), said, “i have avoided talking about this with my children. i am scared to. now, after this workshop, i can go back and really help them understand what happened.” many feelings were stirred within me in the course of my time there—some included the usual “am i doing enough, will i ever do enough?” feelings, and some were less familiar, such as my countertransference feelings of harboring extreme expectations of my workshop participants. i found myself to be inordinately invested in their level of commitment to the process. if i was committed to this work, having traveled the seven seas, then by the same right, so should they. right? it was only when i became aware of my zealous attachment to this rather ridiculous expectation that i let it go…stubbornly. i had to accept that each person would walk away with his or her own level of inspiration and commitment to this process, sparked by the unique events in his or her own life. i couldn’t expect anything more of them besides their attention at my workshop, if even. yet, this expectation was hard to let go. it still is. but none of my feelings were as dramatic as the ones that were evoked when i would visit the relief camps. the quotes presented at the beginning of this paper were from some of the people i met there. here, i would see the true impact of the tsunami. folks sitting on tarps, with one or two boxes of belongings, sometimes none, sitting in the scorching heat for months with no one to talk to, no one to offer hope, and, most of all, no one to simply listen. their eyes would light up when i would visit, yet, unselfishly, they never burdened me with their expectations. no, i made sure i did that for myself. today, my own life has subtly shifted. i am blessed to have a larger framework for events than i did before. where before narrow concerns of my limited existence were all-consuming, now they are processed against the backdrop of all that i have recently witnessed. and the ravages of the tsunami, while devastating to glimpse into, have given me resolve and a renewed commitment to the work that most of us in the field of psychology are passionate about. it is in moments like these that i am so grateful to do this work—work that is excruciatingly demanding, yet gloriously fulfilling. running head: effects of munchausen graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university effects of munchausen syndrome by proxy on the victim kimberly glazier teachers college, columbia university the perpetrators of munchausen syndrome by proxy (msbp) produce symptoms that often result in multiple doctor visits, hospitalizations, incorrect diagnoses, and unnecessary procedures for the victim. immediate physical harm exists for all suffers of msbp. however, growing research suggests that there are lasting adverse physical, psychological, and social effects for individual victims of msbp. the mortality rate and risk of further abuse for children who are returned home after they receive a diagnosis of msbp suggests greater consideration should be given before allowing a child to continue living with the perpetrator. studies show that msbp is not culturally dependent. the difficulty in diagnosing cases of msbp indicates the prevalence rate may be underestimated. the term munchausen syndrome (ms) was first described by asher (1951), who suggests that the main goal of individuals with ms was to trick healthcare professionals with false illnesses and to gain attention and care from providers. the deceptiveness of those with ms, in part, has caused a delay in the identification of the disorder; it was not classified until the 1950s. twenty-six years after asher coined the term munchausen syndrome, meadow (1977) introduced the term munchausen syndrome by proxy (msbp). the two conditions are categorized in the diagnostic and statistical manual of mental disorders iv-tr as factitious disorders (american psychiatric association, 2000). the subcategory factitious disorder not otherwise specified is where msbp, also known as factitious disorder by proxy, is classified. msbp is diagnosed in cases where a caretaker intentionally produces or feigns illness for another individual. the motive for inducing symptoms results from the desire for attention and sympathy. these cases typically involve, but are not limited to, a mother as the perpetrator and her child as the victim. due to the nature of the illness, the prevalence rates for ms and msbp are difficult to determine. one study by hamilton and feldman (2006) reported a probable prevalence rate for ms of .2-1% for hospital inpatients, while another 2-year prospective study reported a prevalence rate of msbp at .00075% for children under the age of 16 (mcclure, davis, meadow & sibert, 1996). the literature shows that the majority of individuals with ms tend to be white males between the ages of 30-50 years (hamilton & feldman, 2004). the majority of msbp perpetrators tend to be white mothers of no specific age (brannon & carroll, 2008). little other demographic data is available, and research examining whether or not religion and socioeconomic status may be significant predictors of ms and msbp would be helpful. 1 correspondence: kimberly glazier, kimberlyglazier@gmail.com perpetrators of msbp bools, neale, and meadow (1994) examined characteristics of msbp perpetrators. the medical files of 62 families from the united kingdom with a known history of msbp were examined. sufficient information on the mothers (the perpetrator of the msbp cases) was gathered from 47 files and 19 mothers completed in-person interviews. the data showed that 19 of the 47 mothers had criminal records. a more detailed examination of mothers who completed in-person interviews found that 15 of the mothers reported childhood emotional neglect or abuse, 12 had a history of self-harm, and 8 reported a lifetime history of alcohol or drug problems. also, 15 met the diagnostic criteria for somatizing disorder, eight for histrionic personality disorder, five for borderline personality disorder, two for dependent personality disorder, and one for avoidant personality disorder. on the whole, the data suggest that as a group, msbp perpetrators face adverse childhood experiences and suffer from a range of psychological disorders. cases of msbp one of the first investigations of msbp was conducted by meadow (1982). nineteen cases of msbp occurring in england were examined. data were gathered on 19 children (10 boys and 9 girls), under the age of 7, from 17 families. the mothers of these children consistently presented false clinical histories and fabricated symptoms that resulted in unnecessary harmful medical investigations, hospital admissions, and treatment. the data were derived from physician’s medical records. the results showed that all of the children were subjected to hospitalizations. one subject missed 13 months of schooling, spent 5 months as an inpatient at a hospital, underwent 12 procedures, and was prescribed 27 medications. at the time of follow-up, which ranged from 1 to 4 years, two of the children in the study had died, and eight of the subjects were removed from their home environments. records from two of the nine children 70 effects of munchausen 71 who remained living with the perpetrator showed that frequent trips to doctors persisted. in seven of the 17 families with siblings, there were signs suggestive of similar practices with siblings. in one family, a sibling died under suspicious conditions. the findings of meadow’s 1982 study helped spark an increase in the amount of attention and research devoted to msbp. rosenberg (1987) performed an extensive review (1966 to 1987) of the existing literature on munchausen syndrome by proxy. rosenberg obtained 117 reported cases of msbp and divided the symptoms of the victims into two categories: simulated or produced illness. simulated illness was assigned to children when the mother did not directly cause harm to the child (e.g., infecting the child’s urine sample with outside contaminants). in produced illness cases, the mother physically caused harm to the child, such as inducing bone fractures or subjecting the child to sunlamp exposure that resulted in severe burns. the method of symptom induction was available for 72 of the cases. the findings showed that 25% were simulated illness only, 50% were produced illness only, and 25% were a combination of the two. rosenberg further investigated the morbidity of msbp by delineating short-term and long-term morbidity. shortterm msbp morbidity was defined as discomfort and/or illness that once resolved did not have a negative lasting impression on the overall health and development of the child. long-term msbp morbidity was defined as permanent adverse effects that resulted from the pain and/or illness. all of the cases met the criteria for short-term morbidity and 8% of the living subjects were determined to be affected by long-term morbidity. ten of the 117 children in the study died, resulting in a 9% mortality rate. also, 10 siblings of the 117 msbp victims died under unusual circumstances. among the msbp victims that died, 20% of the mothers were diagnosed with msbp prior to the child’s death. despite knowledge of the mother’s illness, these children were allowed to live with the mother, which resulted in the subsequent death of the child. overall, 24% of the perpetrators were diagnosed with ms or possessed features of ms. furthermore, 1% of the sample reported sexual abuse, and 1% reported physical abuse. similar to rosenberg’s review, sheridan (2003) performed an extensive search for incidences of msbp (1987-1999). the study showed that 57.2% of the cases involved physically produced symptoms. sheridan also found a msbp long-term morbidity rate of 7.3%, a 6% mortality rate, and a 25% mortality rate for siblings of msbp victims. the data also showed that 61.3% of the siblings had documentations of suspicious illnesses or similar symptoms as the index subject. in 29.3% of the cases the perpetrator was diagnosed with ms or possessed features of ms; however, data on the number of perpetrators diagnosed with msbp prior to the child’s death was not provided. furthermore, rates of sexual and physical abuse for the victims of msbp were not documented. neither rosenberg (1987) nor sheridan (2003) examined whether the manner of fabrication significantly impacts the future well-being and adjustment of msbp victims. investigating such relationships would be an interesting area to explore. victims becoming perpetrators according to rosenberg (1987), it is possible that “child victims of msbp grow into adults who perpetuate msbp or who suffer from munchausen syndrome or somatization” (p. 557). incidence rates for the evolution of victims to msbp becoming perpetrators of msbp are not currently known; however, if rosenberg’s belief were true, one would expect most msbp victims to be female given that the vast majority of msbp perpetrators are female. in both rosenberg’s (1987) and meadow’s (1982) studies, all perpetrators were the mother of the child. in sheridan’s (2003) study, 76.5% of the perpetrators were mothers and only 6.7% were fathers. in rosenberg’s study, there were no significant gender differences among victims of msbp (46% male, 45% female, and 9% unknown). in meadow’s study, there were 10 male and nine female victims. sheridan showed similar gender rates among victims; 52% male and 48% female. this data suggests, that at least for males, being a victim of msbp does not predispose the individual to become a perpetrator of msbp later in life. more research is needed to determine whether or not a positive correlation between being a victim of msbp and becoming a perpetrator of msbp exists for females. potential complications for victims of msbp psychological conditions have not been assessed in the majority of the msbp subjects. schreier and libow (1993) noted that out of the 178 articles found on msbp, 143 were located in medical journals, while only 19 were in psychiatric or psychological journals. however, rosenberg (1987) noted three cases of psychological disturbances for msbp victims. the symptoms included severe withdrawal, preoccupation with being poisoned, emotional disturbances specifically related to fear of blood and death, fixation with bodily integrity, and aggression. the lack of data on psychological disturbance and msbp highlights the need for future work examining whether or not the onset of certain psychological disorders are positively correlated with msbp victimization. schreier and libow’s (1993) study identified the mortality rates associated with msbp. questionnaires assessing for msbp were mailed to 1,258 pediatric doctors (870 neurologists and 388 gastroenterologists). the response rates for the two groups were 22% and 32%, respectively. the results showed 273 confirmed and 192 highly suspected cases of msbp. furthermore, in 25.8% of the cases, siblings of the victim were also believed to have been subjected to msbp. in total, the mortality rate was 9.7% for children suffering from msbp and 4.8% for their siblings. these glazier 72 studies showed the immediate consequences of msbp and support the notion that more protection needs to be provided to victims of msbp as well as other children living in the home. davis et al. (1998) conducted a follow-up study to mcclure’s 1996 study of the epidemiology of msbp, nonaccidental poisoning, and non-accidental suffocation. questionnaires were sent to the pediatricians who participated in the earlier study to assess the outcome of the cases previously submitted to the british paediatric association surveillance unit (bpasu). the response rate for completion of the surveys was 93%. excluding deaths, 91 cases of mbsp were identified. physical harm was identified in 52 cases. thirty of the 39 msbp victims with no physical harm were returned to live at home. during the follow-up period, five cases of further abuse were reported, resulting in a 16.7% re-abuse rate. two children suffered further instances of msbp and three were victims of emotional abuse. excluding cases involving suffocation or poisoning, 13 cases of msbp with physical harm were documented. nine of those children were returned home and one case of further mistreatment was found, which constitutes an 11.1% re-abuse rate. the 2-year prospective study combined with the 1-year follow-up study provides further support for harm associated with msbp and the danger of returning victims to live with the perpetrator. few studies have specifically examined the impact msbp has on its victims after receiving an msbp diagnosis. a follow-up study conducted by bools, neale, and meadow (1993) included a follow-up assessment of individuals diagnosed with msbp. the initial study, which identified 56 msbp cases occurring between 1976 and 1988, examined methods used to fabricate illnesses and the symptoms induced by the perpetrators were reported (bools, neale and meadow, 1992). the follow-up study sample was comprised of 54 cases (26 males and 28 females). two children died in the lapse between studies. the duration between detection of msbp and follow-up ranged from 1-14 years with a sample mean of 5.6 years. clinical interviews were conducted with the parent or current guardian of the victim if researchers determined that potential adverse effects for the child were minimal. upon follow-up, 30 of the 54 children remained living with the mother, who was also the perpetrator. in 10 cases the mother was still feigning sickness in the subject. no fabrication of illnesses was found in the children living with foster or adoptive parents. this data suggests the importance of permanently removing msbp victims from the home environment. sufficient data to determine current psychological functioning of the individual was obtained for 38 children. twenty-seven of these children were considered to have significant disorders and 10 of these subjects, although significantly impaired, were beginning to display signs of slight improvement. the children suffered from a range of symptoms that affected their physical, psychological, and social wellbeing, including: somatic symptoms, nocturnal enuresis, developmental delay, irreversible brain damage leading to quadriplegia and severe learning disabilities, coordination issues, emotional problems, specific phobias, conduct disorder, hypochondriacal behavior, nightmares, concentration difficulties, social development delay, theft, school non-attendance, and school suspension. these studies indicate the short-term consequences of msbp, while bools, neale, and meadow (1992, 1993) also demonstrate that many victims continue to suffer even after a diagnosis of msbp was determined. adult survivors of msbp to research the lasting impact that msbp has on child victims, libow (1995) conducted a retrospective study that examined the adult lives of 10 msbp survivors. the subjects completed a questionnaire and were offered an optional follow-up interview. the reports found that the perpetrator was the mother in nine cases and the father in one case. in response to a question regarding his or her childhood years, most participants reported emotional disturbances and two reported serious physiological problems. one respondent told of dramatic weight issues: being anorexic as a young child and 50 pounds overweight in her adolescence. another suffered from significant growth problems, weighing 47 pounds and standing 47 inches tall as a freshman in high school. half of the subjects reported suffering from a variety of depressive symptoms. four individuals experienced difficulties in school that resulted from physical or psychological factors. one child missed 8 years of schooling due to the mother’s insistence of her illnesses. another reported difficulty concentrating in school due to the constant anxiety that her mother’s abuse would recommence. with regard to the victims’ adult lives, two reported not being significantly affected by their childhood abuse; however, both of these subjects reported avoiding visits to doctors and ignoring health and medical issues. while these individuals did not consider their behaviors problematic, significant adverse consequences could result from ignoring potential health concerns and avoiding doctor appointments (e.g., early detection of cancer). the remaining subjects reported a range of lasting and damaging psychological symptoms, which included trouble sustaining relationships, inability to separate one’s identity from that of being a victim, and difficulty distinguishing reality from fantasy especially regarding bodily symptoms and the need to seek medical attention. furthermore, decreased feelings of selfworth, doubt, searching for maternal love, generalized rage toward family members, suicidal ideation, and feelings of anxiety and depression were all described as long-term consequences due to the msbp abuse. subjects were also given a 27-item questionnaire that screened for posttraumatic stress disorder (ptsd). nine adults completed the questionnaire and results found that six of the subjects had at least four symptoms of ptsd. also, seven of the adults had received psychiatric or psychological counseling and one patient reported having a clinical effects of munchausen 73 diagnosis of bipolar disorder. these findings suggest that victims of msbp can endure lasting negative psychological effects. out of the eight msbp parents still alive at the time of the interview, only four participants reported having some contact with the parent. these adults expressed ongoing fear of the perpetrator. furthermore, none of the eight parents admitted to the abuse, even when confronted by the participant. the direct effect of not receiving proper acknowledgement from the perpetrator cannot be determined from this study. however, in future studies it would be helpful to examine the parent-child relationship and the effect of proper acknowledgment of the abuse from the parent perpetrator. limitations one limitation of msbp research is the reliance on participants’ retrospective memory of childhood. however, retrospective self-reports are used in the majority of research that examines the effects of childhood physical and sexual abuse on later life development (e.g., libow, 1995). a study conducted by bernstein et al. (1994) explored the validity and reliability of the childhood trauma questionnaire (ctq; bernstein, 1995), a retrospective instrument used to assess childhood abuse. the results found an internal consistency ranging from .79 to .94 and a test-retest reliability of .88. the high validity and reliability of this measure supported libow’s decision to use the self-reporting method (1995). another shortcoming associated with msbp research relates to the complexity of uncovering msbp cases. a 2year prospective study looked to examine the epidemiology of msbp, non-accidental poisoning, and non-accidental suffocation among children under the age of 16 (mcclure et al., 1996). pediatricians from the uk and the republic of ireland reported all diagnosed or suspected incidences of msbp, non-accidental poisoning, and non-accidental suffocation that occurred from september 1992 through august 1994 to the bpasu. the results showed 97 cases involving msbp (55 msbp only; 26 msbp and poisoning; 14 msbp and suffocation; and 2 msbp, poisoning, and suffocation). the office of population census and survey reported a population of 12,725,936 during the time period of the study. from these statistics the prevalence of msbp was found to be .75/100,000; however, this percentage only included cases detected by the pediatricians. other factors help make determining the true prevalence of msbp difficult. meadow (1995) listed the following differential diagnoses for msbp: unrecognized physical abuse, overanxious parents, mothers with delusional disorder, masquerade syndrome, hysteria by proxy, doctor shopping, and mothering to death. there have also been multiple instances when the victim had informed professionals of the perpetrators’ production or simulation of the symptoms and the child was not believed (libow, 1995). another aspect that may make diagnosing cases of msbp even more challenging results from blended cases, which libow (2002) described as the collusion of symptoms between caregiver and child. in these cases, the intentions of both parties coincide. consequently intentional revealing of the deceit could make subsequent diagnosis more difficult for practitioners. detecting and properly labeling cases of msbp has been proven difficult. these challenges undermine accurate reporting of prevalence, and suggest that current rates of msbp incidences are underestimated. an international look at msbp while most research of msbp has been conducted in western societies, the universal presence of msbp should not be ignored. feldman and brown (2002) searched multiple databases, articles, chapters, and books to investigate the existence of msbp in countries excluding australia, canada, new zealand, ukraine, and the united states. the results found a total of 129 cases of msbp from 24 different countries. gender information was available for 81 cases (54% male and 46% female). in the 93 reports where the perpetrator was identified, 86% were the mother, 4% were the father, 4% were spouses unrelated to the child, 2% were the grandmother, and 4% were other. while information documenting the detrimental effects and mortality rate for the victims was not provided, the study did show that msbp existed throughout developed, developing, and underdeveloped countries. another international study reported on cases of msbp throughout japan (fujiwara, okuyama, kasahara, & nakamura, 2008). in 2004, 11 leading japanese physicians specializing in child abuse were asked to identify confirmed or suspected cases of msbp they encountered from 1995 to 2004. twenty one cases were reported, consisting of 10 male and 11 female victims. incidences were categorized as either having predominantly physical or psychological symptoms (16 and 5, respectively). eighteen of these cases were reported to the child guidance center and eight of the children were returned home to live with the abuser. two of the victims who returned home died; both of the victims were classified as having predominately physical symptoms. this study provides further proof that msbp also occurs in non-western cultures, with similar negative outcomes for victims. the findings also note the risk of returning victims of msbp to the home environment. lastly, another avenue for future exploration may be potential differences between perpetrators who produce physical versus psychological symptoms in the child, and more specifically predictive outcomes based on the four types of symptom feigning (i.e., physical, psychological, simulated, and produced). conclusion significant literature and research has been conducted since the introduction of msbp in the 1970’s. however, more attention and study needs to be given to the disorder. the literature currently shows the damaging short-term and glazier 74 long-term risks that may arise due to msbp victimization. the harmful complications compounded by the mortality rate for victims and siblings suggest that more consideration needs to be given to removing children from homes when msbp has been diagnosed. future research should more thoroughly address psychological issues among those exposed to msbp. an increase in knowledge surrounding psychological complications will help provide appropriate services to care for victims of msbp. furthermore, the prevalence of msbp and its signs and symptoms need to be made more publically accessible across all countries and cultures. greater awareness regarding msbp will hopefully decrease the duration between the onset of msbp and its diagnosis references american psychiatric association. (2000). diagnostic and statistical manual of mental disorders (revised 4th ed). washington, dc: author. asher, r. (1951). munchausen syndrome. lancet, 1, 339341. bernstein, d. p., fink, l., handelsman, l., foote, j., lovejoy, m., wenzel, k., et al. (1994). initial reliability and validity of a new retrospective measure of child abuse and neglect. american journal of psychiatry, 151, 11321136. bools, c. n., neale, b. a., & meadow, s. r. (1992). comorbidity associated with fabricated illness (munchausen syndrome by proxy). archives of disease in childhood, 67, 77-79. bools, c. n., neale, b. a., & meadow, s. r. (1993). follow up of victims of fabricated illness (munchausen syndrome by proxy). archives of disease in childhood, 69, 625630. bools, c. n., neale, b. a., & meadow, s. r. (1994). munchausen syndrome by proxy: a study of psychopathology. child abuse and neglect, 18, 773-778. brannon, g. e. & carroll, k.s. (2008). munchausen syndrome by proxy. retrieved march 24, 2009, from http://emedicine.medscape.com/article/295258-overview. davis, p., mcclure, r. j., rolfe, k., chessman, n., pearson, s., sibert, j., et al. (1998). procedures, placement, and risks of further abuse after munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. archives of disease in childhood, 78, 217221. feldman, m. d. & brown, r. m. (2002). munchausen by proxy in an international context. child abuse and neglect, 26, 509-524. fujiwara, t., okuyama, m., kasahara, m., & nakamura, a. (2008). differences of munchausen syndrome by proxy according to predominant symptoms in japan. pediatrics international, 50, 537-540. hamilton, j. c. & feldman, m. d. (2006). munchausen syndrome. retrieved march 24, 2009, from http://emedicine.medscape.com/article/295127-overview. libow, j. a. (1995). munchausen by proxy victims in adulthood: a first look. child abuse & neglect, 19(9), 1131-1142. libow, j. a. (2002). beyond collusion: active illness falsification. child abuse & neglect, 26, 525-536. mcclure, r. j., davis, p. m., meadow, s. r., & sibert, j. r. (1996). epidemiology of munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. archive of disease in childhood, 75, 57-61. meadow, r. (1977). munchausen syndrome by proxy: the hinterland of child abuse. lancet, 310(8033), 343-345. meadow, r. (1982). munchausen syndrome by proxy. archives of disease in childhood, 57, 92-98. meadow, r. (1995). what is, and what is not, ‘munchausen syndrome by proxy’? archives of disease in childhood, 72(6), 534-538. rosenberg, d. a. (1987). web of deceit: a literature review of munchausen syndrome by proxy. child abuse and neglect, 11, 547-563. schreier, h. a. & libow, j. a. (1993). munchausen syndrome by proxy: diagnosis and prevalence. american journal of orthopsychiatry, 63(2), 318-321. sheridan, m. s. (2003). the deceit continues: an updated literature review of munchausen syndrome by proxy. child abuse and neglect: the international journal, 27, 431-451.   3 graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university managed care and the mental health professions: history and effects on outpatient care gregory erickson teachers college, columbia university the purpose of this article is to offer a brief review of how managed health care companies have affected mental health services. an abbreviated history of these organizations is given followed by a discussion of how they operate to reduce both costs and service utilization. the consequences of their practices on outpatient treatment are then examined. results indicate that the overall breadth and quality of outpatient services available to the public have been substantially reduced by managed care. furthermore, clinicians themselves have been harmed by having to accept onerous administrative, economic, and ethical burdens because of managed care policies. the article concludes with suggestions on how to remediate some of these deficits in care and adjust to future challenges. the rapid growth of the managed care industry has indelibly changed the face of medicine over the last 30 years and nearly every facet of the health-care industry has been affected. physicians have had to abandon their role as the sole decision maker in treatment and adopt one in which the market partially determines who receives care (agrawal & veit, 2002). pharmaceutical companies, too, have had to make radical adjustments to their business practices including regularly negotiating with third-party payers for medication, accepting increased pressure to sell generics, and directing marketing away from doctors and towards patients (pollard, 1990). lastly, the medical insurance industry itself has changed as large free-market managed care plans have gradually eclipsed smaller, individualized health insurance options offered through employer benefit programs (scofea, 1994). in the midst of these paradigmatic shifts in health care delivery and finance, one particular group often gets left out of discussions regarding the future of medical care in the united states: those who treat mental illness. as this paper demonstrates, psychiatrists, psychologists, and other non-physician mental healthcare workers have also endured sweeping changes in their clinical practice. in general, the results of these changes have not been well-received; commentary from these groups about managed care has been overwhelmingly negative both in academic journals (appelbaum, 2003; watt & kallmann, 1998) and in the public media (sharfstein, 2001). one should note, however, that there are some advocates of the managed care system who argue that it provides necessary cost containment without any                                                                                                   correspondence concerning this article should be addressed to gregory erickson, 250 w. 100th st., apt. 307 new york, ny, 10025, tel: 847-612-5163, email: gregerick@gmail.com diminution in quality of care or patient satisfaction (broskowski, 1991). still others make the case that managed care companies are unfairly maligned for ethical dilemmas that have always existed in medical practice in different forms (meyers, 1999). yet, such defenders of the current health care system are generally rare among mental health care providers. in order to understand the reasons for this, the current paper presents a brief overview of the history of managed care in the united states and typical strategies that these companies use to reduce health care utilization and costs. criticisms of the current mental health system by psychologists and other practitioners are then examined with special emphasis on the effects of managed care on outpatient psychotherapy. finally, strategies to either combat or adjust to ongoing changes in the mental health field are discussed. overall, there seem to be considerable drawbacks to managed care from both the perspective of mental health workers and their clients. it is important that clinical psychologists recognize the extent of these challenges and seek opportunities for continued growth in the field of applied psychology. history and structure of managed care while public discourse about managed care has become increasingly shrill in recent decades, the practice of providing pre-paid, group health care is not new. kaiser permanente, currently the largest health maintenance organization (hmo) in the united states, originated in the provide comprehensive medical services for employees working on the hoover dam. similar plans were also put in place to cover the healthcare needs of employees in the lumbering, mining, and farming industries in various parts of the country during the great depression. all these forerunners of modern hmos shared the common features mailto:gregerick@gmail.com erickson     4 of contracting with a limited number of clinicians for standardized fees, usually paid in advance (deleon & vandenbos, 1991). unlike current managed healthcare organizations, however, these practices were often limited to certain commercial and federal employees and were mostly delivered by non-profit organizations. enrollment in these plans was further limited by aggressive lobbying by -paid plans accounted for only a small fraction of the health insurance industry (broskowski, 1991). all this began to change after the passage of the health maintenance organization act in 1973 under the nixon administration. the law provided federal funds for the establishment of hmos if they met certain criteria for the program. the legislation was initially passed and later amended to curb the burgeoning costs of healthcare, which had steadily increased to approximately 11% of gross national product by 1987 (broskowski, 1991). prior to the passage of this bill, hospitals and clinics had had little incentive to operate efficiently or to invest in preventative medicine because most procedures were covered by traditional indemnity insurance plans in which medical procedures were paid for on a fee-for-service basis rather than through a single upfront fee. investment in increasingly expensive equipment and technology by health care providers was also problematic, especially when more cost-effective means for treatment existed. as such, one of the major objectives of the new law was to streamline the delivery of healthcare, using such methods as treatment authorization by third-parties, periodic review of clinician performance and financial incentives to lower costs all methods currently employed by hmos. seeing a possible avenue for financial reform already in place, legislators merely sought to encourage hmo growth. one of the ways they attempted to do this was by extending the proposed grants to for-profit companies. managed care companies insurance leaders sought to take advantage of these and other economic incentives such as lucrative contracts to provide services for medicare. this growth has been so rapid that as recently as 6 years ago an estimated 175 million americans, or about 58% of the population, were enrolled in some form of managed health care (sanderson, 2004). soon after the passage of the 1973 hmo act, other institutional forms of managed care grew up alongside hmos, including preferred provider organizations (ppos) and independent practice associations (ipas). while the details of the care packages offered under these plans differ somewhat from those of traditional hmos, all three organizational types share common features. first, managed care plans use a pretreatment authorization process to assess whether medical care is warranted given a performed by a primary care doctor or sometimes by a nonphysician case manager. in insurance parlance this person controls the flow of patients to healthcare specialists that (richardson & austad, 1991). mental health professionals are considered a part of this latter category of providers. once the decision has been made to treat a patient, the specialist may then be asked to present a treatment plan to a utilization review committee either before or during the course of treatment. the committee will often request that changes be made to the treatment protocol, especially if alternate treatment methods can be used in a time-limited recommendations, the patient may receive only a small portion of the benefits to which they are entitled by contract. another common aspect of managed care insurance plans includes the payment of practitioners via capitation, in which hourly rates per patient are predetermined. fees may also be withheld based on how cost-effective clinicians tend to be. outpatient and brief therapy the economic policies mentioned above create potential barriers for patients seeking treatment for psychological disorders. perhaps the most severe effects have been felt in the realm of outpatient psychotherapy services. although federally chartered hmos are mandated to offer up to 20 sessions of outpatient psychotherapy per year (richardson & austad, 1991), many patients receive far less. in fact, data indicates that most beneficiaries receive closer to 6 sessions per year and clinicians have even reported being explicitly told to drop patients within this time frame by their managed care company (karon, 1995). data from a national survey of outpatient psychotherapy utilization in 1997 paints an even more dismal picture: only 10.3% of psychotherapy users made more than 20 visits to a therapist and approximately onethird of psychotherapy patients received only one or two sessions (olfson, marcus, druss, & pincus, 2002). although unethical coercive practices of prematurely dropping patients are barred, the dual processes of preauthorization of treatment and utilization review are enough to limit participation in outpatient therapy. many patients have reported being told by their primary care physicians that their psychological distress did not constitute a that is, it was not severe enough for referral to a mental health professional (miller, 1996). conversely, other incidences have come to light in which a the limited treatment available through the managed care plan, in which case he or she would be forced to pay out of pocket for specialists (donovan et al., 1994). regardless of the ostensible reason for the denial, it seems clear that outpatient psychological services have been singled out by managed care companies for cost containment initiatives. psychologist lee hersch hypothesizes that this effort to cut outpatient care stems from both skepticism among corporate and insurance leaders about the value of managed care   5 psychotherapy and the difficulties of demonstrating easily quantifiable outcomes among patients (1995). both objections are questionable and, moreover, do not represent good fiscal policy on the part of insurers. considering the vast difference between the costs of inpatient psychiatric hospitalizations and less expensive preventative methods like outpatient treatment, the latter should be preferred. savings from increases in productivity and functionality accrue during the course of longer-term treatment. still, in the absence of hospitalization, patients who give up on therapy or go elsewhere to seek treatment represent a financial success for most managed care companies. mental health consumers are not the only ones affected by the effort to restrict or deny outpatient therapy. substantial changes are also beginning to take place within the psychotherapeutic community that treats managed care patients. the limitations on session frequency and duration have created a shift in emphasis away from long-term therapy toward shorter courses of treatment. as such, the modality in its own right, distinct from the traditional therapies that preceded it. in other words, brief therapy is not just long-term therapy condensed into 10 or 20 sessions, but represents a significant shift in the overall delivery of treatment (miller, 1996). although the techniques and theories underpinning brief therapy are beyond the purview of the current paper, they involve more direct intervention on the part of the therapist and focus on specific treatment goals such as symptom reduction (charous & carter, 1996). this does not necessarily imply, however, that all brief therapies eschew strategies from insight-based treatments. even so, the practice of insight-oriented therapies is becoming less common under managed care because such treatments are not well-suited to the utilization review process (charous & carter, 1996). to many clinicians and academics this may not represent a problem because metaanalyses have shown that short term treatments are often just as efficacious at alleviating psychological disorders as long-term psychodynamic therapies (luborsky, digeur, luborsky, & schmidtco, 1999; luborsky et al., 2002). still some evidence exists that for certain patients, particularly those with comorbid conditions, chronic psychological problems or personality disorders, long-term psychodynamic psychotherapy provides superior results (leichsenring & rabung, 2008). managed care providers, on the other hand, are more likely to offer such patients group and educational interventions due to their potential cost-savings when compared to individual therapy. medication is also a frequent component of treatment because it requires minimal supervision, thus saving time on the part of managed care clinicians and staff. while the efficacy of medication for treating psychological conditions is generally beyond dispute, solely treating patients with pharmacotherapy may raise other issues such as lack of physician supervision, medication non-compliance, and increased risk for prescription drug abuse. they are standardized, one-size-fits-all treatments that do not sufficiently address individual differences among patients. therapists argue that both the limited number of sessions and the sometimes constrictive treatment protocols result in poor outcomes. a cursory glance at research on the typical course of therapy in the u.s. would seem to confirm this conclusion: the median number of sessions per visitor to a mental health practitioner between 2001 and 2003 was only 7.4 (wang et al., 2005), yet studies estimate ions is needed to achieve a modest 50% rate of improvement (anderson & lambert, 2001; kopta, howard, lowry, & beutler, 1994). as ivan j. miller (1996) has pointed out, patients are most susceptible to the placebo effect in the early course of their treatment and thus there is little reason producing change. moreover, it is likely that patients who disorders which are not appropriate for brief treatment. these patients, who would benefit the most from therapy, are therefore the least likely to receive a sufficient amount of it. ultimately, the only way to determine whether brief therapy is effective is to consult outcome and efficacy studies. psychological literature provides contradictory evidence, however, with some studies showing efficacy equal to that of long-term therapy and some showing reduced or non-significant efficacy (plante, 2005). until further studies are done, the success of most outpatient therapies in managed care settings will remain unclear. more troubling is the fact that the existing brief therapy research focuses on interventions that last from 25 to 30 sessions (miller, 1996). the services that managed care offers are oft knowledge, there are currently no controlled studies of this type of therapy. difficulties for c linicians in addition to concerns over the effectiveness of managed care treatment, many mental health workers experience stress related to increased ethical, administrative, and economic burdens. ethical concerns may arise because of divided loyalty between third-party insurers and patients. psychologists employed by hmos, for instance, might be forced to follow a treatment plan that is inappropriate according to his or her clinical judgment and, as mentioned earlier, may even be pressured to discontinue treatment. practitioners who contract with insurers as independent agents (ipas, ppos) can encounter similar ethical dilemmas as they attempt to ensure their own financial stability. employees who are paid via a capitation system are particularly vulnerable to conflicts of interest since they assume most of the financial risk associated with treating clients. in an environment where cost-containment is of such paramount importance, it may be difficult for erickson     6 clinicians to balance the financial limitations imposed on them by insurers with the needs of their client base. onerous administrative responsibilities such as having providers can also provoke feelings of bitterness between parties in the managed care system. the utilization review process involves intense scru often by case managers who lack the same professional credentials as the person whom they are reviewing. although it would be easy to accuse high-level practitioners resent having their decisions second-guessed by administrative personnel employed in business related settings. confrontations can be a frequent occurrence. a study by ronda callister and james wall jr. (2001) showed that health care practitioners employed by managed care companies are highly susceptible to anger and may engage in retaliatory behavior such as poor collaboration and refusals to compromise. callister and wall found that a key determinant in the development of conflict between clinicians and case managers was the disparity between the professional prestige of the individual parties and that of their respective organizations. interactions were most likely to become hostile between high-status clinicians who worked for weak institutions (like small private practices) and low-status case managers in powerful insurance organizations (callister & wall, 2001). in such instances, in which each side seeks to manipulate the other according to different power criteria. in the end, the person with the least organizational power usually ends up capitulating typically the clinician (callister & wall, 2001). future directions despite the vicissitudes that both mental health consumers and providers face in dealing with managed care in the u.s., there are ample opportunities to adjust to and even benefit from current changes in health policy. in his article on adapting to modern health care reform, lee hersch has outlined three basic strategies that current and future clinicians can use to ensure that the field of applied psychology will continue to flourish in the 21st century (1995). the first two approaches are top-down strategies that seek to bring about change through legislative, judicial, and regulatory interventions. first, he supports lobbying for parity with respect to government spending on psychological disorders in comparison with other medical conditions. second, he encourages apa members to support political candidates will be likely to endorse such initiatives. clinicians should also work with receptive politicians to create laws or sue for judicial rulings which require increased transparency from managed care companies. one of the greatest impediments to an accurate assessment of the managed care system is the lack of both empirical and anecdotal evidence regarding its practices. adequate information for the comparison of managed care plans remains inaccessible, even for insurance industry surveys (miller, 1996). prospective buyers of managed care are often misinformed about the details of the plan and important company policies limiting treatment options are never disclosed. deficiencies in coverage are often discovered only after medical problems have arisen and consumers have sought funding or reimbursement. with respect to outpatient care, the maximum number of therapy sessions covered in the contract does not accurately represent the number that will actually be received because usly discussed practices (miller, 1996). for those practitioners that are not in a position to lobby for governmental action, the resource is to simply express their concerns by voting during state and national elections. the third strategy that hersch suggests for improving the quality of mental health care is for clinicians to work toward diversifying the applications of clinical psychology to the medical sciences while simultaneously integrating the delivery of services so that greater coordination exists between providers at all levels of patient care. with respect to diversification, hersch notes an encouraging proliferation of specialty areas in psychology, especially in fields related to general medical treatment. it is estimated that 60% of doctor visits are due to stress or other psychologically related problems (vandenbos & deleon, 1988). it is not surprising, therefore, that psychologists see overall level of health. integration, on the other hand, can be achieved through the creation of multi-disciplinary mental health groups composed of social workers, drug counselors, psychologists, psychiatrists, and other mental health care professionals. this increased coordination of care may better enable clinicians to contract directly with business and industry to provide superior mental health care without the encumbrances of third party insurers. moreover, these organizations could more easily create working relationships with other medical providers including nurses, pediatricians, obphysicians, and other primary care physicians. while managed care has clearly brought about a host of difficulties that affect the quality, delivery, and funding of mental health care, the outlook for future clinicians and patients is not as grim as one might believe. rather than an obstacle to the future of clinical psychology, managed care can be viewed as a catalyst for much needed changes in the health care system. it is therefore incumbent on psychological professionals to meet the challenges presented by managed care by rededicating themselves to mental health service that combines superior clinical practices with fiscally responsible and efficient methods for meeting patient needs. managed care   7 references 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(1998) managing professional obligations under managed care: a social work perspective. community health, 21(2), 40-49.   75 graduate student journal of psychology 2023, vol. 20 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university educating college students about dating violence bystander behaviors: evaluating an innovative animated intervention micah herman1 & karen m. o’brien2 1university at albany 2university of maryland, college park dating violence, or the threat or presence of physical, emotional, sexual, financial, or cyber abuse in a romantic relationship, affects college students at distressing rates, with between 10% and 50% experiencing at least one form of dating violence (kaukinen, 2014). such violence puts those who experience dating violence at high risk for substance abuse, suicidality, risky sexual behavior, and eating disorders (rakovec-felser, 2014). researchers pointed to the primacy of peers, substance use, limited relationship experience, being away from home, and the ubiquity of social media as significant in the perpetuation of dating violence on college campuses (duval et al., 2020; libertin, 2017). to reduce dating violence on college campuses, bystander intervention programs have been developed to teach students how to identify dating violence and intervene effectively (banyard et al., 2007; moynihan & banyard, 2008). the purposes of this study were to revise an online bystander intervention educational program (stop dating violence; o’brien et al., 2021) and to conduct a randomized controlled trial to test the effectiveness of the revised intervention. specifically, the stop dating violence intervention was converted into an engaging animated video format and then tested for its effectiveness. ultimately, this intervention could reduce rates of dating violence on college campuses. theoretical framework the model of bystander behavior (latane & darley, 1970) provides the theoretical foundation for this study. a bystander is defined as any person who witnesses or learns of an incident of dating violence. bystander behavior is engagement in actions to stop a given behavior. the individual and cultural impact of bystander behaviors is understood by sociologists as a kind of feedback loop in which individual people are shaped by the way that they participate in social systems, which in turn shapes the systems themselves (katz et al., 2011). bystander behaviors are spread through college student’s social networks, ultimately resulting in community-level changes in social norms (coker et al., 2015). moreover, when bystander behaviors are not performed, bystanders implicitly reinforce abusive behavior (katz et al., 2011). the model of bystander behavior (latane & darley, 1970) described the contingencies that are required for bystanders to become involved: bystanders must be aware of the problematic situation, perceive it as an emergency, decide that they have a responsibility to take action, and determine what help they are able to provide. also, multiple psychological processes may impede bystander interventions, such as diffusion of responsibility (i.e., bystanders believing that others will bear the responsibility for intervention), evaluation apprehension (i.e., bystanders worrying about acting in ways that may harm their reputation in the eyes of other bystanders like offering to help a victim and having the victim’s boyfriend be angry or think poorly of the bystander), and pluralistic ignorance (i.e., bystanders believing that dating violence situations are not emergencies based on the inaction of due to the extensively social nature of college campuses, peer intervention is a valuable tool for the reduction of college dating violence. while bystander training programs are becoming a common tool for addressing student welfare concerns on college campuses, there is little research evaluating the efficacy of these interventions. the purposes of this study were to revise an online bystander intervention program (stop dating violence; o’brien et al., 2021) and conduct a randomized controlled trial to test the effectiveness of this revised intervention. specifically, the intervention was modified and converted into an engaging animated video and then tested for its effectiveness. college students (n=335) were randomly assigned to one of three conditions: (1) the stop intervention, (2) a website containing information about dating violence, and (3) a control condition. students who viewed the stop dating violence video intervention had the greatest knowledge of bystander interventions when compared to the website and control conditions. thus, the stop dating violence video has potential to successfully educate undergraduates about appropriate bystander interventions for dating violence in a cost-effective manner. keywords: dating violence, college students, online intervention, bystander 76 other bystanders who are witnessing the abusive interaction; latane & darley, 1970). theory suggests that bystanders are more likely to report engaging in bystander behaviors if they feel a greater sense of responsibility and self-efficacy, and believe that the benefits of intervening outweigh the costs (jouriles et al., 2016). another relevant theoretical consideration is the ecological model of bystander intervention (banyard, 2011), which seeks to expand upon latane and darley’s model by considering community-level variables. this model emphasizes the importance of macrolevel factors in promoting change among individuals, highlighting the importance of interventions that are easily widely disseminated for the promotion of increased engagement in bystander intervention against dating violence on college campuses. bystander interventions to reduce dating violence on college campuses bystander intervention for dating violence evolved from the development of bystander intervention tools for sexual violence. the bystander approach was first applied to the prevention of campus violence in the mid-1990s (katz, 1994). researchers pointed to community norms as playing a significant role in the perpetuation of violence, especially on college campuses (dekeseredy et al., 2018). a large-scale shift in cultural and social norms was needed, requiring actions (e.g., bystander interventions) from the campus community (banyard, 2003). bystander intervention educational programs are relatively new in the field of dating violence prevention, but their outcomes are encouraging. however, these programs are few in number and inconsistent in terms of their potential reach and cost-efficiency (shorey et al., 2012). most of the programs designed for college campuses are in-person interventions focused on preventing sexual assault rather than dating violence. researchers tested the efficacy of bystander intervention programs and noted significant limitations. for example, project peace, which is an in-person intervention for college students, had mixed findings (jaffe et al., 2017). a study examining the men’s project, an educational program for college men, found that when men had a support group, they were able to use bystander strategies while challenging their sexist environment (barone et al., 2007). however, this program was limited by its focus on male students. a program by moynihan and banyard (2008) that targeted campus greeks and athletes, the populations with the highest rates of sexual violence on college campuses, successfully improved scores from pretest to posttest on six relevant outcome variables. also, a program called bringing in the bystander increased the likelihood of helping, confidence in bystander behaviors, and taking responsibility for ending college dating violence among sorority women (moynihan et al., 2011). these programs were limited by high costs, small sample sizes, and circumscribed target populations, suggesting the need for the development of effective online interventions. online interventions are beneficial for college students because they are accessible to (and convenient for) large numbers of students at low cost (o’brien et al., 2021). in addition, online interventions have been shown to be effective in educating college students on a variety of topics (e.g., sexual assault; devine, 2018, substance use; barry et al., 2016, responding to bereaved peers; hill & o’brien, 2021). online bystander training programs focused on reducing dating violence also show considerable promise (hines & palm reed, 2017). an intervention called friends helping friends increased participants’ perceived responsibility to help, skills to act as a bystander, and intention to help when compared to a control group (amar et al., 2015). however, this study was limited in its generalizability because it was only tested with female students and non-random group assignments. a promising online intervention that was effective in educating college students about dating violence and appropriate bystander behaviors was the stop dating violence program (o’brien et al., 2021). originally, the 3-component intervention was in the format of a prezi slideshow, which is now a less recent medium for disseminating information to college students. the first component, “education about warning signs of dating violence,” taught college students to recognize the warning signs of dating violence, including psychological and physical abuse (o’brien et al., 2021). it was consistent with the first two steps in latane and darley’s (1970) model of bystander behavior, which indicates that becoming aware of a problematic situation and perceiving the situation as an emergency are the first steps to intervention. the use of risk recognition as a tool in interventions against sexual assault and domestic violence was well-established, but rarely applied to programs focused on dating violence (o’brien et al., 2021). survivors of dating violence were not as likely to herman & o’brien 77 recognize danger in domestic violence vignettes as participants who had not experienced such violence (witte & kendra, 2010). the inability of those who experience dating violence to recognize risk supports the need for increased bystander intervention training efforts. the second component, “education intended to eradicate psychological barriers to helping,” educated bystanders about impediments to action according to latane and darley’s (1970) model: diffusion of responsibility, evaluation apprehension, and pluralistic ignorance. the third and final component, “education regarding desired bystander behaviors,” provided bystanders with a series of actions that they can use to assist those who experience dating violence. this component addressed recommendations to emphasize the role of bystanders in reducing dating violence (shorey et al., 2012). research on dating violence and sexual assault prevention identified bystander education that teaches students to proactively interfere when they witness potentially harmful or controlling behaviors as key to prevention of abusive behaviors (banyard, 2011). current study and hypothesis the purposes of this study were to revise the stop dating violence bystander intervention program (o’brien et al., 2021) and conduct a randomized controlled trial to test the effectiveness of this revised intervention. after the intervention was updated and converted from a prezi to a video format, this study assessed the effectiveness of the updated intervention by evaluating the degree to which individuals exposed to the intervention learned desired bystander behaviors when compared to those who did not receive the video intervention. one group of participants that did not view the video intervention looked at a website containing information about intimate partner violence to simulate self-directed information-seeking, while another group completed an unrelated filler task. we hypothesized that participants exposed to the video intervention would have more knowledge about bystander interventions when compared to students who viewed related information on a website and individuals in a no-intervention control group. method participants an a priori statistical analysis was calculated using the g*power v3 software (faul et al., 2007) to determine the number of participants needed to achieve statistical power of 0.95, a medium effect size (f = 0.25), with an overall α = 0.05 for a regression. all assumptions for an ordinary least squares regression were met. the results suggested that a total sample size of 204 participants was needed. initially, 456 undergraduate students accessed the online survey via qualtrics; 449 students met inclusion criteria (e.g., proficiency in english, between 18 and 24 years old, and enrolled at our large mid-eastern university), and provided informed consent. participants who did not complete at least 85% of the items were removed from the sample (42 individuals, n = 407). then, the 72 participants who failed to provide the correct responses to two validity check items (i.e., “please select ‘strongly disagree’ for this item” and “please select ‘strongly agree’ for this item”) were not included in the sample, resulting in a total of 335 valid responses. there were 122 participants in the control condition, 120 in the intervention condition, and 93 in the website condition (see figure 1). there were fewer valid responses in the website group as a number of participants in that condition failed to complete at least 85% of the items, perhaps due to the length of the time (10 minutes) that they were asked to review the website. the average age of the participants was 19.43 (sd = 1.13), and the majority identified as women (73.1%) and straight (89.9%). most were single (63%), and had not experienced dating abuse (77%) or violence in their families of origin (83.3%). students were enrolled in a wide range of college majors with the top three being psychology (35.8%), information sciences (15.5%), and biology-related (10.7%). additional demographic information can be found in table 1. procedure after receiving approval from the university institutional review board, participants were recruited through the department of psychology subject pool (consisting of students from across the university who were enrolled in an introductory psychology course), flyers, and social media, where they received a link to a qualtrics survey. students who accessed the survey, met the inclusion criteria, and provided consent were invited to complete a demographic questionnaire and then a pretest survey assessing their knowledge about appropriate bystander interventions. participants then were randomly assigned to one of three conditions. the intervention group watched the 7-minute stop dating violence video intervention. the web college dating violence 78 herman & o’brien site group scrolled through loveisrespect.org, a website containing information about dating violence including warning signs of abuse in an intimate relationship and steps for supporting friends and peers who may be experiencing intimate partner violence for 10 minutes. the control group was asked to complete filler tasks (i.e., write an essay about your favorite college course). participants in the intervention group were unable to move past the page containing the video until seven minutes had elapsed, and those in the website group were unable to move past the website page until 10 minutes had elapsed. then, participants in every condition completed a posttest survey made up of the same items as the pretest survey. all participants were provided with information about two domestic violence hotlines and their campus counseling center upon completion of the study. the procedural pathways for participants in each condition are provided in figure 2. students received one research credit toward a psychology course requirement for completing the survey. stop dating violence intervention the stop dating violence intervention was created to educate college students about recognizing dating violence and intervening in situations of dating violence (o’brien et al., 2021). as described previously, the intervention has three components, the first and third of which were adapted to create the stop dating violence animated video intervention. the modifications made to the stop dating violence intervention can be conceptualized through the frame model, which systematizes the modifications by considering who is involved in the process, what is modified, the level of delivery and context in which modifications are made, and the nature of the content modification (stirman et al., 2013). the modifications were made by a team of two researchers, one of whom led the development of the original stop dating violence intervention. the content and context of the intervention was modified through the conversion from prezi to animated video, simplifying and modernizing the format for participants engaging with the intervention. the second component was not included in the video to shorten the length of the intervention and to focus on the effectiveness of education about warning signs of dating violence and bystander behaviors. for this study, the presentation first was modified to shorten the content to maximize participant engagement. specifically, multiple-choice questions were removed from the first component and presented as open-ended questions that were answered by the narrator. for example, the narrator posed the following: “now that we have described dating violence, we want you to imagine your best friend has been dating someone for three months. what are some “red flags” or warning signs of dating violence that you might notice?” after a brief pause, several common red flags were described by the narrator. consistent with the original intervention, information was delivered in a brief lecture format and then applied to vignettes in which dating violence occurred in typical college settings (e.g,, in a residence hall, in a shared apartment, and at the campus gym) so that students saw how the bystander behaviors could be used in real-life situations. the vignettes were created by a team of researchers (comprised of professors and graduate students in psychology, several of whom had experience working in shelters for abused women and their children) and were informed by the dating violence literature to depict different dimensions of dating violence occurring among a diverse sample of people (o’brien et al., 2021). the team conducted a thorough literature review about dating violence, bystander interventions, and the best practices for online interventions before writing and editing the scripts. important information was repeated, and time was provided for participants to think and respond to narrator questions about the stop steps. for example, in the video intervention, the narrator says the following: “ok, over the last month you noticed that one of your close friends has stopped coming to pickup basketball games on friday nights. when you see him at the gym, you ask why he hasn’t been around. he says that he’s really busy – and that his girlfriend wants him to spend all of his time with her. he tells you that he tried to break up with her but she threatened to kill herself. he feels stuck but he would feel really guilty if something bad happened to her. how might you respond to this situation?” at this point, there is a pause in the video. then, the narrator applies each step of the stop model to this vignette. for this study, a video was created using online animation software (vyond), the modified script and voiceover recording. the characters shown in the vignettes were of diverse ethnic backgrounds and represented a range of sexualities and dating preferences. the video intervention can be found at go.umd.edu/datingviolence 79 college dating violence warning signs and go.umd.edu/datingviolencehowtohelp). measures knowledge regarding appropriate interventions eight items from the knowledge of appropriate bystander interventions scale (o’brien et al., 2021) were used to measure knowledge regarding appropriate bystander behaviors outlined in the stop dating violence intervention. responses were provided on a 6-point likert scale ranging from 1 (strongly disagree) to 6 (strongly agree), e.g., “it’s important to help in a dating violence situation even if it means that i might be in danger.” items 1, 2, 3 and 6, which were incorrect statements about appropriate bystander interventions, were reverse scored and the responses were summed to create an index of knowledge about recommended bystander intervention practices from the stop dating violence intervention. high scores indicated greater knowledge about general bystander behaviors and those emphasized in the stop intervention. in prior research, the reliability of the 8-item measure was not calculated because the items assessed different dimensions of knowledge and were not expected to correlate. support for validity was found in a prior study as students who completed the stop dating violence intervention scored the highest on this measure (o’brien et al., 2021). demographics participants also responded to items assessing gender, age, sexual orientation, major, relationship status, the length of their relationship, and whether they experienced violence in their families or relationship abuse. analyses responses that did not meet the inclusion criteria (n = 6), did not pass the validity checks (n = 72), and did not complete at least 85% of the items (n = 42) were removed before data analysis. the means, standard deviations, and ranges for the pre and posttest scores on the knowledge of appropriate bystander interventions scale were calculated and are provided in table 2. an ordinary least squares regression was used to test the hypothesis by examining differences in scores on the measure of knowledge about appropriate bystander interventions at posttest across conditions. the main explanatory variable was the experimental condition, with pretest score as a linear control. the model included the interaction of condition with pretest score; posttest score was the dependent variable. an alpha level of .05 was used to test for significance. significant differences were found among conditions for scores on the measure assessing knowledge of appropriate bystander interventions (r2=.522, f (5, 332) = 71.904, p <.01, partial η2 = .319). bonferroni-adjusted pairwise comparisons indicated that the intervention condition had a higher mean than those in the website group (by 1.92 points, 95% ci [1.00, 2.83]) and the control group (by 4.82 points, 95% ci [3.97, 5.67]), and that the website group had a higher mean compared to the control group (by 2.90 points, 95% ci [1.99, 3.81]). all comparisons were significant at p < .001. to summarize, students in the intervention condition had the most knowledge regarding appropriate bystander interventions at posttest. discussion findings from this study suggested that the updated stop dating violence video intervention was effective in educating undergraduate students about appropriate bystander interventions. participants who viewed the stop dating violence video intervention had the greatest knowledge of appropriate bystander interventions at posttest when compared to participants who were in the control and website conditions. this finding is important because it indicates that the video intervention effectively aids college students in learning about desired bystander behaviors in dating violence situations. moreover, this finding represents an important first step in the future process of changing campus cultures. if students can be educated about warning signs of dating violence and how to intervene when it occurs, the potential exists for them to disseminate this knowledge and these behaviors through social networks, thus contributing to community-wide changes in social norms (coker et al., 2014). additionally, a large portion of data collection took place during campus closures due to covid-19. the success of the intervention during this time demonstrated that educational videos may be valuable tools for sharing information regardless of student and campus location. should these findings be replicated, the stop dating violence video intervention may serve as a low-cost and effective educational tool to reduce rates of dating violence on college campuses. limitations there are several important limitations of this study. first, the sample was predominantly comprised of straight women, perhaps because a significant por 80 herman & o’brien tion of participants were recruited through the department of psychology study pool which contains more women than men. it is important to ensure that the intervention works well for all genders and sexualities. while the intervention utilized inclusive language and provided examples of many different kinds of relationships, it is necessary to assess its effectiveness for a broader population to ensure that the results are generalizable. additionally, no constructs were assessed besides knowledge of appropriate bystander interventions. constructs like intention to intervene or self-efficacy may be important in gauging the effectiveness of the intervention, as knowledge alone may not be enough of a catalyst for bystander action. other facets of participant perspectives could play valuable roles in determining the effectiveness of the measure including general knowledge of dating violence, core beliefs about gender and sexuality, susceptibility to social desirability, and life experience. it also is important to note that participants in the intervention group were asked to think about how to apply what they learned about appropriate bystander behaviors to vignettes presented in the intervention video, while participants in the website group were not asked to reflect on what they learned. it is possible that inviting the participants to apply the stop model to hypothetical situations contributed to the retention of the information. thus, some variability in knowledge scores across groups could have occurred because of the lack of opportunities to apply the stop model in the website condition. another limitation of this study was that participant knowledge was assessed about bystander interventions in generalized dating violence situations rather than in specific circumstances. the vignettes provided in the video were specific and nuanced, and it would be valuable to assess how participants would apply their knowledge to different forms of dating violence and the complexities associated with specific situations (e.g., monitoring a partner who had cheated on them previously). similarly, we did not include a measure of participant engagement; future research should assess the degree to which participants were engaged in the shortened video version when compared to the longer prezi presentation. finally, increased knowledge about dating violence and desired bystander interventions may not result in actual bystander behaviors in real-life settings. numerous factors including social pressure, substance use, or other variables may impact motivation to intervene in dating violence situations. relatedly, psychological processes that impede engagement in bystander behaviors were not explicitly addressed by the intervention. inclusion of these factors could encourage college students to challenge thoughts that limit involvement and engage more fully in bystander actions. future research directions research is needed to further evaluate whether the stop dating violence video intervention is more effective than the original prezi presentation. additionally, it is important to assess whether knowledge gained from bystander training interventions, including the stop dating violence video intervention, translates into actual bystander behaviors in real-life dating violence situations. conducting this research is challenging because it requires students to have witnessed dating violence. in addition, students may not be aware that what they have witnessed or heard about was dating violence, or they may be unable to remember exactly what occurred. a promising mechanism for evaluating bystander behaviors in real-life dating violence situations is the use of diary collection methods which involve repeated participant self-reports for a specified amount of time. such methodology would enable participants to immediately log their experiences of any encountered dating violence onto their phones or computers, allowing for more accurate recall of the event and their reactions to incidents of dating violence. a similarly challenging but important future direction is to examine the barriers and facilitators associated with bystander behaviors in real dating violence situations. many factors ranging from social norms to core values could play a role in making it easier or more challenging to intervene. information about salient barriers and facilitators could be collected in conjunction with self-reports about bystander behaviors in real-life dating violence situations. after participants report having seen dating violence and the actions that they took, they could then respond to measures asking them about what factors facilitated and hindered intervention. these factors must be studied so that researchers can develop educational programming focused on the most important factors that impact the decisions of college student bystanders. another important future direction is to see whether participation in this intervention affects 81 students’ ability to recognize dating violence in their relationships and to leave an abusive relationship. an ideal and most effective intervention would allow students to recognize dating violence in their lives as well as in the lives of their peers. finally, it is important that future interventions address how the nuances of specific situations may change bystander perceptions of dating violence and plans to intervene or engage in helpful bystander behaviors. real-life situations of dating violence are likely to be complex and confusing for bystanders who are considering taking action. to counteract blaming those who experienced dating violence and lacked bystander confidence as a result of contextual nuance, interventions should emphasize that the behaviors described as dating violence call for responsible bystander action under all circumstances. conclusion to conclude, dating violence is a common and harmful occurrence on college campuses. college students are often unsure how to provide assistance to peers experiencing dating violence. the stop dating violence video intervention may serve as a cost-effective, engaging, and informative educational tool that teaches students how to recognize 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(2017). feasibility and initial evaluation of project peace: an intervention for college students at risk for dating violence. partner abuse, 8, 281314. https://doi.org/10.1891/1946-6560.8.3.291 jouriles, e.n., rosenfield, d., yule, k., kelli, s., & sargent, r. (2016). predicting high-school students’ bystander behavior in simulated dating violence situations. journal of adolescent health, 58(3), 345-351. https://doi.org/10.1016/j. jadohealth.2015.11.009 katz, j. (1994). mentors in violence prevention playbook. boston: center for the study of sports in society. katz, j., heisterkamp, a., & fleming, w. m. (2011). the social justice roots of the mentors in violence prevention model and its application in a high school setting. violence against women, 17(6), 684–702. https://doi.org/10.1177/1077801211409725 kaukinen, c. (2014). dating violence among college students: the risk and protective factors. trauma, violence, and abuse, 15(4), 283-296. https://doi.org/10.1177/152483801452132 latané, b., & darley, j. m. (1970). the unresponsive bystander: why doesn’t he help? new york (n.y.): appleton-century-crofts. libertin, a. (2017, november 30). the truth about domestic violence on college campuses. healing abuse working for change. https://hawcdv. org/the-truth-about-domestic-violence-on-college-campuses/ moynihan, m.m. & banyard, v.l. (2008). community responsibility for preventing sexual violence: a pilot study with campus greeks and intercollegiate athletes. journal of prevention and intervention in the community, 36(2), 23-38. h t t p s : / / doi.org/10.1080/10852350802022274 moynihan, m. m., banyard, v. l., arnold, j. s., eckstein, r. p., & stapleton, j. g. (2011). sisterhood may be powerful for reducing sexual and intimate partner violence: an evaluation of the bringing in the bystander in-person program with sorority members. violence against women, 17(6), 703-719. https://doi. org/10.1177/1077801211409726 o’brien, k.m., sauber, e.w., kearney, m.s., venaglia, r.b., & lemay, e.p. (2021). evaluating the effectiveness of an online intervention to educate college students about dating violence and bystander responses. journal of interpersonal violence, 36, np7516-np7546. https://doi. org/10.1177/0886260519829769 rakovec-felser, z. (2014). domestic violence and abuse in intimate relationship from public health perspective. health psychology research, 2(3), 1821. https://doi.org/10.4081/hpr.2014.1821 shorey, r.c., zucosky, h., brasfield, h., febres, j., cornelius, t.l., sage, c., & stuart, g.l. (2012). dating violence prevention programming: directions for future interventions. aggression and violent behavior, 17(4), 289-293. https://doi.org/10.1016/j.avb.2012.03.001 witte, t. h., & kendra, r. (2010). risk recognition and intimate partner violence. journal of interpersonal violence, 25(12), 2199–2216. https://doi.org/10.1177/0886260509354880 83 college dating violence table 1 demographics (n = 335) 84 herman & o’brien 85 college dating violence table 2 means, standard deviations, ranges, and correlations among the measures note. *correlation is significant at the .01 level. 86 figure 1 participant assignment to conditions 456 recruited through undergraduate psychology courses met inclusion criteria and consented to participate (n = 449) finished over 85% of quantitative items (n = 407) valid responses (n = 335) intervention condition (n = 120) website condition (n = 93) control condition (n = 122) did not meet inclusion criteria (n = 6) did not finish over 85% of quantitative items (n = 42) did not respond correctly to both validity check items (n = 72) herman & o’brien 87 college dating violence figure 2 procedural pathways all participants completed a pretest assessing knowledge of appropriate bystander interventions the control group completed a filler task (writing a brief essay about their favorite college course) the intervention group watched the 7-minute stop dating violence video intervention the website group scrolled through a website containing information about dating violence for 10 minutes all participants completed a posttest made up of the same questions as the pretest all participants were provided with information about two domestic violence hotlines and their campus counseling center upon completion of the study     8   graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university race-matching in psychotherapy: findings, inconsistencies, and future directions jerren c. weekes university of cincinnati race-matching has been proposed as a viable approach for increasing mental health treatment utilization and enhancing treatment outcomes among ethnic minorities. however, consistent empirical support for race-matching has been lacking since the initial investigations in the 1960s. the variability in findings may result, in part, from methodological inconsistencies across race-matching studies. the purpose of this literature review was to examine the methodology and inconsistent findings among race/ethnicity-matching articles published between 1990 and 2009. it was determined that race-matching findings differed according to the outcome of interest and analytic strategies. based on the findings and gaps in the literature, recommendations were provided in an effort to facilitate scientific progress and improve treatment outcomes for ethnic minorities. race -matching in psychotherapy (the coupling of client and therapist based on self-reported race/ethnicity) 1983 and has continued to be an issue of interest. the controversy stems from the disagreement between supporters of intra-cultural and cross-cultural counseling. according to atkinson (1983), the cross-cultural perspective posits that culturally sensitive therapists can provide effective care regardless of racial and ethnic differences with their clients, whereas supporters of intracultural counseling assert that counseling is most effective in racially matched psychotherapy dyads. several studies have been conducted to assess the impact of racial dissimilarity on psychotherapy for ethnic minorities. findings reveal that racial dissimilarity may serve as a barrier to treatment, as it counteracts the establishment of a strong therapeutic alliance thereby negatively influencing the client-therapist interaction (terrell & terrell, 1984; watkins, terrell, miller, & terrell, 1989). sue and sue (1977) note that it is not simply racial dissimilarity that serves as the barrier, but that cultural differences between the therapist and client can lead to poorer communication, understanding, and rapport. in an attempt to address the barrier of racial dissimilarity, race-matching has been proposed as a method to increase ethnic minority treatment use. however, contradictory research findings make it difficult to deduce the efficacy of race-matching, thereby contributing to the ongoing controversy. for example,                                                                                                   correspondence concerning this article should be addressed to jerren c. weekes, university of cincinnati, department of psychology, 4150 edwards building one, po box 210376, cincinnati, oh 45221-0376, fax: 513/556.1904, email: weekesjc@mail.uc.edu. consider the first race-matching study conducted by banks, berenson, and carkhuff (1967) in which eight black college undergraduates were coupled with a black or white therapist. results indicated that black clients were willing to return to treatment when racially matched with therapists, but black clients in racially dissimilar dyads were unwilling to return to treatment. a subsequent study conducted by cimbolic (1972), in which seventeen black college freshmen participated in treatment with black or white therapists, yielded different results. the results from this study did not indicate a client preference or that racial dissimilarity was a deterring factor for the black clients involved. several race-matching outcome studies were conducted after the investigation by banks and colleagues (atkinson, 1983); however, the findings of research on the impact of race-matching on treatment outcomes remain inconsistent to date. for example, in a study that examined race-matching in a sample of 302 drug users entering an outpatient substance abuse treatment facility (66% female, 43% african american, 30% white, 23% latino, 4% asian, m age = 34.1), race-matching was associated with greater ratings of counselor empathy, but was not found to be associated with abstinence from drug use (fiorentine & hillhouse, 1999). in contrast, a study investigating the impact of race-matching on substance use in a sample of 96 substance-abusing adolescents in family therapy (43 hispanic and 43 white, m age = 15.7) found a significant effect such that matched hispanic adolescents showed a significant decrease in their substance use (flicker, waldron, turner, brody, & hops, 2008). the results discussed above are a few examples of the inconsistent findings regarding the impact of race-matching on treatment outcomes and service use. it is believed that methodological inconsistencies between race-matching weekes   9   studies may contribute to the contradictory findings. as such, the aim of this article is to (1) serve as a brief review of race-matching literature, (2) identify relevant inconsistencies in the race-matching literature that may have led to contradictory findings, and (3) provide recommendations for research in an effort to facilitate scientific progress. the paper is organized into four sections. the first section summarizes the search results and procedures used to gather relevant literature. the second section serves as a brief overview of the racematching literature retrieved (aim 1). the third section describes factors that may account for, or contribute to, the contradictory findings found in the literature (aim 2). the last section provides specific recommendations for future research (aim 3). m ethod search m ethod pubmed and psychinfo databases were searched for articles that assessed racial and ethnic match within mental health treatment. search terms included psychotherapy and either race, racial similarity, race-matching, or ethnic match. the reference lists of retrieved articles were then reviewed to search for publications that did not appear in the initial database search. this analysis included a review of sample information, methods, statistical analysis, and results of the selected articles. articles included in the current review met the following criteria: (1) assessed the utility of race-matching within mental health care, (2) were written in english, and (3) were published between 1990 and 2009. the third criterion was established to avoid potential overlap with a similar review conducted by atkinson (1983), in which the prior race-matching literature was reviewed and assessed. search results using these methods, 30 articles were selected and analyzed by the author. of the 30 articles, 70% (n = 21) assessed the relationships between racial and ethnic match and treatment utilization, 50% (n = 15) assessed treatment outcomes (e.g., symptom improvement), and 20% (n = 6) assessed therapist-patient alliance and treatment satisfaction. sixty percent (n = 18) of the studies utilized archival data, and 40% (n = 12) used clinical samples. within these studies, data was primarily gathered at community mental health or university/college counseling centers. summary of the l iterature several general themes emerged after a review of the literature. first, race-matching is effective for a variety of ethnic minority groups (e.g., farsimadan, draghi-lorenz, & ellis, 2007). second, empirical support has been found for race-matching in child, adolescent, and adult samples (e.g., jerrell, 1998; yeh, eastman, & cheung, 1994). third, findings focus on the efficacy of race-matching with regard to increasing service utilization (fujino, okazaki, & young, 1994; halliday-boykins, schoenwald, & letourneau, 2005), enhancing treatment retention (e.g., jerrell, 1998), the working alliance, counselor effectiveness, and perceived benefit of therapy (e.g., farsimadan, draghi-lorenz, & ellis, 2007). race-m atching in various racial and e thnic g roups multiple studies support the efficacy of race-matching for asians/asian americans (e.g., fujino, okazaki, & young, 1994), african americans (e.g., thompson & alexander, 2006), and hispanics (e.g., flicker, waldron, turner, brody, & hops, 2008). flaskerud and liu (1991) assessed race, gender, and language match in a diverse asian sample and found that ethnic match related to increased treatment duration (i.e., number of sessions attended), and a significant decrease in the drop-out rate for asian clients. in 2007, farsimadan, draghi-lorenz, and ellis investigated the utility of race-matching in a multi-ethnic adult sample (n = 100). race-matching was found to be useful in increasing client-reported therapist credibility, bond/alliance, and treatment outcomes for south asian, middle eastern, black african and black caribbean clients. race-m atching in child, adolescent, and adult populations empirical support for the effect of race-matching for children, adolescents, and adults was also found. though the number of race-matching investigations with child participants is fewer than those for adolescents and adults, studies (e.g., jerrell, 1998) have found that children in racially-matched treatments remained in treatment longer than those who were not in racially-matched dyads. a racematching study conducted by yeh, eastman, and cheung (1994) found that minority adolescents, particularly mexican and asian americans, who were racially matched with therapists were likely to attend more sessions, less likely to drop out of treatment, and more likely to have higher global assessment of functioning (gaf) scores at discharge than adolescents who were not racially matched. several studies found race-matching to have beneficial effects in adult samples (e.g., farsimadan, draghi-lorenz, & ellis, 2007; thompson & alexander, 2006). for example, a study of an ethnically diverse sample consisting of asian american, african american, white, and latino adults found that clients who were racially matched had lower odds of dropping out of therapy than unmatched clients, except for african americans (sue, fujino, hu, takeuchi, & zane, 1991). in the same study, ethnic match was associated with more sessions attended for matched clients than nonmatched, and related to improved treatment outcomes for mexican americans. race-matching in psychotherapy   10   t reatment utilization empirical support for the impact of racial similarity between therapist and client on treatment use has been provided (e.g., flaskerud & liu, 1991). for example, a 2005 study investigating racial similarity between therapists and primary caregivers (n = 1711) in multisystemic therapy, a family based intervention s delinquent behaviors, found that racial similarity led to greater treatment enrollment, decreased symptoms, and higher likelihood of meeting treatment goals for the african american, asian, latino, and other ethnic minority child/adolescent clients involved (hallidayboykins, schoenwald, & letourneau, 2005). t reatment satisfaction and outcomes racial similarity between client and therapist has been demonstrated to increase treatment satisfaction for minority clients. for example, race-matching was not found to affect the number of sessions attended, but did impact client perceived benefit of treatment and higher self-reported acceptance of therapist strategies (thompson & alexander, 2006). therapist credibility and empathy ratings have also tended to be higher in matched than nonmatched dyads (farsimadan, draghi-lorenz, & ellis, 2007; fiorentine & hillhouse, 1999). although there is reasonable empirical support for the impact of race-matching on treatment utilization (i.e., increased sessions completed, lower dropout rates), there is a paucity of empirical support for the beneficial effects of race-matching on treatment outcomes. in addition, the use of race-matching has been questioned based on methodological flaws (e.g., measure of race vs. cultural match, which is the better proxy for similarity) and negligible effect sizes (karlsson, 2005; maramba & hall, 2002). while client satisfaction, working alliance, and counselor effectiveness are of great importance, the purpose of psychotherapy is to facilitate change within the client that leads to better functioning and quality of life. to this point, the beneficial effect of race-matching on treatment outcomes has not been consistently supported. given these equivocal findings, it is difficult to determine exactly what researchers and clinicians are to deduce from the assortment of empirical results surrounding the effects of race-matching. inconsistencies in research m ethodology: m ajor contributing factors despite evidence for the positive effects of race matching, the overall findings, particularly those surrounding treatment outcomes, have been inconsistent. variability in how previous race-matching studies have been conducted may account for these conflicted findings. two specific factors may be related to the discrepant findings: 1) variability in outcome variable(s) and 2) analytic strategy. first, race-matching findings differ depending on whether the researcher is studying treatment utilization, treatment outcomes (e.g., substance use or externalizing behaviors), or therapeutic alliance/treatment satisfaction. it is clear that the aim of a study assessing the effect of racematching on treatment use, retention, and client functioning (yeh, eastman, & cheung, 1994) largely differs from the focus of a study assessing the impact of race-matching on patterns of diagnosis (mathews, glidden, murray, forster, & hargreaves, 2002). the outcomes of these studies cannot be compared for multiple reasons, principally, dissimilar study aims and outcome variables. researchers must take note of differing aims of race-matching investigations, especially those who will be conducting meta-analyses in the future. second, race-matching findings differ according to the analytic strategy used. this occurs as a result of collapsing ethnic minority groups instead of conducting separate analyses for each racial and ethnic group represented in the sample. while the former is likely due to an insufficient number of subjects in each identified racial and ethnic group, combining different racial and ethnic minorities groups into one category is not best practice (okazaki & sue, 1995), as it does not yield detailed information about the impact of race-matching on treatment outcomes for independent ethnic minority groups. where race-matching could be more effective for one racial minority group than another, combined (i.e., collapsed) analyses may not reveal that valuable information. collapsing ethnic categories may be done to preserve statistical power, but it ignores the heterogeneity among ethnic minority groups (burlew, feaster, brecht, & hubbard, 2009). thus, it is possible that observed empirical differences in treatment outcomes may be due to methodological strategy rather than actual group differences. recommendations and future directions the inconsistencies in the existing race-matching literature have important implications for future research in this area. additionally, several identified gaps in the literature should be addressed: 1. a meta-analyses examining effect sizes for differential outcome variables, client characteristics, and analytic strategies among race-matching studies would be beneficial to the field. meta-analyses with inquiry focused upon evaluating the efficacy of race-matching based on specific outcome variables (e.g., the meta-analysis by maramba and hall in 2002) or client characteristics will assist the field in coming to an understanding of the efficacy of race-matching. 2. combining individuals of different racial and ethnic backgrounds into one group for analysis should be weekes   11   avoided to steer clear of inaccuracy and overgeneralization. separate analyses for each racial group represented may prove to be most beneficial. qualitative interviews foc thoughts surrounding race-matching should be conducted with clients of varied racial and ethnic backgrounds, ages, and presenting mental health that have been overlooked thus far. 3. future studies should assess the extent to which the effects of race-matching differ based on treatment modality. mental health treatment modalities (e.g., case management, group/family therapy, and variants of individual therapy) differ in fundamental assumptions, objectives, and processes. as such, the findings may differ in certain treatment contexts due to the unique way in which therapists must interact with clients. for example, the duties and role of a family therapist versus an individual therapist differ. in the family treatment context the therapist must establish rapport with all members present, understand the family dynamics, process the family interactions, and enter into the family system in order to elicit change. the family unit may accept therapists more easily if racial similarity, and a deeper level of cultural understanding, exists. since treatment modalities differ in fundamental processes, it is possible that racial similarity may be more important in certain treatment contexts than others. research is needed to deduce more about the importance of treatment modality as it impacts the relationship between race-matching and treatment outcomes. 4. future studies should also assess the extent to which the effects of race-matching are moderated by client age and social-cognitive development. yeh, eastman, and cheung (1994) found race-matching to be effective in increasing session attendance, decreasing treatment drop-out, and increasing the global assessment of functioning (gaf) scores for adolescent minority clients in their sample. however, race-matching was not found to be effective in any way for the children (ages 611) within their study. jerrell (1998) found that racematching was effective in increase treatment use of ethnic minority children; however, treatment outcomes (e.g., symptom improvement, improvement in overall functioning, or a decrease in externalizing behaviors) were not included as variables of interest. yeh, eastman, and cheung (1994) suggested that further research be conducted to determine if and why racematching has differing effects on child outcomes than adolescent and adult outcomes. 5. the differential effects of race-matching may also be attributed to the varied social-cognitive development between children, adolescents, and adults regarding race perception, bias, and out-group (i.e., racially dissimilar groups) derogation (cameron, alvarez, ruble, & fuligni, 2001; quintana, 1998). in addition, as a person progresses in his/her racial identity development the preference for a same-race therapist may become more salient. for example, parham and helms (1981) discuss the relation of same-race counselor preference in the context of black racial identity development. black/african american individuals in pre-encounter stage, a stage in which american culture/ideals, were more likely to have a strong preference for white therapists and non-acceptance for black therapists. preferences differed, however, for individuals in the latter stages of the racial identity model. given the statements above, it is possible that racial similarity of a therapist may increase in importance as children advance in age and development. future studies should seek to evaluate the importance of race-matching in child and adolescent populations, and conduct analyses to assess whether age and developmental stage act as moderator variables. 6. studies examining the utility of race-matching within underrepresented racial and ethnic minority groups can provide valuable information and should be considered. as the united states continues to diversify, the issues of race become more than just black and white. an increase in race-matching studies for other ethnic groups (such as hispanic, pacific islander, alaskan/native american, and middle eastern) is needed. for example, only one reviewed study included middle eastern ethnic groups into race-matching analyses (farsimadan, draghi-lorenz, & ellis, 2007). studies should seek to recruit individuals from the aforementioned racial groups in an effort to provide information on client preferences and effective components of psychotherapy for these underserved and increasingly populous groups. 7. race-matching studies should include cultural similarity, acculturation, and racial identity measures in an effort to better assess client-therapist cultural similarity and understand the pathway(s) through which race-matching has its impact. to date, studies have not included those measures. this may be due to the fact that a good portion of race-matching analyses utilized archival data in which racial identity, acculturation, and cultural commitment measures were not a part of the initial study design. including such measures will allow for greater understanding of the dynamics of cultural similarity and sensitivity that are particularly helpful in the therapeutic process. 8. additional variables that relate to race-matching and treatment outcomes should be investigated. extant racematching literature has not fully described the factors associated with the success or limited effect of racematching. there are several important variables that have not been investigated that will prove helpful in delineating race-matching in psychotherapy   12   possible mediator or moderator variables. variables including, but not limited to, socioeconomic status, family history (e.g., parental or sibling drug use or legal problems) or family conflict, and the severity of client problems (e.g., severity of externalizing behaviors) are worthy of exploration. race-related research has revealed a distrust of professional health services that can deter ethnic minorities from seeking psychological treatment (terrell & terrell, 1984; whaley, 2001). due to numerous factors (e.g., distrust, stigma), ethnic minorities have been noted to largely underutilize mental health treatments (u.s. department of health and human services, 2001). racematching has been proposed as a method to increase ethnic minority treatment use, treatment retention, and satisfaction with treatment, while associated research has been utilized to gain a better understanding of the effective factors in psychotherapy for ethnic minorities. while this line of research appears promising, the inconsistent findings make it difficult to glean a clear understanding on the efficacy of race-matching. race-matching findings differed based on the outcome assessed (i.e., treatment satisfaction, treatment use, treatment outcomes) and analytic strategy used. it is believed that the noted inconsistencies account, in part, for the discrepancy in findings. the recommendations above are meant to facilitate scientific progress and advance knowledge regarding race-matching in psychotherapy. it should be noted that extreme race-matching practices (i.e., automatically race-matching without consulting the client first) is not advocated here. racial identification and acculturation vary from individual to individual (karlsson, 2005), and there are multiple factors that contribute to identity development racial and ethnic factors notwithstanding. as such, there are within-group differences regarding the facet of identity individuals and age may be more important than race for some minority clients. race-matching should not be imposed on clients, but considered in an effort to increase minority client satisfaction, treatment engagement and retention, and to address mental health disparities that currently exist. lastly, it is fully recognized that agencies across the united states may not have diverse representation in staff to meet the request for race-matching in psychotherapy. the lack of minority professionals may stem from the lack of minority representation in higher education, specifically clinical psychology programs (maton, kohout, wicherski, leary, & vinokurov, 2006). while the field may not realistically be able to provide racially similar therapists to all clients who request one, it is important to reiterate that race-matching is not the end point. this line of research is a pathway to improve understanding of the therapeutic dynamics needed to provide better services to ethnic minorities. research must continue, as it can inform the training of therapists from all racial and ethnic backgrounds on how to best work with racially and ethnically dissimilar clients. as the inconsistencies are clarified, and gaps in the literature filled in, significant gains will emerge in regards to the nature and quality of psychotherapeutic services provided to racial and ethnic minorities. references atkinson, d. r. 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(1994). children and adolescents in community health centers: does the ethnicity or the language of the therapist matter? journal of community psychology, 22,153-163.   mindfulness-based cognitive therapy for prevention of relapse in depression – a useful approach for patients with cardiovascul graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university mindfulness-based cognitive therapy for prevention of depression relapse: a useful approach for depressed patients with cardiovascular disease? traci r. stein columbia university medical center, division of pain medicine major depressive disorder (mdd) has a high prevalence rate, particularly in patients with cardiovascular disease (cvd). furthermore, depression has been associated with increased risk of morbidity and mortality in this population. regardless of medical status, patients who have had mdd manifest high relapse and recurrence rates, with as much as an 80% likelihood of experiencing another major depressive episode. mindfulness-based cognitive therapy (mbct), an approach combining techniques and principals of both cognitive behavioral therapy and mindfulness-based stress reduction, has been efficacious in reducing depressive relapse and recurrence in preliminary trials. though mbct’s utility in reducing depression relapse or recurrence in patients with cvd has yet to be examined, the promising findings with other populations, as well as the severity of health consequences for depressed patients who have cvd, suggest this may also be a worthwhile therapeutic approach for those with heart disease. depression is a serious and sometimes debilitating illness that continues to be a leading cause of disability in the united states (murray & lopez, 1996). depressive syndromes and major depression are extremely common, with lifetime prevalence rates of major depression estimated to be 20% in women and approximately 10% in men (kessler et al., 2005; kessler, mcgonagle, swarz, blazer, & nelson, 1993; steffens et al. 2000). some researchers have found an almost 3-to-1 female-male ratio of depression (kessler et al., 1993), as well as a family effect, with rates 2to-3 times higher in those with a depressed first-degree relative (klerman & weissman, 1989). in medically ill patients, particularly those with chronic illnesses, depression is more prevalent, with 8% of those who have a physical illness meeting criteria for major depression and 15% to 36% meeting criteria for another depressive disorder (feldman, mayou, hawton, ardern, & smith, 1987). moreover, depression is particularly tenacious in both older adults and the medically ill, often with incomplete resolution in these populations despite clinical treatment (irwin, 2002). this paper will describe the prevalence and impact of depression on patients with cvd, provide an overview of the research on mindfulness-based cognitive therapy (mbct) with other patient populations, and examine the evidence for using this approach for those cvd patients who have recurrent major depression. recurrent depression in patients with a history of major depressive disorder relapse and recurrence following major depressive disorder (mdd) is common, with the risk of relapse1estimated at more than 80% (teasdale et al., 2000). correspondence: traci stein, division of pain medicine, columbia university medical center, 622 west 168th street, ph-5, new york, ny 10032 or ts2007@columbia.edu this comes at tremendous personal and social costs. it has been theorized that repeated associations between depressed mood and patterns of negative, self-devaluative, hopeless thinking increase vulnerability to relapse (teasdale, 1988, 1997). specifically, the type of thinking activated by dysphoria is similar to those patterns present during depressive episodes. easy accessibility of depressing thoughts, memories, and attitudes during periods of low mood activates feedback loops in the body associated with depressive states (segal, williams, & teasdale, 2001). furthermore, a ruminative response style, characterized by the tendency to prolong sad feelings (nolen-hoeksema & morrow, 1991), has been linked to relapse and recurrence. although patients may dwell upon negative feelings in an effort to understand their emotions, this tendency is associated with a decreased, rather than increased, ability to restore more positive mood states (lyubormirsky & nolenhoeksma, 1995). finally, with repeated episodes of depression, less stress is required to provoke relapse (post, 1992). depression and cardiovascular disease depression is prevalent among patients with cardiovascular disease. estimates of major depressive disorder (mdd) among patients with acute coronary syndromes have ranged from 15-25% (glassman et al., 2002; januzzi, stern, pasternak, & desanctis, 2000). furthermore, patients undergoing cardiac surgery often experience depression as a side effect of the procedure itself, although the reasons for this are not well understood at present (cay & o’rourke, 1992). postoperative anxiety and depression occur in about 25% of patients who undergo coronary artery bypass graft (cabg) surgery. depression also varies along the recovery trajectory. timberlake et al. (1997) found that 37% of their cabg patients were 40 mbct for depression in cvd 41 depressed preoperatively. at 8 days, this figure had risen to 50%, but by 8 weeks it had decreased to 24%, and at 12 months was 23%. those cabg patients who were depressed preoperatively had higher levels of postoperative mood disturbance than those who were not depressed prior to the procedure. although postoperative rates of depression decreased over time, the 12-month rates of depression were higher among patients with cardiovascular disease than in the general population. thus, it appears that depression in this population is both prevalent and enduring. although a number of studies have documented the link between depression, anxiety, and other emotional states and heart disease, evidence for the relationship between depression and cardiovascular outcomes has been stronger than for other mood states in predicting additional cardiac events (mccrone, lentz, tarzian, & perkins, 2001). the first research by the medical community regarding the link between depression and mortality was in the early 20th century (malzberg, 1937, as cited in glassman & shapiro, 1998, p.4). in this study, the mortality rate of depressed, hospitalized patients was compared to that of the general new york state population. though the rate for depressed inpatients was elevated, as were the rates for those in the general population who had cardiovascular and infectious diseases, the study confounded the effect of depression with chronic institutionalization. thus, the link between depression and mortality was neither taken seriously, nor explored further until investigators revisited this issue in the late 1970s (glassman & shapiro, 1998). at this time, using data from a national registry, danish researchers identified individuals with either unipolar or bipolar depression. when they examined the causes of death, they noticed a 50% increase in deaths from cardiovascular disease in depressed individuals as compared with the danish general population (weeke, juel, & vaeth, 1987). a subsequent study by the same researchers explored the question of whether the use of tricyclic antidepressants, which had been in common use since the time of the maltzberg study, were associated with the increased mortality in this group. both the sparse literature available at the time and the results of this study revealed that treatment with tricyclic antidepressants and lithium was associated with reduced, rather than increased, mortality in this population. this further supported the link between depression and health outcomes (glassman & shapiro, 1998; week et al., 1987). for patients with cardiovascular illnesses, the impact of depression on health functioning is significant, and can produce impairments in measures of physical functioning, pain, general health, and decrements in emotional health. although these impairments may decrease in severity over time, there may be residual disability due to the chronic and recurrent nature of the disorder (blazer, 2002). epidemiologic data highlight the negative impact of certain psychiatric disorders on the development of, and prognosis in, coronary artery disease (cad; von kanel, mills, fainman, & dimsdale, 2001). for these patients, the consequences of being depressed are particularly severe, as several studies have revealed a link between depression and increased morbidity and mortality from cad and poorer outcomes following coronary events (hemingway & marmot, 1999; irwin, 2002). specifically, depressed cad patients face higher readmission rates and poorer quality of life in the first year after a cardiac event (pignay-demaria, lesperance, demaria, frasure-smith, & perrault, 2003). furthermore, the risk of cardiac death in the six months after an acute myocardial infarction is approximately three-tofour times greater in depressed than nondepressed patients (connerney, shapiro, mclaughlin, bagiella, & sloan, 2001; frasure-smith, lesperance, & talajic, 1993, 1995). these health risks remain even after controlling for known physiological risk factors, including smoking (glassman & shapiro, 1998; pignay-demaria et al., 2003), and the increased risk of cardiac mortality for depressed cad patients may persist even 18 months after cardiac surgery (frasure-smith et al., 1995). despite the clear association between depression and poorer outcomes in patients with cardiovascular disease, few patients who are depressed after serious cardiac events, including myocardial infarction, receive treatment for their depression (carney & jaffe, 2002). because of the cardiotoxicity associated with older antidepressants, and because heart disease is still a standard exclusion criterion in clinical trials of antidepressants, little is known about the safety and efficacy of newer antidepressants in this population. to date, selective serotonin reuptake inhibitors (ssris), which have not been shown to have cardiotoxic effects in healthy depressed patients, have not been adequately studied in patients with cardiovascular illness (roose, 2003). this has contributed to their relatively sparse use in this population (carney & jaffe, 2002). although psychotherapy is considered to be a safe and efficacious alternative to antidepressants, it is also currently underutilized among cardiac and other types of medically ill patients. this is possibly due in part to varying availability and insurance coverage (carney & jaffe, 2002). the challenge for health care providers continues to be how to address the problem of depression and its attendant physical health risks in a way that is palatable to patients, minimally invasive, and cost-effective. treatments for major depressive disorder pharmacotherapy and cognitive behavioral therapy at present, maintenance pharmacotherapy is both the most widely used and most validated approach in the prevention of relapse, although recent studies suggest maintenance psychotherapy may also be effective (teasdale et al., 2000). specifically, cognitive behavioral therapy (cbt) administered during depressive episodes appears to be effective in reducing subsequent relapse and recurrence (teasdale et al., 2000). studies comparing the outcome of patients who recovered following treatment with antidepressant medications (from which they were stein 42 subsequently withdrawn) to that of patients treated with cbt have found lower rates of relapse in the cbt group (evans et al., 1992; shea et al., 1992; teasdale et al., 2000). this reduction in relapse/recurrence is most likely accomplished through the development of skills and fostering of changes in thinking that protect against future depression. thus, cbt may be a valuable prophylactic treatment for major depression. most recently, patients with depression have been successfully treated with a combination of pharmacotherapy during the acute phase and subsequent psychological interventions following recovery. teasdale and colleagues (2000) sought to examine whether a strategy combining acute pharmacotherapy with psychological prophylaxis in the form of a group skills-training approach would provide an efficacious and cost effective relapse prevention alternative. the group skills-training approach they used, known as mindfulness-based cognitive therapy (mbct), combines principles of cognitive therapy and a form of attentional control, otherwise known as “mindfulness” training, developed by kabat-zinn and colleagues (1990) at the university of massachusetts medical center. mindfulness-based cognitive therapy mindfulness-based cognitive therapy is a manualized group skills-training program that integrates aspects of cbt for depression (beck, rush, shaw, & emery, 1979) and mindfulness-based stress reduction (mbsr; kabatzinn,1990; kabat-zinn et al., 1992). the latter approach teaches patients in remission to observe thoughts, feelings, and bodily sensations in a de-centered, non-judgmental manner, and view them as mental events, rather than identifying with them or viewing them as necessarily factual. the program also teaches patients to disengage from dysfunctional, automatic cognitive routines as a way to reduce future risk of depressive relapse and recurrence. since the emphasis is not on changing one’s thoughts, the techniques can be applied with patients in the remitted state (when it may not be necessary to “change” cognitions). mbsr has been efficacious in reducing both psychological and physiological symptoms, including anxiety (kabat-zinn, et al., 1992), chronic pain (kabat-zinn, lipworth, & burney, 1985), psoriasis (kabat-zinn et al., 1998), fibromyalgia (kaplan, goldenberg, & galvinnadeau, 1993), and more recently, reducing both state and trait anxiety in women with breast cancer (tacon, caldera, & ronaghan, 2004). only one study has examined whether mbsr would be beneficial for cad patients, however. tacon and colleages (2003) assessed whether mbsr would reduce anxiety in women with heart disease. in their trial, 18 women with documented cad were randomly assigned to either a wait-list control group or an eight-week mbsr program that included didactic, inductive, and experiential components (yoga, meditation, and the body scan) as per kabat-zinn (1990). the researchers measured state and trait anxiety, emotional control (as measured by the degree to which one suppresses negative feelings, rather than observing them in a detached way), and health locus of control (e.g., reactive, reflective, or suppressive). significant between group differences were observed for state anxiety, emotional control, and reactive coping. specifically, women in the mbsr group experienced significant decreases in state anxiety, decreased tendency to suppress the expression of negative emotions, and decreased use of impulsive, reactive coping as compared to controls. a key limitation of this study was the small, homogeneous sample (comprised of mostly white, middle class women), which limits the generalizability of its findings. similar to mbsr, mbct is delivered by an instructor in eight weekly, 2-hour group training sessions that involve homework in the form of listening to guided imagery and performing unguided awareness exercises designed to facilitate present-moment, non-judgmental awareness. participants learn to observe thoughts, feelings, and bodily sensations in a de-centered manner. practicing various exercises helps participants integrate these skills into daily life (teasdale et al., 2000). in contrast to the habitual patterns of cognitive-affective processing employed by patients with recurrent depression, patients learn to develop a more aware, less judgmental, “mindful” mode of being. like cbt, mbct attempts to foster a greater awareness of thoughts and feelings, examines the role that thoughts have in triggering mood, and aims to cultivate understanding of how depressive thinking patterns and worry promote depression. mbct also teaches participants to identify warning signs of impending declines in mood (mason & hargreaves, 2001). unlike cbt, however, mbct does not explicitly suggest changing thoughts or set out to identify depressive schema, as the skills taught encourage awareness of feelings, regardless of whether or not these are characterized by depression. mbct for prevention of depression relapse in the first multicenter trial of mbct, teasdale and colleagues (2000) randomized 145 patients who were in remission or recovery from major depression as defined by the diagnostic and statistical manual of mental disorders (3rd ed.; dsm-iii-r; american psychiatric association, 1987) to receive either treatment as usual (tau) or tau plus mbct for a period of eight weeks and follow up for a period of one year. to meet entry criteria, patients had to have been treated with a recognized antidepressant medication, but be off medication and in recovery/remission at the time of baseline assessment and for at least the preceding 12 weeks. this is in contrast to the standard approach of introducing therapy during the course of medication withdrawal. at baseline, patients had to have a hamilton rating scale for depression (hrsd; hamilton, 1960) score of less than 10 for inclusion. patients were stratified on two variables: recency of recovery from the last episode of mdd (up to 12 months vs. 13-24 months prior to mbct for depression in cvd 43 randomization) and the number of previous episodes of mdd (two vs. three or more). although mbct did not reduce the risk of recurrence to that of what would be expected in a “normal” (not previously depressed) sample, the investigators found that patients with three or more previous episodes of mdd treated with at least four of the eight sessions of mbct experienced relapse/recurrence rates that were reduced by half during the course of the follow up period. this finding was both statistically and clinically significant, and this reduction in depression was independent of medication use. notably, mbct did not significantly reduce risk of depression in patients with two or fewer previous depressive episodes. in a recent study by ma and teasdale (2004), as in the study by teasdale et al. (2000), recovered, recurrently depressed patients were randomized to tau or tau plus mbct. the findings from the previous study were replicated, with relapse rates reduced from 78% to 36% in patients with three or more depressive episodes. the authors found that mbct was most effective in preventing relapses not preceded by life events. notably, relapses were more often associated with significant life events in the twoepisode group than in the three-or-more episode group, suggesting that these groups represented two distinct populations. although the above studies have shown mbct to be a useful approach for reducing depressive relapse, and patients with cardiovascular illnesses have both high rates of depression and severe, negative health effects as a result, a review of the literature revealed only one study of mbct with patients diagnosed with a vascular (but not cardiac) health problem. in this study, moustgaard (2005) examined whether mbct would reduce depression and anxiety and improve quality of life in 23 patients who had suffered a stroke. participants were assessed at baseline, after completion of the nine-week program, and three months after the conclusion of the intervention. mbct was associated with a significant improvement between baseline and completion on measures of depression, anxiety, and quality of life, and these changes were maintained at follow up. among the limitations of this study were the small sample size and lack of a control group. possible mechanisms of action of mbct in a study of autobiographical memory, williams and colleagues (2000) found that mbct reduced recovered depressed patients’ general memory, suggesting that the encoding and retrieval of personal events can be altered by this treatment approach, and that mbct’s effects are partly cognitively mediated. teasdale (1999) has suggested that a theoretical cognitive framework called interacting cognitive subsystems (ics; teasdale & barnard, 1993) may explain mbct’s effects. the assumption of this framework is that knowledge and experience are contained in qualitatively different forms. for individuals who are prone to depression, generic, richly elaborated schematic models contain global negative beliefs about the self and other depression-related thoughts and feelings. when these are triggered, a “depressive interlock” occurs in which sensory feedback from the body and cognitive feedback in the form of thoughts maintain depressed affect (mason & hargreaves, 2000). mbct – a potential treatment for depressed patients with cardiovascular disease? there is preliminary evidence that mbct is an effective treatment for patients with recurrent mdd and clear evidence of the need for additional treatments for depressed patients who have heart disease. however, a review of the literature revealed no studies of mbct with depressed patients who had a comorbid cardiac illness, and only one small study with stroke patients. depression has been demonstrably linked with poorer health outcomes, including increased mortality, in patients with cardiovascular ailments. considering both the insufficient data on the safety of antidepressants for this patient population and the tendency toward relapse/recurrence in patients with mdd, it seems clear that more research on potentially beneficial psychotherapeutic approaches for those with heart disease is warranted. given the evidence for mbct’s efficacy in reducing depressive relapse in non-cardiac patients, future research should explore whether this therapeutic approach might be useful for recovered, depressed patients with cardiovascular illnesses. references american psychiatric association. 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(2000). mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. journal of abnormal psychology, 97, 89-96. microsoft word vol10_bernstein_avk_#2af806.doc 64 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 starving to win: an exploration of eating disorders in female athletes sarah j. bernstein teachers college, columbia university although viewed as paragons of fitness and health, many female athletes struggle with eating disorders. athletes participating in sports that emphasize aesthetics or a thin-build, such as gymnastics, figure skating, and endurance running, are at particular risk for the development of eating disorders. while anorexia nervosa and bulimia nervosa affect an athlete’s emotional and psychological well-being, they also cause permanent damage to physical health. the female athlete triad refers to the three-fold condition of disordered eating, amenorrhea, and osteoporosis that commonly occurs in physically active girls and women. this paper examines the etiology of disordered eating in female athletes, explores the influence of coaches on eating disorder development, and introduces potential complications in treatment. with the 1988 olympic games rapidly approaching, 15-year-old u.s. gymnast christy henrich’s dream of winning an olympic gold medal was in clear sight. however, when a national judge recommended she lose weight, the 4’10, 90-pound henrich began a routine of unhealthy eating practices. she developed both anorexia nervosa and bulimia nervosa, struggling for seven years before finally dying of multiple organ failure at age 22. at the time of death, henrich weighed a minuscule 47 pounds. although horrific, henrich’s battle with an eating disorder was not uncommon in the gymnastics community. as her mother recalled, “the first thing other athletes told her was if there’s something you want to eat, eat it and throw it up. that’s the first thing you learn when you’re on the u.s. national team” (ryan, 1995, p. 57). society views female athletes, particularly those competing at the elite level, as the quintessential models of fitness and health. yet as cases like the death of christy henrich suggest, these athletes may not be as healthy as they appear. according to a u.s. olympics study of 215 elite female athletes from 18 different sports, more than half of the athletes fasted, restricted fluid intake, took laxatives and/or diuretics, and engaged in efforts to increase sweating by wearing plastic suits and using saunas. moreover, the majority of the female athletes reported intense pressure to lose weight from coaches, fellow teammates, parents, and the media (franseen & mccann, 1996). thus, despite the appearance of hale physical conditions, many athletes struggle with eating disturbances. there is a strong relationship between female athletes and eating disorders; studies show that 15-62% of female adult athletes display weight control behaviors (nativ, 1994). rates of eating disorders among female athletes have also risen over the correspondence to sarah bernstein at sjb2136@columbia.edu. last 10-15 years (berg, 2000). in a study of eatingdisordered women who were hospitalized, davis and kennedy (1994) found that 60% of the patients had been involved in competitive athletics or dance prior to the onset of their disorder. the results of these studies are sobering, indicating the need for a closer inspection into the connection between athletes and discrepant eating patterns. in the case of eating disorders, who is at risk? are some athletes more susceptible to eating disturbances than others? this paper will examine possible risk factors, health concerns, and eating-related identification issues in the female athlete population as well as explore potential treatment options. types of eating disorders the term ‘eating disorder’ encompasses a wide range of disturbances in eating patterns. ninety percent of those with eating disorders are female (thompson & sherman, 1993). due to the relatively lower prevalence of eating disorders in males, this paper will restrict its focus to the psychopathology of eating disorders in females. the major types of eating disorders are anorexia nervosa (an), bulimia nervosa (bn), and eating disorder, not otherwise specified (eating disorder, nos). the latter category describes individuals who have an eating problem but do not fit the diagnostic criteria for an or bn (kalodner, 2005). the dsm-iv-tr (american psychiatric association, 2000) defines four specific criteria for an. the first is that the individual refuses to maintain a normal body weight, and often weighs 15% below what is expected for her age and height. even though the individual may be drastically underweight, she has an intense fear of gaining weight and becoming “fat,” and experiences disturbances in the way she views her body (e.g., an emaciated individual may report feeling overweight). the individual is in denial of the seriousness of her low body weight condition and has an eating disorders in female athletes 65 absence of at least three consecutive menstrual cycles, a medical condition known as amenorrhea (american psychological association, 2000). a female can also be diagnosed with amenorrhea if her periods occur only when induced by estrogen hormones (wilson & walsh, 1991). other medical signs and symptoms of an include hair and nail loss, lanugo (the appearance of fine hair on the face and arms), muscle weakness, gastrointestinal problems, cardiac arrhythmia, hypotension, hypothermia, and dehydration and electrolyte deficiencies. anorexia has a mortality rate that ranges from 1-18% each year (thompson & sherman, 1993). unlike individuals with an who practice restrictive eating or starving, individuals with bn recurrently vacillate between episodes of binge eating and compensatory purging behavior. during a binging episode an individual suffering from bn consumes a large amount of food over a small period of time, experiencing a major loss of control over eating. to prevent weight gain she then engages in subsequent purging behaviors, which may take the form of self-induced vomiting, strict dieting/fasting, excessive exercise, or laxative and/or diuretic use. to be diagnosed with bn, the dsm-iv-tr requires a minimum average of two binge eating/purging episodes per week for at least three months (american psychological association, 2000). some signs and symptoms of bn are menstrual irregularities, dental/gum disease, electrolyte imbalance, swollen parotid glands, gastrointestinal problems, dehydration, and lightheadedness and dizziness (thompson & sherman, 1993). as with an, an individual with bn has a persistent concern about her body shape and weight, which may in turn affect self-evaluation (wilson & walsh, 1991). etiological and psychosocial factors of eating disorders in female athletes although twin studies have demonstrated that eating disorders have a strong genetic component (bulik, sullivan, & wade, 2000), they are linked to certain psychosocial factors as well. some of these social factors include, but are not limited to, family attitudes around eating, peer influences, and unrealistic media images of thin women (polivy & herman, 2002). according to social learning theory, people view others as tools to model their own behavior, with the individual and her environment influencing each other. this was supported by cash and fleming (2002), who found that peers shape one another’s body image in significant ways. thompson and sherman (1993) coined the term contagion effect to describe how dangerous eating behaviors are often spread through a peer or social group. applying the framework of social learning to eating disorders and female athletes, studies illustrate how the culture of an athletic team affects subsequent eating behaviors among its members. burckes-miller and black (1991) observed that peers from athletic teams may exert a more powerful influence on body image than peers from other social settings. the researchers attributed this finding to shared team values often promoted within the athletic environment. for example, in high-endurance sports such as long distance running, many athletes and coaches believe that the thinner the runner, the faster the runner (thompson & sherman, 1993). furthermore, since individual scores are summed together for a total team score, team members may encourage one another to maintain a low weight in the interest of the group. eder and parker (1987) also found that among members of female athletic teams, there are numerous interactions regarding appearance and body image. in addition, there is a positive correlation between teammate influences and changes in eating or dieting behaviors (hausenblas, 2000). this “do it for the team” mentality may cause athletes to feel responsible for not only their own place on the team, but for the competitive status of the team as a whole. accordingly, many successful athletes view successful, slim athletes as role models for body-related attitudes and behaviors (burckes-miller & black, 1991). further, since many cross-country, gymnastics, swimming, and diving teams (among others) traditionally have team dinners before competitive events, athletes may adapt their eating styles to resemble those of their calorie-restricting teammates (thompson & sherman, 1993). the female athlete triad eating disordered behavior can adversely affect multiple organ systems, sometimes with permanent or even fatal consequences. the female athlete triad is a term used to describe the three-fold condition of disordered eating, amenorrhea, and osteoporosis that commonly occurs in physically active girls and women. there are many causes of the triad, but the pressure placed on young women to achieve or maintain a low body weight is often cited as an overarching force in development (otis, drinkwater, johnson, loucks, and wilmore, 1997). the greatest risk for the development of the female athlete triad occurs in aesthetic sports that emphasize a lean physique or appearance (e.g., ballet, gymnastics, and figure skating), and in performance sports where coaches and athletes believe that lower body fat enhances performance (e.g., running, cross country, and swimming; berg, 2000). amenorrhea is classified as either the absence of menstruation by age sixteen (primary amenorrhea), or the absence of three or more consecutive menstrual cycles after menarche (secondary amenorrhea). amenorrhea linked to eating disorders or exercise is hypothalamic in origin, and results in decreased ovarian hormone production and hypoestrogenemia. in a 1996 study conducted by fogelhom, lichtenbelt, wouter van marken, ottenheihm, and westerterp in the netherlands, examining the prevalence of amenorrhea among 113 professional and student ballet dancers (mean age = 23.3 years), it was found that two dancers had primary amenorrhea, and 9.8% of those not on oral contraceptives had secondary amenorrhea. other studbernstein 66 ies have also found a high risk of amenorrhea in ballet dancers. a meta-analysis conducted by fogelhom and colleagues (1996) revealed a mean prevalence of amenorrhea in ballet dancers of 31.4%. in addition to amenorrhea, many dancers described in these studies also faced menstrual irregularities. similarly, benson, bourdet, and loosli (1985) found that 55-67% of ballet dancers had irregular menstrual cycles. the sports environment, healthy eating, and body image the sports environment is both a protective and risk factor for the development of eating-related behaviors in women. in some situations, participation in sports is protective and fosters a positive body image. according to hausenblas (2001), women who play sports are more trusting of other people, have positive body image, and have higher self-esteem. in a study with 114 female highschool aged participants (athletes and non-athletes) hausenblas (2001) found several differences between the two groups. specifically, compared to the non-athletes, the athletes in her study reported feeling 53% more in control of their lives. the athletes also conveyed a higher body image than those who did not engage in any sort of athletic activity, and 31% of athletes experienced lower levels of body dissatisfaction. however, the type of sport must also be considered. sports that highlight physical stature, strength, and power tend to favor athletes who are taller and heavier. studies have shown that from age ten years, female rowers and soccer, basketball, softball, volleyball, and hockey players exceed the 50 th percentiles of the female reference population in physical build (malina, 1994). however, other sports such as gymnastics, figure skating, diving, cheerleading, and ballet promote aesthetics along with technical ability, rewarding the smaller athlete. these thin body build (tb) sports reinforce the importance of slenderness, equating low body weight and a small body size with optimal athletic performance (patel, greydanus, pratt, & phillips, 2003). research has suggested that females who participate in sports where appearance is emphasized (such as those noted above) are at an increased risk for developing eating disorders. borgen and corbin (1987) found that more athletes in the tb sports had eating disorder inventory scores (garner, olmsted, polivy, 1983) similar to or above those of individuals with an. otis et al. (1997) outlined some common guidelines shared by the tb sports, further examining how the nature of these sports perpetuates the risk for eating disorder development. these ‘at-risk’ sports include a diverse group of activities: endurance sports, sports where an athlete’s performance is subjectively scored by judges, sports where athletes are required to wear revealing clothing, sports using weight categories for participation (horse racing, some martial arts, wrestling, rowing), and sports that idealize a pre-pubertal body type (figure skating, gymnastics, ballet, diving). the typical female athlete participating in a tb sport confronts body image pressure at multiple levels. athletes in sports like gymnastics and longdistance running reported a greater sense of body dissatisfaction than both non-athletes and those participating in non-thinness-demand sports, despite weighing significantly less than both the other groups (davis & cowles, 1989). in the figure skating world, in particular, elegance and grace are foremost associated with thinness. professional skaters performing on ice sometimes receive reduced pay for being ‘overweight’ (thompson & sherman, 1993). skaters who are unable to achieve or maintain the physical ideals of the sport often experience negative affect, which in turn may cause attempts to control body size through disordered eating (harris, 1986). for competitive pairs (male-female partner) figure skating, a lean female body is an unspoken requisite to compete. pairs competitions require the male to lift, throw, and maneuver the female into difficult positions in the air; these acts can be physically straining and cause injury to both partners. thus for practical, physical, and aesthetic purposes, it is important that the female partner be lightweight. in their study on the symptomology of eating disorders in canadian competitive figure skaters, taylor and stemarie (2001) found that 92.7% of the forty-one skaters surveyed reported pressure to lose weight. the skaters also indicated that in efforts to maintain the thin ideal, they engaged in various weight control measures such as vomiting and/or restrictive dieting at some point. after extensive clinical study of eating disorders in non-athlete women, rezek and leary (1991) determined a relationship between self-restricted eating and perceived locus of control. since figure skating is an aesthetic sport where outcomes are controlled subjectively by judges, athletes may reconcile their perceived lack of control over performance with restricted eating. according to scourfield and colleagues (2003), a goodness of fit exists between an individual and his/her environment. in other words, people seek out contexts or environments that match their psychological and genetic dispositions. applying the goodness-of-fit hypothesis to the prevalence of disordered eating in female athletes, one can hypothesize a “goodness of fit” between an athlete and her chosen sport. some researchers have suggested that athletes who are predisposed to developing an eating disorder tend to self-select a certain type of athletic activity, a phenomenon known as the “self-selection” or “sport-attraction” hypothesis (thompson & sherman, 1993, p. 25). accordingly, an individual scoring high on the edi may idealize the graceful, fragile-looking prima ballerina, choosing to emulate both the ballerina’s body type and intense training regimen. in their study of female runners, estok and rudy (1996) found that 25% of women who ran more than 30 miles per week had high eating attitudes test scores for anorexia or bulimia. when asked what had initially drawn them to the sport, the eating disordered women indicated that they were attracted to running because it represented a salient image of thinness. since high edi-scoring individuals often display controlled, obsessive, and perfectionistic eating disorders in female athletes 67 types of behaviors, it is not surprising that they choose to participate in athletic activities in which these behaviors are encouraged. eating disorder identification issues in the female athlete populations the sports environment has the potential to trigger, worsen, or legitimize an eating disorder in vulnerable individuals. in this context, eating disorder diagnoses are complicated by the fact that some athletes are relatively satisfied with their bodies and do not meet the dsm-iv-tr criteria for “fear of becoming fat.” however, they may still engage in unhealthy dieting or eating behaviors due to a perceived belief that their success in the sport depends on their attainment of a low body weight or fat content. ziegler and colleagues (1998) found such a paradoxical weight-related concern in a study of junior elite figure skaters who ironically reported positive body image. the skaters were not dissatisfied with the shape of their bodies, yet strove to reduce weight either gradually (by dieting and exercising) or rapidly (by vomiting). however, since ‘body dissatisfaction’ is at the core of most eating-related issues, such athletes cannot clearly be diagnosed with an eating disorder despite their unhealthy eating behaviors. the drive for thinness in female athletes may come from a different source. many sports, particularly those at the elite level, stress the message of “no pain, no gain.” it is not surprising then that male and female athletes of competitive sports often take drastic measures to succeed, including training during physical injury, using steroids, and losing/gaining weight over a short period of time. in this regard, the sports environment often portrays success as the end result of a long journey of arduous physical work and strain. while female athletes may not necessarily wish to lose weight, they may do so because they believe it will maximize chances of winning or accomplishment. this ‘light at the end of the tunnel’ effect may make it easier for athletes to hide or justify weight-related issues, which in turn stalls identification and proper treatment of eating disorders (thompson & sherman, 1993). another issue informing the identification of eating disorders lies in the exercise component of the sport itself. how does one determine how much exercise is too much? at the elite level, it is customary for athletes to train for six or more hours a day. athletes with bn may use such rigorous exercise as a vehicle to maintain the disorder. regardless of whether exercise is designed to enhance performance, athletes with bn may look to excessive exercise as a weight loss tool that can undo the effects of bingeing. for example, after bingeing, a cross-country athlete with bn may run 6-8 miles to punish herself for “being bad” (thompson & sherman, 1993, p. 89). such maladaptive behavior may go unnoticed by parents, coaches, and teammates who see the athlete as dedicated rather than disordered. certain personality traits found in good athletes and individuals with an are found to correlate with one another, further complicating proper eating disorder diagnosis (thompson & sherman, 2001). both elite athletes and individuals with eating disorders are often willing to work to the point of overwork, have a high need for achievement, are selflessly committed to their team, comply obligingly with coaching instructions, are able to endure intense physical discomfort or pain, are willing to lose weight in order to enhance performance, and are perfectionists (thompson & sherman, 1993). the similarities that exist between hard-working athletes and eating disordered individuals were further illuminated in a study conducted by yates, leehay, and shisslak (1983). the researchers compared the behavior and demographics of 60 male marathon and trail runners to a sample of women with an, drawing parallels between the two groups. yates and colleagues found that the obligatory runners resembled the anorexic women in familial background, socioeconomic class, and several personality traits. like the male athletes, the women with an displayed high self-expectations, demonstrated tolerance for physical discomfort, denied potential physical debilities/injuries, exhibited an inhibition of anger, and showed a tendency toward depression. although the results of this study were controversial, it demonstrates an association of trait similarities shared among athletes and individuals with an. impact of coaches on eating disordered behavior in certain sports that emphasize a lean body type, coaches have been found to increase the risk of eatingrelated disturbances through some of their attitudes and behaviors (heffner, ogles, gold, marsden, & johnson, 2003). coaches may assume that reducing body fat or weight can enhance an athlete’s performance, and may encourage rapid weight loss (thompson & sherman, 1993). it is important to note that many elite athletes also begin their vigorous training at a young age. during this period of primary growth and development, the athletes spend several hours a day with coaches who may often advocate unhealthy or restrictive eating practices. coaches’ disparaging comments may catalyze disordered eating behaviors. rosen and hough (1988) researched the eating behaviors of 42 female gymnasts on five college teams, finding that 67% of the gymnasts were told by their coaches that they were too heavy. of this group, 75% reported that they frequently engaged in pathogenic methods (vomiting, laxative abuse, diuretics, diet pills, fasting, and fluid restrictions) to control their weight. in a similar study, burgess (1995) found that a gymnastics coach’s personality directly corresponded to the number of team eating-related issues. the researcher found that in relation to personality, the coaches of eating disordered collegiate gymnasts were narcissistic, inflexible, and high in dominance traits. while these studies provide interesting evidence, they do not produce answers to causal bernstein 68 questions regarding the relationship between coaches and their gymnasts. perhaps the athletic environment, another potential causal factor, is responsible. it is possible that the intense, high-stress atmosphere of collegiate-level competition cultivates strong personality traits in coaches and eating disordered behavior in athletes. intervention and treatment strategies for female athletes with eating disorders given all that is known about the ways in which eating disorders are manifested in female athletes, treatment needs occur in the form of intervention and therapy. treatment should not be limited to athletes—coaches and parents need to be educated about eating disorders as well. since a coach serves as an instrumental authority figure to an athlete’s success, it is important that he or she approach weight loss in a healthy, constructive way. a positive, authoritative coach can assuage risks for eating disorder development and promote a healthy body image in his or her athletes. the effects of a positive coaching style have been demonstrated by bisecker and martz (1999) in their study on the impact of coaching style on athletes’ eating problems. after assigning 110 male and female college athletes to a negative or a positive coaching vignette condition, the researchers measured body image anxiety and eatingrelated disturbances. in the negative vignette condition, the coach was performance-centered and focused on issues of weight in a threatening and controlling manner. while the coach also stressed low body weight in the positive vignette condition, he behaved in a problem-centered, caring manner. bisecker and martz (1999) found that regardless of gender, participants in the negative vignette condition showed higher instances of dieting, body image anxiety, and fear of becoming fat. although participants in the positive vignette condition still dieted, they did so in a healthy manner, and did not exhibit the same pathogenic behaviors as the participants in the negative coach condition. approaching dieting in a problem-centered way makes it so the athlete does not feel threatened or attacked. coaches of all backgrounds and coaching styles should be informed about proper nutrition, the daily caloric requirements of athletes, healthy dieting behaviors, and the different types of eating disorders and their respective risk factors. although it may be difficult to confront an athlete about a potential eating-related problem, interventions should be led on a collective level by parents, trainers, coaches, and members of the sports management team. although the athlete may be resistant to treatment and in denial of her eating disorder, proper action must be taken. such protocol would ideally require every athlete to undergo regular medical examinations. if these examinations reveal extreme weight loss or signs of other health conditions, then critical steps must be taken to protect the athlete’s health. these steps may include the termination of all training until the athlete’s health improves. a team of qualified sports psychologists, medical professionals, and nutritionists must closely monitor an athlete suspected of an eating disorder. it also may be beneficial for an eating disordered athlete to begin therapy sessions with a licensed psychologist to successfully address the root of her eating problems. conclusion despite generally representing a healthful atmosphere, the sports environment can serve as a potential host for eating disorders. although eating disorders are more prevalent in aesthetic or appearance-related activities or sports, the female athlete triad does not discriminate in its damaging effects. some athletes’ perfectionist personalities may make them more disposed to disturbances in eating, which are only exacerbated by the influences of authoritarian or weight-obsessed coaches. eating disorders need to be addressed on the team, coach, familial, and individual levels to prevent serious bodily harm. 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(1998). body image and dieting behaviors among elite figure skaters. international journal of eating disorders, 4, 421–427. journal_cover special tenth anniversary issue issn 1088-4661 2008 volume 10 published annually by the department of counseling and clinical psychology teachers college, columbia university graduate student journal of psychology anitha venkataramani-kothari jessica a. keith editors graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 30 school violence exposure and adolescent substance use: a rural investigation elizabeth w. milligan, heidi l. radunovich, & brenda a. wiens university of florida the purpose of this study was to examine the relationship between school violence exposure and adolescent substance use. the study looked at three types of school violence (witnessed violence, violent victimization, and violence perpetration) and their relationship to substance use frequency (marijuana use and the use of other illicit substances) during adolescence. a total of 766 high school students from a rural school district participated in this study by completing a survey used to assess youth risk behaviors over the past 12 months. although results found that overall school violence exposure and adolescent substance use were highly correlated, increased frequency of witnessing violence at school in particular were related to increased frequency of substance use. no significant relationships were identified between violence perpetration or victimization at school and adolescent substance use. potential implications of these findings for substance use prevention, particularly for adolescents residing in rural areas, are discussed. recent findings from the national survey on drug use and health (substance abuse and mental health services administration [samhsa], 2009) indicate a connection between youth violence and substance abuse. results from the samhsa study suggest that adolescents between the ages of 12 and 17 who engage in violent behavior are more likely to have also used illicit substances within the last 30 days (samhsa, 2009). violence exposure in community settings has demonstrated a severe emotional impact on children, resulting in impaired social relationships and externalizing problems (cooley-quille, turner, & beidel, 1995), and according to timmermans and colleagues (2008), externalizing behaviors are linked to adolescent substance use.  additionally, experiencing acts of physical and sexual assault have been shown to increase the risk for adolescent alcohol and substance use and lower the age of substance use onset (kilpatrick et al., 2000). sullivan et al. (2007) suggest that exposure to violence results in numerous negative outcomes for youth, including substance use. specifically, research suggests that those who report having witnessed violence at a greater frequency also report higher levels of substance use (sullivan et al., 2007), and witnessing violence almost triples the risk of substance use disorders in adolescence (kilpatrick et al., 2000). witnessing violence has also proven to be a better predictor elizabeth milligan, department of family, youth and community sciences, university of florida; heidi l. radunovich, department of family, youth and community sciences, university of florida; brenda a. wiens, department of clinical and health psychology, university of florida. elizabeth milligan is now at the school of professional psychology, pacific university. correspondence concerning this article should be addressed to elizabeth milligan, school of professional psychology, pacific university, 190 se 8th ave, hillsboro, or 97123. email: mill2080@pacificu.edu of externalizing behavior problems than victimization (cooley-quille et al., 1995; janosz et al., 2008). recent statistics on violence and substance use suggest high prevalence rates among adolescents (samhsa, 2009). in 2003, nearly one-tenth of high school students reported being threatened or injured with a weapon at school (brener, lowry, barios, simon, & eaton, 2004), and in 2007, 1.5 million students between the ages of 12 and 18 were victims of nonlethal crimes at school (dinkes, kemp, baum, & synder,,2009). according to dinkes and colleagues (2009), school crime rates for students between the ages of 12 and 18 remained constant from 1992 to 2007, illustrating that school violence remains a persistent problem. in addition, adolescence is the developmental period that assumes the greatest risk for substance use onset (perkonigg et al., 2006), and early adolescence is a distinct period of vulnerability for youth, with rates of substance use increasing drastically (abbey, jacques, hayman, & sobeck, 2006). according to perkonigg and colleagues (2006), the overall prevalence of adolescent substance use in the united states is exceptionally high in comparison to some european countries, with about half of all adolescents in the u.s. having tried at least one illicit substance prior to graduating. a study funded by the national institute on drug abuse, the monitoring the future study (national institute on drug abuse [nida], 2009), suggests that current rates of substance use among youths are a cause for concern. between 10.3% and 31.7% of students in grades 8-12 have used marijuana at least once in the year prior to being surveyed, while 3.7% to 8.3% had used inhalants, 1.8% to 4.4% had used cocaine, and 1.5% to 4.5% had used mdma (ecstasy). these results indicate that marijuana use among adolescents is reported more often than all other illicit substances, a finding which has been supported by other studies showing that marijuana is the most popular illicit substance among students (mccrystal, percy, & higgins, 2006). therefore, it is important to explore milligan, radunovich, & wiens 31 marijuana and illicit substance use as separate entities to better understand substance use behaviors in adolescence as well as the relationship between the use of marijuana and other illicit substances, if any. according to sussman and ames (2001), it is important to explore trends of adolescent substance use because substance use among adolescents differs from adult substance use in several ways. first, frequent substance use in adolescence may be classified as abuse more readily because of the potential for such use to impede developmental growth and to compromise adjustment tasks, whereas similar use may or may not be considered abuse in adults. secondly, adolescents may display less physical dependence and fewer physical symptoms in relation to substance use and can also use a smaller amount to achieve a similar effect. substance use during adolescence has been linked to many negative outcomes, including continued substance use, lower educational attainment, and frequent displays of delinquent behavior such as violence (abbey et al., 2006). furthermore, it is essential to study the effects of violence exposure as a whole, as well as the effects of exposure to individual types of violence because individual types of violence exposure have been found to have differential effects on substance use, such as increased risk for developing a substance use disorder and increased impairment in cognitive coping abilities (kilpatrick et al., 2000; brady, tschann, pasch, flores, & ozer, 2009). previous research studies have not examined all types of violence-related behaviors simultaneously. thus, this study examined school violence exposure and substance use among adolescents, and specifically investigated whether overall school violence exposure or a specific category of school violence exposure (witnessed violence, experienced violence, or perpetrated violence) had any impact on the frequency with which adolescents reported using illicit substances. martino, elickson, and mccaffrey (2008) suggest that living in a rural area might serve as a protective factor against various forms of substance use because adolescent substance use has primarily been an issue in metropolitan areas. however, rates of substance use among urban and rural youths are becoming more comparable as rates of violence are beginning to increase in rural communities (martino et al., 2008). geographic estimates of prevalence have also been confounded by the relative dearth of research in rural areas. historically, much of the research on violence exposure in adolescence has been conducted within community settings and has focused on violence within that community (i.e., drive-by shootings, murders, etc.). thus, little is known about the types of violence and the extent to which youth are exposed to violence in rural areas (slovak & singer, 2002). however, frequent community violence is likely an uncommon experience for adolescents living in rural areas. therefore, in order to evaluate the extent to which adolescents are being exposed to violence in rural areas and how this exposure might be related to substance use frequency, it is important to study these factors in an environment in which adolescents spend much of their time, such as the school. according to researchers, current research in schools is lacking, especially in rural areas (reid, peterson, hughey, & garcia-reid, 2006; lowry et al., 1999). based on the existing literature, it was expected that as rates of overall school violence exposure increased, rates of substance use would also increase. it was also expected that students who reported frequent incidents of witnessing school violence would report using substances more frequently than those who reported perpetrating violence at school and those who reported experiencing violent victimization at school. comparing violence-related behaviors in this way may provide unique findings about violence exposure at school and its relationship to illicit substance use in adolescence. method participants the sample for this study included participants from a federally funded prevention and intervention program for youth risk behaviors and consisted of all students attending public high schools (grades 9-12) in a rural county in florida, excluding students enrolled in educable mentally handicapped classes. all students in attendance on the day of testing were asked to complete an anonymous questionnaire during the first class period of the day; only students who were absent on the day of testing or who chose not to fill out the survey were excluded from this study. a total of 1859 surveys were collected from the 2,720 students enrolled in grades 9-12 in 2008, resulting in an initial response rate of approximately 68%. the following criteria were used as validity checks to identify invalid surveys: 1. the endorsement of the use of a fictional drug (i.e., “xanthidol”). 2. the use of an invalid response pattern (e.g., entering the same response for each question or “christmas treeing” responses). 3. reports of “daily” use of cocaine, hallucinogen, or ecstasy use, or the “daily” occurrence of being physically hurt by a student with a knife (extremely unlikely over a 12-month period). 4. answering “no” to the question, “have you answered the items on this questionnaire truthfully?” 5. the occurrence of mismatching demographic information (i.e., reporting an age of 20 and reporting being in the 6th grade). as a result of these screening procedures, a total of 288 surveys (approximately 15% of the surveys collected) were discarded and not included in the data set for the federally funded program from which the data for this study were obtained. this left a total of 1571 valid surveys. for the purposes of this study, however, only surveys completed by high school students that assessed for substance use and violence-related behaviors within the past 12 months were used. this resulted in a total of 766 valid surveys. a breakdown of participants by grade level and demographic characteristics is provided in table 1. school violence and adolescent substance use 32 while questions regarding socioeconomic status were not included due to school board policies and doubts regarding adolescents’ abilities to accurately estimate family income, it is important to note that data was collected in a rural school district with a relatively low socioeconomic status. approximately 24% of the county’s population under the age of 18 falls below the poverty level and 60% of students in this particular district qualify for free or reduced lunch (education information and accountability services, 2009). materials and procedure the data used for this study were collected as part of a larger questionnaire designed to evaluate a federally funded prevention and intervention program for youth risk behaviors. the measure used in this study was the risk incidence for schools inventory (risci). this measure was developed by faculty in the department of clinical and health psychology at the university of florida. questions used in this measure were adapted from measures shown to be reliable and valid when used in the monitoring the future survey and other studies evaluating substance use among adolescents (bachman, johnston, & o’mally, 2001). the university’s institutional review board approved the use of this data for research purposes. per school district policy, parents are informed that their children will be asked to participate in district-wide surveys and are given the opportunity to decline participation. students were also provided with the opportunity to choose not to complete the questionnaire. this study includes data collected during the spring semester of 2008 as part of an ongoing program evaluation that began in 2003. students were asked to anonymously report the frequency with which each behavior occurred over the last 12 months. the 2008 risci consisted of 84 questions. for the purposes of this study, eight questions related to substance use frequency and 12 questions related to violence exposure were selected as the primary foci for analyses. hierarchical linear regression analyses were performed to determine which outcome variables were influenced by overall school violence exposure and to examine any relationships between specific school violencerelated behaviors and adolescent substance use. analyses were conducted in two parts: once using marijuana use frequencies as the dependent variable, and once using illicit substance use frequencies as the dependent variable. results race/ethnicity, age, and sex were collected from all participants (n = 766). these data are presented in table 1. race/ethnicity was collapsed into four categories: white, african american, hispanic, and other (asian/pacific islander, native american, and mixed origin). the majority of participants identified as white (66.2%, or n = 506). breakdowns of race/ethnicity for this sample (66.2% white, 19.9% african american, 6.5% hispanic, and 7.4% other) appear to be relatively similar to demographic information gathered on this particular school district from the department of education (doe): 69.67% white, 21.45% african american, 4.14% hispanic, and 4.73% other (florida department of education, education information & accountability services, 2010). the average age of respondents was 16.1 (sd = 1.23) and the male to female ratio was very close with 46.7% of the participants being male (n = 355) and 53.5% being female (n = 405). according to information gathered by the doe on high schools in this county, the gender breakdown found within this sample is similar to that of the population, which is 48.85% male and 51.15% female (florida department of education, education information & accountability services, 2010). therefore, the sample included in this study should be considered a representative sample of the population from which it was drawn. frequencies of substance use behaviors and violencerelated behaviors were determined using a response scale ranging from 1 (“never”) to 6 (“daily”). substance use was divided into two variables: the use of marijuana and the use of other illicit substances (cocaine, ecstasy, inhalants, and hallucinogens). given that students reported more frequent use of marijuana than other illicit substances, separate analyses were conducted for each substance use variable to reduce effects on results. for marijuana use, possible scores ranged from 1 to 6. actual sample scores ranged from 1 to 6, with a mean of 1.48 (sd = 1.19). the illicit substance use table 1 summary statistics for demographic variables (n=766) n % grade 9 242 31.6 10 220 28.7 11 206 26.9 12 98 12.8 total 766 100.0 race/ethnicity white 506 66.2 african american 152 19.9 hispanic 50 6.5 other 56 7.4 total 764 100.0 sex male 355 46.7 female 405 53.3 total 760 100.0 age 14 68 9.0 15 191 25.2 16 226 29.8 17 181 23.9 18 75 9.9 19 13 1.7 20 3 0.5 total 757 100.0 milligan, radunovich, & wiens 33 variable was created for each student by adding their answers to each of the four illicit substance use questions and using the total score in the analysis, resulting in a possible range of 4 to 24. actual sample scores ranged from 4 to 12, with a mean of 4.13 (sd = 0.77). types of violence were identified as witnessed violence, violent victimization, or violence perpetration. items used to assess witnessing violence involved students witnessing violent acts committed by another student (e.g., “in the past 12 months, in general, how often have you seen another student carrying a knife, gun, or other weapon?”). items used to assess violent victimization involved students experiencing violence at the hands of a fellow student (e.g., “in the past 12 months, in general, how often have you been threatened with a gun, knife, or other weapon by a student?”) and items used to assess violence perpetration involved students admitting to committing violence against a fellow student (e.g., “in the past 12 months, in general, how often have you hurt a student by using a knife, gun, or other weapon?”). again, responses for each item ranged from 1 (“never”) to 6 (“daily”). violence category scores were created for a particular student by summing their answers to each question within that category and using the total score in the analysis. the possible range for the witnessing violence category was 5 to 30, the possible range for the violent victimization category was 4 to 24, and the possible range for the violence perpetration category was 4 to 24. actual scores ranged from 5 to 30 for witnessed violence (m = 8.00, sd = 4.12), from 4 to 22 for violent victimization (m = 4.91, sd = 1.98), and from 4 to 19 for violence perpetration (m = 5.48, sd = 2.68). to determine the internal consistency of these variables, inter-item reliability tests were conducted. the cronbach’s  for each category of violence are as follows: witnessing violence,  = .828; violent victimization,  = .637; and violence perpetration,  = .641. correlations between demographic information, type of violence, and substance use frequencies are presented in tables 2 and 3. these correlational analyses suggest that all types of violence were highly correlated with one another and were also highly correlated with the outcome variables (frequency of marijuana use [table 2] and frequency of illicit table 2 marijuana use frequency correlations (1) (2) (3) (4) (1) marijuana use frequency -.222* .113* .182* (2) witness -.535* .568* (3) victimization -.535* (4) perpetration - notes. n = 766. reported marijuana use and exposure to violencerelated behaviors were assessed using a 12-month time frame. *p < .001. substance use [table 3]). next, two sets of hierarchical regression analyses were conducted. in spite of the large sample size, the data were positively skewed. based on tolerance values for the data, there was no evidence of multicollinearity among variables. variables were introduced into the regression model in the following order: (a) demographic variables (i.e., race/ethnicity, age, and sex); (b) witnessing violence; (c) violent victimization; and (d) violence perpetration. these analyses were run once using frequency of marijuana use as the dependent variable and once using frequency of illicit substance use as the dependent variable. hierarchical regression results indicate a significant relationship between overall school violence exposure and marijuana use frequencies, f2 = 0.06, p < .001 (table 4) as well as illicit substance use frequencies, f2 = 0.12, p < .001 (table 5). table 3 illicit substance use frequency correlations (1) (2) (3) (4) (1) illicit substance use frequency -.326* .174* .222* (2) witness -.534* .568* (3) victimization -.533* (4) perpetration - notes. n = 766. reported illicit substance use and exposure to violence-related behaviors were assessed using a 12 month time frame. * p < .001 table 4 hierarchical regression for marijuana use frequency r2 r2  95% ci step 1 .008 .012 race/ethnicitya .066 [-.007, .131] sex -.092 [-.389, -.043] ageb .014 [-.059, .086] step 2 .056 .051* witness .188* [.026, .077] victimization -.042 [-.079, .028] perpetration .090 [.000, .082] notes. n = 766. arace/ethnicity = white, african american, hispanic/latino(a), asian/pacific islander, native american, mixed origin, and other; bage = 10-20; ci= confidence interval. all information, including reported marijuana use and exposure to violence-related behaviors were assessed using a 12 month time frame. *p < .001. school violence and adolescent substance use 34 these relationships suggest that increased exposure to overall school violence is related to increased marijuana and illicit substance use. the addition of witnessing violence, specifically, accounted for a significant amount of variance over and above the relationship between demographic variables and outcome variables, suggesting a relationship between witnessing violence and increased marijuana use, sr2 = 0.03, p < .001 (table 4) and illicit substance use, sr2 = 0.05, p < .001 (table 5). thus, increased levels of witnessing violence were related to increased frequencies of marijuana use and illicit substance use. results did not suggest any significant relationships between substance use frequencies and violence perpetration or violent victimization. discussion the purpose of this study was to examine the relationships between school violence exposure and adolescent substance use. the study explored the relationship between overall school violence, as well as specific violencerelated behaviors, and adolescent substance use frequencies. the violence-related behaviors examined in this study included witnessed violence, violent victimization, and violence perpetration. in addition, adolescent substance use was divided into two categories: the use of marijuana and the use of other illicit substances. the first hypothesis posited that as overall exposure to school violence increased, the frequency of substance use would also increase. results showed that the addition of overall school violence exposure into the regression models for both marijuana use and other illicit substance use frequencies accounted for a significant amount of variance. thus, findings indicate that overall school violence exposure was related to increased frequencies of marijuana use and increased frequencies of other illicit substance use. next, it was hypothesized that students who reported high levels of witnessing violence at school would report using substances more frequently than those who reported perpetrating violence or being victimized by violence at school. findings from this study indicate that witnessing violence was significantly related to both increased marijuana use and increased illicit substance use. these findings are consistent with other research (cooley-quille et al., 1995; janosz et al., 2008) on witnessing violence in adolescence. however, no significant relationships were found between violence perpetration or violent victimization and adolescent substance use when witnessing violence was included in the model. although research suggests that physical aggression, which can be associated with violence perpetration, appears to be the best predictor of health risk behaviors in adolescence (timmermans et al., 2008), the current study did not support a relationship between violence perpetration and substance use behaviors when accounting for witnessing violence. other research suggests that violent victimization is not associated with adolescent substance use (brady et al., 2009); these conclusions were supported from the findings of this study. the finding that witnessing violence is related to increased frequencies of substance use is supported by previous research, which suggests that witnessing violence is among the most influential risk factors for substance use (kilpatrick et al., 2000) and that witnessing violence and substance use may share a common set of risk factors (sullivan, kung, & farell, 2004). however, these risk factors have not yet been identified. previous research has also shown that witnessing violence is a strong risk factor for poor adolescent adjustment, and that this exposure often results in feelings of powerlessness, insecurity, and fear (janosz et al., 2008). poor adjustment and increased feelings of powerlessness and fear may be a reflection of poor coping skills that may potentially result in increased substance use, whereby substances are used as a coping method. therefore, the relationship between witnessing violence and substance use should be examined further to determine underlying mechanisms that link these two variables (sullivan et al., 2004). in addition, increased exposure to overall school violence was related to increased frequencies of substance use, for both marijuana use and other illicit substance use. although previous research in this area has not examined how all three types of school violence exposure are related to adolescent substance use, results from this study highlight the importance of understanding the consequences associated with exposure to witnessing violence because of its relationship to increased frequency of substance use. it may be true that those who are more likely to witness violence at school associate with violent classmates and may also be more likely to participate in other deviant behaviors, such as substance use. findings from this study suggest a relationship between the two; however, these results do not prove causality or directionality in any way. therefore, it is impossible to know whether violence exposure leads to increased substance use or whether increased substance use table 5 hierarchical regression for illicit substance use frequency r2 r2  95% ci step 1 .003 .007 race/ethnicitya .049 [-.016, .076] sex -.056 [-.202, .027] ageb .042 [-.020, .076] step 2 .106 .106* witness .300* [.038, .017] victimization -.019 [-.042, .027] perpetration .060 [-.009, .045] notes. n = 766. arace/ethnicity = white, african american, hispanic/latino(a), asian/pacific islander, native american, mixed origin, and other; bage= 10-20; ci= confidence interval. reported marijuana use and exposure to violence-related behaviors were assessed using a 12 month time frame. *p < .001. milligan, radunovich, & wiens 35 leads to violent behaviors, or if there is any causal relationship at all. as with all studies, this study had several limitations. first, although we attempted to obtain a representative sample of an adolescent population by providing surveys to all high schools located within this rural county, no measures were taken to ensure that students absent on the day of testing were able to fill out surveys later. this could pose a threat to the generalizability of this study, because those students who were absent on the day of testing may have provided unique responses regarding substance use and violent behaviors in relationship to their peers. in addition, data presented in table 1 reveal that students in the 12th grade were underrepresented in comparison to other grades. participation in on-the-job training (a program in which students receive vocational training off-site during school hours) could help to explain this discrepancy, but a more representative sample of this grade level could have provided useful responses for both substance use behaviors and school violence exposure. given that substance use behaviors were more common among older students, the inclusion of more high school seniors may have provided more data on these behaviors in particular. however, it is expected that overall absences occurred randomly and in small numbers, so it is not expected that this missing data should seriously impact results. second, although many validity checks were employed to ensure that data included in the study was accurate, the use of self-reported data can sometimes compromise the validity of results. however, according to sullivan et al. (2007), selfreported data may provide the best source of information on witnessing violence and violent victimization as well as an important perspective on adolescents’ experience of externalizing behaviors. additionally, although the sample size of the study was relatively large, the number of students who reported the use of illicit substances other than marijuana was fairly low, which most likely impacted the results of this study. to reduce these effects, separate analyses were conducted for marijuana use and for the use of all other illicit substances. next, types of violence explored in this study differed somewhat from previous research. violence-related behaviors identified within this study are strictly related to the school environment. previous research involving violence exposure in adolescents typically dealt with more extreme types of violence within the community and within the home. experiencing extreme exposure to violence in this context may have a very different impact on adolescents than typical violence experienced at school. furthermore, the sample included in this study involved adolescents from one rural county. the type of violence exposure and the availability of substances for potential use may deviate from those experienced in a more metropolitan area, or in other parts of the country. these factors could potentially limit the generalizability of the findings from this study; however, they may also provide a unique perspective on school violence exposure and substance use behaviors in a rural school setting. future research in this area should consider focusing on identifying the set of risk factors common to those who experience violence and substance use during adolescence in hopes of understanding more fully the repercussions associated with violence exposure and its relationship to adolescent substance use. specifically, longitudinal studies that assess risk behaviors, violence exposure, and substance use may be useful in determining a causal link between violence exposure and frequency of substance use. findings from this study suggest that there are differences in substance use behaviors for marijuana relative to other illicit substances; adolescents reported using marijuana more often and more frequently than other illicit substances. therefore, it would also be important to evaluate perceptions about marijuana use relative to other illicit substances and to determine what protective factors exist to deter adolescents from using any and all substances. findings from this study may also play an important role for violence and substance use prevention programs within schools. results suggest that witnessing violence bears a significant relationship to adolescent substance use, specifically in its association with increased frequencies of use of marijuana and other illicit substances. witnessing violence has become an important area of interest for school personnel and counselors and should be incorporated as a risk factor in substance use prevention programs to address the needs of students who witness threats and fights at school (flannery, wester, & singer, 2004), as well as to educate students on how to avoid unsafe areas and to handle adaptively thoughts and emotions associated with witnessing violence (sullivan et al., 2007). substance use during adolescence remains a cause for concern in today’s society. there are many factors related to the frequency with which adolescents use substances. students who witness violence are at risk for more frequent substance use. exposure to violence-related behaviors may affect individuals in very different ways, but results from this study suggest a relationship between witnessing violence and adolescent substance use. in essence, it is important to understand the developmental pathways associated with adolescent substance use in order to reduce any long-term consequences or health-risks accompanying these behaviors. in order to reduce the impact of substance use in adolescence, we must understand what factors contribute to this phenomenon and work to minimize their effects. acknowledgment the data used for this study were collected as part of project catch, which was funded by safe schools/healthy students initiative (s184l020327). school violence and adolescent substance use 36 references abbey, a., jacques, a., hayman, l. w. jr., & sobeck, j. 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(2009). results from the 2008 national survey on drug use and health: national findings. retrieved from http://oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cf m#ch5 sullivan, t. n., farrell, a. d., kilewer, w., vulin-reynolds, m., & valois, r. f. (2007). exposure to violence in early adolescence: the impact of self-restraint, witnessing violence, and victimization on aggression and drug use. the journal of early adolescence, 27, 296-320. doi:10.1177/0272431607302008 sullivan, t. n., kung, e. m., & farrell, a. d. (2004). relation between witnessing violence and drug use initiation among rural adolescents: parental monitoring and family support as protective factors. journal of clinical child and adolescent psychology, 33, 488-498. sussman, s., & ames, s. l. (2001). the social psychology of drug abuse. philadelphia, pa: open university. timmermans, m., van lier, pol, a. c., & koot, h. m. (2008). which forms of child/adolescent externalizing behaviors account for late adolescent risky sexual behavior and substance abuse. journal of child psychology and psychiatry, 49, 386-394. doi:10.1111/j.1469-7610.2007.01842.x 45     graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university panic disorder subtype gastrointestinal response: phenomenon and treatment recommendations kevin ashworth pacific university allison bonifay pacific university johan rosqvist pacific university while research has shown strong associations between panic disorder and symptoms of gastrointestinal distress, there is a dearth of evidence on limited symptom panic disorder with the primary symptom of gastrointestinal distress. most published studies have been single case studies or small case series, and proper classification remains unclear. although a formal diagnosis does not exist for this presentation, this paper proposes the diagnosis of panic disorder (pd) subtype gastrointestinal (gi) response. this particular cluster of symptoms currently creates a diagnostic conundrum, which can directly affect treatment options. this paper explores the relationship between panic disorder and gastrointestinal distress, and discusses the challenge of differential diagnosis among disorders with considerable symptomological overlap (e.g., obsessive compulsive disorder, agoraphobia, and irritable bowel syndrome). theories such as the brain-gut loop and cognitive theory are discussed to explain how the interaction of cognitions and physiological reactivity maintain and exacerbate the proposed disorder. finally, specific treatment recommendations and behavioral assessment methods are provided. panic disorder (pd) has been conceptualized as a multiple symptom disorder by the american psychiatric association (dsm-iv-tr, 2000). however, limited symptom pd (i.e., one symptom cluster predominates) confounds the categorization and treatment of pd. gastrointestinal (gi) distress and pd overlap considerably, yet there is little research on limited symptom pd with the primary symptom of gi distress. the current article explores the relationship between the two conditions, proposes the diagnosis of pd subtype gastrointestinal response as a more accurate classification of this specific symptom presentation, and offers appropriate treatment recommendations. the criteria for pd includes recurrent, unexpected panic attacks accompanied with four or more of the 13 physiological symptoms (e.g., pounding heart, sweating, trembling, nausea or abdominal distress) and cognitive symptoms (e.g., fear of dying, and fear of losing control) which peak within 10 minutes (dsm-iv-tr, 2000). an unexpected panic attack is defined as one that an individual does not immediately associate with a situational trigger ). additionally, at least one of the following must be experienced for one month following an attack: 1) persistent concern about having additional attacks; 2) worry about the implications of the attack or its consequences; and/or 3) a significant change in behavior related to the                                                                                                   correspondence concerning this article should be addressed to kevin ashworth, pacific university, school of professional psychology, 222 se 8th ave, hillsboro, or 97123, email address: ashw1543@pacificu.edu. attacks. in some cases, patients report experiencing only one or two of these symptoms during a panic attack. symptom specific presentations of panic (e.g., cardiovascular and respiratory systems, and gi distress) that do not meet full criteria for pd have been referred to as a limited symptom panic attack (lelliott & bass, 1990; rosqvist, 2005). pd accounts for approximately 10% of individuals referred for mental health consultation. pd is often accompanied by agoraphobia, characterized by anxiety about being in situations perceived as inescapable; thus dsm-iv-tr, 2000). approximately one-third to one-half of individuals diagnosed with pd in community samples also suffer from agoraphobia (dsm-iv-tr, 2000). panic disorder subtype gastrointestinal response case studies and other research document pd in terms of limited symptom attacks and characterize gi distress as a limited symptom pd (eldridge, walker, & holborn, 1993; hatch, 1997; lelliott & bass, 1990). individuals from select case studies report debilitating symptoms such as abdominal distress, heart palpitations, hot flashes, sweating, and shaking (eldridge et al., 1993; hatch, 1997). ending excessive time contemplating the location of toilets in public is also reportedly common (hatch, 1997). behavioral changes range from spending an increased amount of time in bathrooms and modifying diets by ashworth, bonifay, & rosqvist     46 eliminating certain foods, to eliminating all food intake prior to leaving home or avoiding leaving home altogether (eldridge et al., 1993; hatch, 1997). for example, eldridge et al. (1993) illustrated the suffering endured by one patient. the patient avoided all public situations where she might feel embarrassed by the length of time she spent using the toilet. she was unable to work, ride public transportation, or wait in a line. she also reported distress while waiting for a phone call or a house visitor for fear of experiencing sudden diarrhea. the patient refrained from eating all together on days when she would need to leave her house. her catastrophic misinterpretations of her gi sensations reinforced her need to avoid or escape certain situations. furthermore, her worries were confirmed by evidence that, when she did use the toilet, she experienced diarrhea. in sum, physiological sensations trigger cognitive distortions (e.g., catastrophic thinking) and avoidance behaviors, resulting in impaired daily functioning due to persistent avoidance of situations where access to a toilet is limited (eldridge et al., 1993; hatch, 1997). however, research on this phenomenon is minimal, and likewise, data on prevalence, gender and age differences, and diagnostic criteria remains largely unknown. in addition, the literature indicates an underreporting of pds involving gi functioning, which hatch (1997) ascribes to societal influences that deem speaking of bodily functions, even to medical and health professionals, as improper. as a result of social norms, individuals suffering from irregular bowel functions and fear of incontinence may feel uncomfortable discussing personal bowel functions. due to the lack of a formalized classification and dearth of research, this presentation remains difficult to diagnose and treat. to better understand the mechanisms governing this particular cluster of symptoms and to make a case for a new diagnosis, we compare existing diagnoses to the proposed diagnosis of as pd subtype gi response. specifically, we discuss psychiatric and medical diagnoses that report manifestations of gi symptoms that may be related to panic symptoms: bowel obsessions (a variant of obsessivecompulsive disorder), agoraphobia without a history of pd, and irritable bowel syndrome (ibs). we then consider brain-gut interaction theory, cognitive theory, and extant treatment strategies used for ibs, ocd, and pd to inform treatment recommendations for the proposed diagnosis of pd subtype gi response. bowel obsessions bowel obsession syndrome (bos) has a similar presentation to pd subtype gi response and has been researched and proposed as a variant of obsessivecompulsive disorder (ocd; hatch, 1997). bos is characterized by excessive worry about fecal incontinence and compulsive behaviors of evacuation checking. secondary symptoms may include fears of social judgment and inaccessibility of bathrooms when not at home. individuals who experience these cognitions also engage in behaviors directed at controlling their bodily functions, such as spending considerable amounts of time in the bathroom as well as limiting food intake (hatch, 1997). debate exists over the diagnosis of bos. some research proposes that bowel obsessions would be better conceptualized as an anxiety disorder, such as pd, due to pharmacological treatment (hatch, 1997). the following study highlights the lack of consensus regarding the diagnosis of bos. hatch (1997) argued that if ocd and bos shared a symptom profile, individuals suffering from bowel obsessions would score highly on obsessive thinking on the yale-brown obsessive compulsive scale (ybocs). however, hatch (1997) showed in two case studies that both patients with bowel obsessions at pretreatment baseline scored lower on the (y-bocs) than classic ocd patients. this suggests that if conceptualized as an ocd variant, bowel obsessions would present within the mild range of severity. due to the debilitating effects of bowel obsessions, it seems disproportionate to diagnose this syndrome as of mild severity. treatment implemented by hatch (1997) included cognitive-behavioral interventions, such as cognitive restructuring and in-vivo exposures, which resulted in significant symptom reduction of bowel obsessions. given the positive response to cognitive-behavioral treatment strategies among bos patients, and the overlapping symptomotology of bos and the proposed pd subtype gi response, we suggest that individuals suffering from pd subtype gi response would benefit from a similar treatment protocol as those with bos. agoraphobia without a h istory of panic disorder the dsm-iv-tr (2000) describes agoraphobia without a history of pd as the presence of agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea) and that criterion have never been met for pd. the fear of fecal incontinence while in public and the fear that access to a bathroom may be limited, overlap with the aforementioned symptoms of bos and pd, and may contribute to certain agoraphobic conditions. while agoraphobia without a history of pd has been questioned as a legitimate diagnosis separate from pd, two models have been proposed. the first model describes the development of agoraphobia as a sequelae of pd and the second model suggests that agoraphobia is a conditioned avoidance response from the pairing of situations (e.g., driving, traffic, shopping) to noxious experiences of panic or fear of vomiting, panicking, or bowel incontinence (dsm-iv-tr, 2000; goisman et al., 1995). goisman et al. (1995) found that individuals who met criteria for agoraphobia without a history of pd had experienced limited symptom attacks that narrowly missed the criteria for pd with agoraphobia, suggesting that both can be seen gastrointestinal panic disorder   47 on the same continuum. goisman et al. (1995) also found that a high number of individuals with agoraphobia reported catastrophic cognitions associated with their disorder, the most common of which were 1) fear of doing something embarrassing (n = 11, 25%), 2) fear of fainting (n = 8, 18%), 3) fear of losing control (n = 7, 16%), and 4) fear of becoming ill (n = 7, 16%; goismann et al., 1995). i r r itable bowel syndrome drossman, li, andruzzi, temple, and talley (1993) reported that functional gi disorders effects 69% of the united states population with 40% complaining of bowel distress. of these sufferers, 8% 17% experience debilitating effects of the disorder. moreover, research indicates that many individuals who seek treatment for ibs have a psychiatric history (lydiard & falsetti, 1999). taylor (2000) speculated that pd presents as one psychiatric disorder often comorbid with ibs because ibs symptoms conceivably include undesirable body sensations that can easily lead to misappraisals. because those with ibs are often hypervigilant of bowel symptoms, any bowel sensation (even those that are benign) could be interpreted as an indication of possible loss of bowel control. this trigger a panic attack. to determine the link between pd and gi symptoms, lydiard et al. (1994) conducted a study among a community-based sample consisting of 13,537 participants. four groups were created from this random probability sample: (a) individuals diagnosed with pd at any time in their lives, (b) participants diagnosed with any other anxiety disorder, (c) individuals diagnosed with any other major psychiatric disorder, and (d) those who did not meet qualifications for any dsm-iii classified disorder. the results of this study showed that participants with pd reported experiencing gi symptoms at a higher frequency than the other groups. symptoms of diarrhea were reported by 12.9% of individuals with pd as compared to 2.9% of those without a psychiatric diagnosis. additionally, lydiard and colleagues (1994) found evidence to suggest that, contrary to previous research on treatment-seeking populations, pd and ibs symptoms do in fact co-exist. this diagnostic overlap generalizes the cooccurrence beyond treatment-seeking populations and speaks to the challenge of differential diagnosis. b rain-gut interaction and cognitive theory the enteric nervous system (ens), which regulates behaviors, such as bowel performance, has been compared to the brain in its organizational and functional structure. similar to the brain, which processes external stimuli transmitted to the central nervous system (cns) through the dorsal root and cranial nerve ganglion cells to control behaviors, the ens responds to stimuli signaled through intrinsic primary afferent neurons (ipans). although both systems can work independently of one another, they generally work in tandem. the cns and ens both rely on receiving information from the bowel to make informed decisions (gershon, 2005). lydiard and falsetti (1999) postulate that by understanding the relationship between the cns and ens, explanations for gi distress may be established. they propose a brain-gut loop model to explain the positive feedback cycle that occurs in ibs patients. this model suggests that when aversive stimuli are detected by the gut, the locus ceruleus (lc), a cns noradrenergic nucleus that mediates fear and arousal states is activated. activation of the lc leads to activation of the cns, sending messages to cns fear and arousal-mediating components, such as the amygdala and medial hypothalamus (coplan & lydiard, 1998). given the interaction between the cns and ens, individuals with increased arousal (or hypervigilance) could experience gi distress due to the increased cns sympathetic outflow and responsive input to the lc creating a positive feedback loop (lydiard & falsetti, 1999). this brain-gut loop explains how hypervigilance and increased sensitivity to aversive stimuli is reinforced by neurochemical feedback sent to the brain by way of the cns and ens, thus validating irrational or negative cognitions associated with sensations experienced during high arousal states. cognitive theory, as described by chambless et al. (2000), conceptualizes panic using a similar feedback loop. when a person grossly misinterprets somatic sensations, anxiety levels are increased. this, in turn, heightens sensitivity to subsequent bodily sensations creating an experience of panic. the negative cognitions and feared bodily sensations interplay with one another to create this positive feedback loop of heightened anxiety followed by heightened sensitivity. understanding the brain-gut interaction and cognitive processes is crucial to informing appropriate treatment interventions focusing on gi-related cognitive distortions and obsessive thinking. many individuals who experience gi distress seek relief through pharmacological interventions. for example, sandler (1990) reported that over two million prescriptions for ibs are written per year in the united states. masand and colleagues (2002) studied treatment effects of paroxetine, a commonly prescribed selective serotonin reuptake inhibitor (ssri), in two groups of ibs patients: (a) 10 patients with coexisting anxiety disorders (specific phobia, pd, and social phobia as indicated by the structured clinical interview [scid]), and (b) 10 patients with no anxiety disorder diagnosis. both groups of patients received 12 weeks of paroxetine at a mean dose of 31 mg/day. results showed that seven patients with anxiety disorders reported a 70% or greater improvement in abdominal pain, versus 20% of the non-anxiety disorder group. diarrhea frequency and severity decreased in 71% of anxiety patients versus 43% of the non-anxiety patients. these results may be due to the effects of psychotropic medication on the interplay between the cns and ens, ashworth, bonifay, & rosqvist     48 particularly for those with co-existing anxiety disorders (masand et al., 2002). t reatment recommendations while cognitive-behavioral treatment of pd has been studied extensively, specific examination of gi symptoms is less widespread (barlow, gorman, shear & woods, 2000; landon & barlow, 2004). a relevant study by lelliot and bass (1990) compared the subjective and physiological responses to imaginal exposure and voluntary hyperventilation of two groups of patients with pd. one group was classified as experiencing cardiovascular and respiratory (cr) symptoms of panic (e.g., shortness of breath, smothering sensations, and chest pain), while the second group primarily reported gi symptoms (e.g., abdominal discomfort, diarrhea, and fear of fecal incontinence). the findings indicated that the gi group experienced significantly less distress than the cr group. the authors concluded that because the hyperventilation exposure induced sensations similar to those experienced during a panic attack for the cr patients, they were more likely to produce distress in the cr group. this finding suggests that pd is heterogeneous in presentation and effective treatment is dependent upon on accurate targeting of the specific symptoms experienced. thus, designing an effective treatment for pd subtype gi response would require use of interoceptive exposures that induce symptoms of gi distress. chambless et al. (2000) endorsed this methodology asserting that cognitivebehavior therapy (cbt) approaches for inducing paniclike experiences should be targeted to induce the symptoms experienced by each patient. as andrews et al. (2003) suggest, in order to improve treatment outcome, exposures should closely resemble the actual feared situations, as well as aim to modify maladaptive cognitions. exposure therapy prompts change by challenging the inappropriate anxiety response that has been conditioned to produce or elicit fear. a reduction in anxiety occurs by reexperiencing the feared stimuli (e.g., limited access to bathroom, travel, and traffic) and associated catastrophic bowel incontinence; rosqvist, 2005). in order for new nonthreatening conditioning to occur, an individual must first habituate to the perceived threatening stimulus. habituation occurs when a person does not flee or avoid anxiety-provoking situations, but remains present. remaining present despite a perceived threat provides the body with a new experience (i.e., new physiological evidence) that actual threat or danger is not occurring and anxiety responses begin to diminish (foa & mcnally, 1996). based on the literature reviewed herein, we recommend a specialized cbt treatment strategy for pd subtype gi response that includes graded exposures to girelated somatic sensations in addition to psycho-education about anxiety, somatic skills training (e.g., utilizing diaphragmatic breathing), and cognitive restructuring (e.g., distorted versus objective thinking). additionally, we suggest integrating bowel control training (e.g., distinguishing normal abdominal sensations from bowel distention), as well as utilizing in-vivo exposures to challenge agoraphobic avoidance and escape behaviors (e.g., eating in public, going places where restroom access is limited). despite the diagnostic challenges the proposed symptom presentations create, recommended intervention strategies would reflect those most commonly used to treat pd, ocd, and ibs. treatment for ibs, for example, mimics similar components used to treat other anxiety disorders (e.g., muscle relaxation, diaphragmatic breathing, activity scheduling) and would, likewise, be presumed effective for pd subtype gi response. in addition, interoceptive and in-vivo exposure, both established treatments for pd and ocd (barlow, 2008), would also likely be effective with gi-related symptoms. assessment strategies to effectively administer and monitor the proposed treatment, psychometrically sound assessment tools are required. cognitive, physiological, and motor information can be gained through self-report, in addition to diagnostic clinical interviews. we recommend the anxiety sensitivity profile (asp) for cognitive aspects of the treatment and the body vigilance scale (bvs) for the physiological symptoms (schmidt, lerew, & trarkowski, 1997; taylor & cox, 1998). in addition to these formal self-report measures, behaviors can be monitored through self-report or agoraphobic exposure experiments. the asp measures cognitions of the perceived danger associated with the anxiety symptoms. the questionnaire consists of 60 questions that list specific bodily sensations and asks the respondent to answer how likely it is that each sensation would lead to something bad happening (e.g., dying). it is divided into six subscales that assess the amount of fear associated with a particular group of experiences: cardiovascular, respiratory, gastrointestinal, observable, neurological, and cognitive dyscontrol. the asp takes approximately 10 minutes to complete. while normative data is not yet available, the reliability found within a group of university students was good with an internal consistency for gi symptoms of 0.88 (taylor & cox, 1998). the bvs consists of a four item self-report inventory. each item uses an 11 point likert scale. the first three questions measure the degree of focus given to internal physiological stimuli. the fourth item lists 15 bodily sensations, as listed in the dsm-iv for panic attacks, and assesses how much attention is given to each sensation. the bvs takes 3 to 5 minutes to complete. the bvs has gastrointestinal panic disorder   49 schmidt et al., 1997). validity of this measure has been studied and found to be supported; patients with pd have been found to have higher scores on the bvs pre-treatment than patients of social phobia or nonclinical trials, and scores on the bvs tend to decrease following cognitivebehavioral treatment (schmidt et al., 1997). utilization of the aforementioned narrow-band measures allows for proper assessment of physiological and cognitive symptoms indicative of pd subtype gi response. such detailed assessment is necessary for accurate conceptualization and treatment planning, while also providing an opportunity for objective symptom tracking throughout the treatment process. conclusion pd with gi response represents a rare but significant form of the disorder, where in the person does not experience the full range of conventional symptoms associated with a panic attack. instead, the single symptom of gi reactivity predominates. while many panic attack sufferers typically experience automatic thoughts (e.g., often dispelled by an emergency room visit, the gi distress symptom can present with an actual reality of fecal incontinence. for those who experience pd subtype gi response, this misappraisal fundamentally changes from a perceived threat to something that has additional social implications. when considering a pd subtype gi response diagnosis, it is necessary to consider and rule out that the particular gi focus is not better explained by another psychological disorder, such as agoraphobia or ibs. therefore, careful diagnostic interviewing is critical. to this end, relying on such diagnostic tools as the anxiety disorders interview schedule fourth revision (adis-iv, 2007), medical records, previous treatment records, and collateral information may aide in accurately diagnosing this type of pd vis-à-vis other conditions that gi problems could represent. due to its unique presentation, pd subtype gi response needs a tailored treatment strategy. while potentially capitalizing on medications (e.g., paroxetine) to reduce sheer gut reactivity, the multi-pronged treatment recommendations include many conventional panic control treatment strategies (e.g., psycho-education, cognitive restructuring), while including an emphasis on bowel control training and in-vivo exposure to feared situations that are related to anticipated bowel problems (e.g., eating in public, taking longer trips while snacking). this strategic approach takes advantage of learning theory and conditioning paradigms to ensure that treatment gains generalize to various natural environments. in conclusion, it remains largely true that the brain-gut relationship is not yet well understood, especially in regards to pd subtype gi response. more research is needed to better grasp how to specifically tailor treatment to accommodate the pragmatic addition of this particular symptom to any panic presentation. additionally, it remains to be determined whether pd subtype gi response constitutes pd per se, or if this unique presentation warrants its own diagnostic category. future research is needed to further understand the nature and consequences of this distressing problem. references american psychiatric association. 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(2000). cognitive-behavioral treatment of irritable bowel syndrome: the brain-gut connection. new york, ny: guilford press.   interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 52 primary prevention of eating disorders in children and a proposed parent education program quinn neugebauer pepperdine university sara mack pepperdine university angel roubin pepperdine university ashley curiel pepperdine university research suggests that body dissatisfaction and concern with weight gain, characteristic of eating disorders, begin in childhood. given that eating disorders have a complex etiology, are often treatment resistant and result in chronic problems, prevention programs offer great appeal. the attitudes underpinning eating disorders begin during childhood, yet remain somewhat malleable, suggesting that prevention programs initiated during elementary school offer the best possibility for success. the current article reviews research on the etiology of eating disorders, general principles of prevention programs, and specific eating disorder prevention efforts developed thus far. the article proposes a parent education program aimed at promoting healthy eating attitudes and body satisfaction in children to help prevent the onset of eating disorders. the target population consists of the various adults involved in a young child’s life, such as parents, teachers, coaches, and mentors. children in grades 3 through 6, approximately ages 8 to 12, are a particularly important group to target. the program is composed of four one-hour sessions, scheduled on four consecutive saturdays, and is offered twice during the academic year. the first three sessions involve parents, teachers, coaches, and mentors and are didactic and interactive in nature. the fourth session includes the children, and involves an interactive puppet show. the current article concludes with a critique of the program and suggestions for future research. significance of the problem younger and younger children are increasingly concerned about their body size and eating behaviors (american academy of pediatrics, 2003). such concerns are often associated with changes in weight, a normative and important part of child development. although adolescence typically involves prominent bodily change, younger children also experience significant physical growth. the body can change significantly over short periods, adding inches to one’s height, drastically altering one’s shape, and creating shifts in weight (u. s. department of health and human services, 2002). therefore, it is no wonder that some children endure what is commonly known as “growing pains.” while the term “growing pains” typically refers to physical aches and pains, physical maturation can have an emotional impact as well, particularly in children whose personalities tend toward perfectionism, inflexibility, and constraint (klump et al., 2004). constant, perhaps relentless, physical change requires a tolerance for uncertainty and a degree of adaptability in both the child and his or her family (polivy & herman, 2002).  correspondence concerning this article should be addressed to: quinn neugebauer, clinical psychology program, graduate school of education and psychology, pepperdine university, 6100 center drive, suite # 559, los angeles, ca 90045. email: quinn.neugebauer@pepperdine.edu the emergence of fears around weight gain is embedded within a cultural context that both glorifies the pursuit of thinness and venerates engagement in dieting behaviors, which reinforces body dissatisfaction (szmukler & patton, 1995). a focus on thinness, coupled with low self-esteem and negative parental attitudes toward weight, presents as considerable risk factors for the development of a variety of eating disorder symptoms (stice, agras, & hammer, 1999). while the prevalence of clinically significant eating disorders among children under the age of 11 does not appear to be increasing (fisher, 2009), studies indicate the underpinnings of such disorders in pre-adolescence (stein & woolley, 1996). adolescents who later present with clinically diagnosed eating disorders show signs and symptoms as young children (bulik, 2002). therefore, effective methods to prevent the development of risk factors for these disorders are of critical importance. this article reviews the etiology of eating disorders, general principles of prevention programs, and eating disorder prevention efforts developed thus far. following this overview, the article proposes a parent education program aimed at promoting healthy eating attitudes and body satisfaction in children to help prevent the onset of eating disorders. the program is described in terms of approach, target population, preparation, structure, content, and assessment of outcomes. finally, a critique of the program is provided. neugebauer, mack, roubin, & curiel 53 overview of eating disorders while a poor relationship with food, hunger, and the body may have various presentations (e.g., reliance on fad diets, emotional eating, etc.), the diagnostic and statistical manual of mental disorders, fourth edition, text revision (apa, 2000) recognizes three specific eating disorders: anorexia nervosa (an), refusal to keep a minimally normal body weight; bulimia nervosa (bn), binge eating and inappropriate compensatory methods to avoid weight gain; and eating disorder not otherwise specified (ednos), a clinically significant eating disorder that does not meet criteria for an or bn. each of these disorders is characterized by a distorted perception of body weight and shape, which commonly involves issues of body dissatisfaction and low self-esteem. nearly all cases of eating disorders are complex (fairburn, cooper, & waller, 2008), and are often difficult to treat (fairburn, 2008). in a review of outcome studies involving 5,590 patients with anorexia nervosa (an), nearly one-half of patients demonstrated a full recovery, one-third improved but still had symptoms, and 20% remained chronically ill (steinhausen, 2002). furthermore, the mortality rate for an is higher than for any other mental illness due to the common medical issues associated with significant loss of body weight and other an symptoms (sullivan, 1995). indeed, prevention of eating disorders is critical, as they are often associated with and contribute to serious medical, social, and psychological problems (american psychiatric association [apa], 2000). etiology of eating disorders in children and adolescents the etiology of eating disorders is multifaceted, complex, and in many ways remains quite unclear (watkins & lask, 2002). researchers currently conceptualize the development of eating disorders according to multidimensional models that relate genetic, biological, psychological, socio-cultural, and familial factors to particular symptoms (jacobi, hayward, de zwaan, kraemer, & agras, 2004). for the purposes of this article, psychological, socio-cultural, and familial factors will be discussed in relation to the development of eating disorder symptoms in children. many young females value the cultural ideal of thinness, at times leading them to question their own bodies and consequently become displeased with their weight, body shape, and self perception (levine & smolak, 2006). unrealistic ideals related to beauty and thinness are presented and reinforced by various media sources that are readily available to many children from diverse backgrounds (herbozo, tantleff-dunn, gokee-larose, & thompson, 2004). these negative images likely initiate a child’s decision to diet or engage in forms of weight management (levine & smolak, 2006). of note, repeated dieting and the associated weight fluctuations have been found to be a risk factor for eating disorders (rohwer & massey-stokes, 2001). although eating disorders typically emerge in adolescence (apa, 2000), many children in grades 3 through 5 already exhibit body dissatisfaction; nearly 35% of children perceive that they “should” diet as early as the third grade (pierce & wardle, 1997). thus, these concerns about body weight and shape are present before the onset of adolescent development, which typically begins around age 11 and includes the additional development of secondary sex characteristics (rohwer & massey-stokes, 2001). the transition from childhood to adolescence entails a reorganization of personality, cognitive, and relational structures as well as alterations in cultural expectations and social roles (rohwer & massey-stokes, 2001). when eating is linked to perceptions of attractiveness, control, success, and self-worth, it can become disordered during this transition (rohwer & massey-stokes, 2001). yet, research indicates that despite the presence of body dissatisfaction and fear of gaining weight in elementary school children, these attitudes and behaviors are not as developed and entrenched as they are in their adolescent counterparts (smolak & levine, as cited by rohwer, 2001). therefore, prevention programs that target this younger population could help reduce the likelihood of future eating disorder symptomatology during adolescence (rohwer, 2001). although eating disorders have been associated with upper-class caucasian females from industrialized western nations, recent research demonstrates that this pathology is increasingly common among minority ethnic groups in the united states (woo & keatinge, 2008). further, tomiyama and mann (2008) found that children who grew up in cultures that foster independence and separation from the family were often at a higher risk of eating disorders when their particular families did not encourage that same individuation. these familial and societal factors are important to consider as they might impact the success of a prevention intervention. prevention of eating disorders in children and adolescents effective prevention programs share some principles in terms of program characteristics, target population, and implementation and evaluation (nation et al., 2003). effective programs are characterized as being comprehensive, having a basis in theory, using various teaching methods, and offering opportunities to build strong, positive relationships. they are timed appropriately, are socio-culturally relevant to their target populations, have well-trained staff and include outcome evaluation (nation et al., 2003). theory-based interventions grounded in research are important for prevention programs (nation et al., 2003). etiological theories address the causes (risk and protective factors), and intervention theories address the optimal means for modifying the risks. intervention theories form the basis for successful prevention programs and have been shown to bring about the desired changes in the causes and then the behavior associated with a given disorder (nation et al., 2003). prevention programs should focus on strengthening protective factors, including social skills and healthy selfperception, which function as a means of building resiliency. primary prevention of eating disorders in children 54 this contrasts with a focus on risk factors, such as social stresses, cultural influences, family dysfunction, and general environmental influences (pransky, as cited by masseystokes, 2001). a focus on protective factors could include the implementation of skill-building strategies that help children develop problem-solving/decision-making skills, improve their abilities to evaluate social messages, and increase selfawareness and feelings of self-worth (rohwer, 2001). primary prevention of eating disorders research on prevention is critical due to the high cost and challenges associated with the treatment of eating disorders (loth, neumark-sztainer, & croll, 2008). prevention programs for eating disorders were initially developed to provide information and later incorporated socio-cultural considerations. more recently, prevention has shifted to targeting groups of at-risk individuals (stice & shaw, 2004). literature on the primary prevention of eating disorders suggests a focus on altering behaviors that impact eating habits, coping skills, body image, and self-esteem (rohwer, 2001). more specifically, rohwer (2001) identified the following topics as central to a successful prevention program in children: pubertal changes in the body, nutrition and the connection between food and emotions, physical health and exercise, weight control and dieting, societal pressures to be thin, gender imbalances, personal identity, coping skills, and eating disorders in general. because there is concern that educating the public about eating disorders may actually encourage them (e.g., by providing ideas on dieting methods), prevention should be geared toward building a positive body image and accepting the bodily changes that occur during puberty (rohwer, 2001). this proposition is in alignment with the general principal that primary prevention consists of decreasing risk factors that influence a problem as well as developing qualities and building conditions that promote wellness (stice & shaw, 2004). in terms of effectiveness, there have been few controlled studies of successful eating disorder prevention programs (russell-mayhew, arthur, & ewashen, 2007). nonetheless, the most effective eating disorder prevention programs have included cognitive interventions to modify maladaptive attitudes such as body dissatisfaction and behavioral interventions to alter dysfunctional behaviors such as fasting (stice & shaw, 2004). in addition, they have utilized interactive approaches that include creating self-esteem strategies and developing social and relational practices that incorporate family and teachers. these approaches work to create an environment that facilitates students' positive view of their bodies (piran, 1997), an approach that has informed wellness-based prevention programs (russell-mayhew et al., 2007). furthermore, the results of one study on the effectiveness of a wellness-based eating disorder prevention program (russell-mayhew et al., 2007) suggested that involving parents and teachers was more effective in altering attitudes (e.g., self-concept) and behaviors of elementary school students than involving the students alone. indeed, parental participation in prevention is essential for a number of reasons (smolak & levine, as cited by massey-stokes, 2001). first, findings support a potential connection between mothers’ attitudes and behaviors and daughters’ dieting and eating behaviors. second, family members’ teasing appears to influence adolescent eating attitudes; teasing is believed to contribute to an in prepubertal youth. third, parents have more control over younger children’s eating behaviors. thus, parents might inadvertently encourage their children’s dieting, particularly if the parents have their own weight and body image issues (massey-stokes, 2001). the proposed program russell-mayhew and colleagues (2007) developed the principle model for the prevention of eating disorders in children. their model is a wellness-based prevention method used to target prevention of eating disorders among elementary and middle school students (grades 4 through 9). the model includes one 90-minute session with parents and one 60-minute session with teachers in addition to a single session with the students. the model's specific application to a younger, elementary-school-aged population provides the theoretical basis of the current proposed program. however, the current program expands on the single session parent/teacher model, providing four adult sessions to encourage practice between sessions, interaction with the material, and opportunities to ask questions and problemsolve. such an approach fulfills the requirement of sufficient dosage that is suggestive of a successful prevention program (nation et al., 2003) and is considered more conducive to learning and knowledge acquisition (ethridge & branscomb, 2009; stice & shaw, 2004). the current program also incorporates recommendations for families that emerged from loth, neumark-sztainer, and croll (2009), a qualitative study that assessed the impact of family environment on the development of eating disorder symptomatology. in the study, participants in treatment for eating disorders identified the following areas that might have possibly prevented the development of their illness: increased parent support, less talk about weight and body shape, the promotion of healthy eating and exercise, increased self-esteem unrelated to physicality, the development of emotional regulation and healthy coping skills, increased awareness of eating disorder symptoms, and parents’ use of support. approach given the complex etiology of eating disorders, some experts have proposed an ecological approach to prevention. such an approach considers the environmental (e.g., personal, group, community, etc.) and socio-cultural factors that may influence whether or not an individual develops a disorder (levine & smolak, 2006). the ecological approach is particularly helpful in understanding the development of eating disorder symptomatology. from this perspective, neugebauer, mack, roubin, & curiel 55 eating disorders are believed to serve as coping mechanisms to aid individuals in functioning within their greater social environment (levine & smolak, 2006). the ecological approach is consistent with the hypothesis that cultural values are primarily communicated through the family (rohwer & massey-stokes, 2001). therefore, the proposed program targets the people in the child's environment. the proposed program is considered a selective prevention program, a type of primary prevention as defined by the institute of medicine (iom; munoz, mrazek, & haggerty, 1996), due to its focus on parents, teachers, and mentors of children who may not be symptomatic but are at heightened risk due to a variety of cultural factors (levine & smolak, 2006). prevention is accomplished by educating participants about normative physical growth in children, healthy eating, and the potential impact of their own attitudes about weight on children’s self-image. the underlying assumption is that knowledge of such topics will better guide the adults' future interactions with the children under their care (lancy & grove, 2010). the following is a description of aspects of the proposed program, including basics of its development and implementation. target population the target population for the proposed program consists of various adults involved in a young child’s life, who might include an elementary student’s parents, teachers, and/or mentors. while the intervention is aimed at preventing eating disorders in children, it is initially implemented via the adults involved in the child’s life due to the aforementioned research that indicates parental and adult involvement is critical in preventive efforts. engagement in the proposed program is particularly relevant for parents with children in grades 3 through 6, approximately ages 8 to 12, as research has shown that many children in this age group already hold maladaptive beliefs about body weight and shape (massey-stokes, 2001). additional findings also support focusing efforts on this age group. for example, females as young as six have been found to internalize cultural expectations of the thin ideal, and females as young as nine have been found to engage in dieting and exercise behaviors solely for the purpose of weight loss (thelen, powell, lawrence, & kuhnert, 1992). further, significant biological changes can also occur during pre-adolescence, making this age group of particular concern for the development of eating disorder symptomatology (smolak & levine, 1996). preparation the proposed program begins with one person who acts as the program “advisor.” his or her primary role is to coordinate the administrator training, schedule dates and locations for the programs, and generally serve as a primary resource for program development. first, the advisor gathers preliminary data (e.g., interest in the program, available resources) about a community to which the program is to be offered. approximately three months prior to the program start date, the program advisor meets with several elementary school principals and counselors to gather information about student demographics. the program advisor also consults with the school’s parent teacher association (pta) or other parent groups that are actively involved in school activities. additional outreach includes visitation to the local ymca, community sports leagues, and other popular organizations among the community’s youth. specific places of focus include dance studios, gymnastics gymnasiums, and performing arts centers, as these activities tend to be more highly related to the development of eating disorder symptoms (masseystokes, 2001). after preliminary research is complete, the program advisor seeks the availability of local psychologists, social workers, or other mental health professionals who are able and willing to participate without compensation. these “administrators” are then familiarized with the program and its objectives and are trained in the application of its techniques. the program advisor then takes steps to market the program to the target community. flyers and other advertising materials are distributed to the schools and facilities previously visited by the program advisor. flyers are posted on elementary school bulletin boards and mailed to each family’s home, along with a cover letter from the principal and school nurse advocating for participation in the prevention program. coaches, mentors, and teachers from these locations are invited to attend the workshops as well, as they also influence children’s perceptions of body image and health. to accommodate those who require childcare in order to attend, older student volunteers are available to provide childcare while parents attend program activities. the additional incentive of free childcare also serves to increase the likelihood of attendance. the program itself takes place in a gymnasium at a select number of elementary schools in the community, or other locations that are familiar and easily accessible. structure the program is composed of four one-hour sessions, scheduled on four consecutive saturdays during the academic year. in addition, the program is offered twice during the academic year (e.g., in october and april) to reach as large an audience as possible and promote participant reflection and internalization of information. finally, free breakfast items and refreshments are offered for thirty minutes prior to the workshop. the first three sessions (each one hour in length) are structured to address parents, teachers, coaches, and mentors. the fourth session, described in further detail below, includes the children in the activities. the program is first offered in the fall, which provides time for the program advisor to make arrangements before long-term school, sports, and activities schedules are established. another installment of the program is provided in the spring for those adults who were unable to primary prevention of eating disorders in children 56 attend the fall program or for those who wish to gain additional knowledge, experience, or support. content the content of the first three sessions emphasizes the collaborative necessity of successful prevention of eating disorders in children (graber & brooks-gunn, 1996). these sessions are both didactic and interactive in nature, as such an integrative approach is considered more conducive to learning and knowledge acquisition (stice & shaw, 2004). these sessions also include psychoeducation, presented through open dialogue, activities, and role-play. specifically, participants are taught the power of modeling and their influence on the younger generation (graber & brooks-gunn, 1996). these sessions encourage open discussion of parental/participant experiences that might have affected their own learning. such an approach may be helpful in addressing societal pressures to be thin (harrison & hefner, 2008). participants are encouraged to examine the messages they could be inadvertently communicating to children and to identify ways to alter their behavior to promote a child’s health (levine, 1987). the participants are encouraged to take steps toward altering their behaviors and monitoring the potential effects of these changes. they are also taught specific skills and strategies, such as relaxation, which has been shown to prevent eating disturbances (deckro et al., 2002). since both direct experience and reflection on that experience is necessary to reinforce learning (ethridge & branscomb, 2009), the adults are encouraged to attempt implementation of the new techniques between sessions and report back with their experiences. adults who participate are given resources and referrals should further intervention be needed (levine, 1987). the fourth and final session of the proposed program is an interactive puppet show initially introduced by the eating disorders awareness and prevention (edap) organization for classroom instruction. based on the russell-mayhew et al. (2007) model, it emphasizes acceptance of diverse body shapes and rejection of the “perfect” body ideal. the proposed program differs in that it invites the participants to perform in the show, even creating their own scripts and practicing the use of healthy dialogue. the show is performed for the children during the last session. after the show, the participants have the opportunity to engage in a guided discussion about the performance with the children and engage in more direct conversation about their beliefs. assessment of outcomes the outcome of the program is assessed based on the use of the piers-harris children's self-concept scale (phcscs) and the children's version of the eating attitudes test (cheat). the phcscs, a self-report questionnaire developed by piers (1999), was utilized by russell-mayhew and colleagues (2007) to measure self-concept in children and adolescents, and includes several subscales, such as physical appearance and attributes and happiness and satisfaction. the cheat (maloney, mcguire, & daniels, 1988), is a self-report measure of children’s eating attitudes, food preoccupation, and dieting behaviors. the children are administered the measures before the beginning of the first session and then again after the puppet show during the fourth session. significant changes on these measures will suggest correlation between the program implementation and the children’s risk of eating disorder development. the adults are also administered the children’s versions of the measures and are asked to complete the measures based upon how they believe their children might respond. these scores are used solely for the purpose of evaluating the correlation between the adults' beliefs and their children's responses. it is hoped that any variance in scores will encourage parents to evaluate their own assumptions about their children’s beliefs and the effectiveness of their communication with their children. teachers, coaches, and mentors who do not have their own children in the program may choose to complete the evaluation to be compared with responses from a child they believe they know well. the effectiveness of the program is also assessed via preand post-test questionnaires, which are provided to the adults only. these questionnaires serve to assess their knowledge of eating disorder prevention, appropriate behaviors to model for children, and how to promote positive coping skills. it is hypothesized that the scores on these program-specific assessments (created by the trainers to assess the content learned during the sessions) will increase at the completion of the program. adults are provided a qualitative feedback form in which they can anonymously report what was most helpful in their application of the techniques acquired. additionally, they are encouraged to provide feedback on their level of satisfaction with the program, including whether they enjoyed the course, would attend again, and would recommend it to others. one of the major benefits of the proposed program is the potential for generalization. for example, tolan and guerra (1994) found clinic-based interventions to be limited in their ability to generalize improvements across settings and to effect lasting change once reinforcement contingencies are discontinued. conversely, community-based interventions produce sustained change and greater generalization because such efforts are anchored in one's daily life (tolan & guerra, 1994). critique of the proposed program strengths of the program the proposed parent education program to help prevent eating disorders presents a number of strengths. first, the program targets parents of children who are at the optimal age for eating disorder prevention. russell-mayhew and colleagues (2007) found that elementary school children and their parents and teachers demonstrated the most unhealthy and negative attitudes and behaviors toward weight and eating, compared to the group composed only of junior high students. this finding presents an opportunity for neugebauer, mack, roubin, & curiel 57 preventative intervention. additionally, these unhealthy attitudes and behaviors are less ingrained in elementary school children, suggesting that primary prevention might be most effective when it includes young children, their parents, their teachers, and/or other adults involved in their lives (smolak & levine, 1994). further, many experts agree that elementary and middle school/junior high school students are the most appropriate age groups for primary and secondary prevention efforts (rohwer, 2001). in fact, one of the only eating disorder prevention programs found to be empirically supported included elementary school children and their parents and teachers, an approach that researchers found particularly effective and indicative of the need to start prevention programs early (russell-mayhew et al., 2007). the primary prevention design is considered the most effective approach to confront eating disorders as its timing addresses problems before they begin. given the complex nature of eating disorders and the subsequent treatment challenges (fairburn, 2008), timing is of utmost importance. second, the prevention program presented primarily targets the parents of elementary school children and welcomes the participation of teachers and coaches. prevention models that include parents and teachers are believed to be more effective (russell-mayhew et al., 2007), as adults greatly influence children's attitudes toward weight and body image (massey-stokes, 2001). research has demonstrated an association between mothers’ attitudes and behaviors and their daughters' eating and dieting behaviors as well as adolescent eating attitudes and family members’ teasing, suggesting that parent involvement in prevention efforts is critical (smolak & levine, 1994). moreover, parents control the foods that are available at home for their children. overall, focusing on parental and teacher involvement as part of a school-based intervention program has shown promise in preventing eating disorders in children (russell-mayhew et al., 2007). third, consistent with the findings of russell-mayhew and colleagues (2007), the program is based at the children's school. rohwer (2001) strongly recommends schools as the site of prevention programs as there are sizeable audiences at one setting, and schools can serve as a location for early identification of eating disorders. fourth, the multisession approach used in the proposed program is consistent with recommendations for sufficient dosage in prevention programs (nation et al., 2003) and is the primary improvement over the russell-mayhew et al. (2007) model, which utilizes a single-session approach. because both direct experience and reflection on that experience is necessary to reinforce learning (ethridge & branscomb, 2009), the current multisession prevention program offers a possible advantage over the russellmayhew et al. (2007) model by promoting participant reflection and internalization of information. weaknesses of the program as with any model, the current prevention program is not without limitations. perhaps the most salient limitation is the focus on parents and adults in children's lives rather than an emphasis on direct contact with the children. although the children participate in the fourth session of the program alongside the parents, one session of direct contact might not be sufficient. additional research is necessary to determine if the proposed program might be implemented in combination with another program focused on working directly with the children. a second limitation of the current program proposal is its limited focus on follow-up assessments. it is possible that administration of the measures immediately following the puppet show may create a recency effect. long-term assessment is crucial to determine if the prevention program resulted in sustained change in attitudes and behaviors. another limitation is that the program depends upon voluntary parent participation. while researchers believe that parents are inherently motivated to participate in programs that might benefit their children (levine & smolak, 2006), it is possible that parents might perceive the program as a critical commentary on their parenting skills and decide not to participate. those parents who are in the most need of help (e.g., those whose children are already demonstrating negative eating attitudes or behaviors) might be especially sensitive to perceived criticism and therefore choose not to attend, thereby limiting the program's ability to reach all children in need of preventive education. should such a scenario present itself, more research on how to potentially make the prevention program mandatory might warrant further exploration. even if parents attend the program, there is the risk that the information obtained might not be put into practice. for example, parents might continue to behave in ways that encourage eating disordered behavior, such as dieting or promoting the thin body shape as ideal. such behavior will be difficult to monitor as the program relies heavily on parental self-report. one way to compensate for these limitations might be to educate parents on how to encourage their children to advocate for themselves, such as seeking outside help from teachers, counselors, or other mentors if needed to avoid total reliance on the parents for assistance. finally, finding mental health professionals to serve as program administrators on a voluntary basis may be difficult. should such a circumstance arise, further research would be necessary to determine whether non-mental health care professionals could be trained to deliver the intervention and whether there are benefits in doing so. conclusion given the serious social, psychological and medical problems associated with eating disorders and the challenges encountered when treating them, prevention programs offer a needed approach and deserve further consideration and examination. the few studies which have investigated the effectiveness of prevention programs addressing eating disorders found that including younger children (e.g., those ages 8 to 12) was particularly beneficial (russell-mayhew et primary prevention of eating disorders in children 58 al., 2007). nonetheless, the russell-mayhew et al. (2007) model does not appear to offer the recommended sufficient dosage for prevention programs (nation et al., 2003). the single session format does not allow time for participants to interact with the material at home and return to ask questions or problem-solve; such interaction is critical in the learning process (ethridge & branscomb, 2009; stice & shaw, 2004). the proposed program addresses these concerns by offering four sessions that are interactive in nature and promote practice between sessions. moreover, this proposed program, while general in nature, could be modified for delivery to culturally diverse communities. ultimately, it is hoped that this approach will foster young children’s healthy attitudes toward eating and body satisfaction and will provide adults with adequate knowledge and tools to build protective factors to prevent the development of eating disorders. references american academy of pediatrics (2003). policy statement: identifying and treating eating disorders. pediatrics, 111, 204-211. doi:10.1542/peds.111.1.204 american psychiatric association. 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(2008). diagnosis and treatment of mental disorders across the lifespan. hoboken, nj: john wiley & sons. http://dx.doi.org/10.1146/annurev.psych.53.100901.135103 https://webmail1.pepperdine.edu/owa/redir.aspx?c=5734804c8cae4c8f99483fbc7f6d6b71&url=http%3a%2f%2fdx.doi.org%2f10.1080%2f10640269408249128 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 37 the tripartite model of anxiety and depression: function and utility in a youth community sample ruifan zeng, shauna kushner, and jennifer l. tackett university of toronto the current study examined the application of clark & watson’s (1991) tripartite model of the internalizing disorders (i.e., anxiety and depression) in non-clinical youth as research is lacking on its functionality in youth compared to adult populations. we attempted to replicate the tripartite constructs (negative affect, positive affect, and somatic problems as an approximation of physiological hyperarousal) in a community sample of youth aged between 6 and 17 years. consistent with the tripartite model, the results showed that na was highly correlated with anxiety and depression symptoms, while low positive affect was related to depression but not anxiety. somatic problems were found to be correlated with both anxiety and depression, which corroborates recent trends in the adult literature indicating that physiological hyperarousal does not uniquely distinguish depression from anxiety. implications and limitations of the current study are discussed. depressive and anxious disorders affect both adult and youth populations. twelve-month prevalence of major depressive disorder (mdd) in adults is approximately 6.7%, and lifetime prevalence of mdd in children and adolescents is as high as 11.2 –13.0% (national institute of mental health [nimh], 2011). for anxiety disorders, 12-month prevalence in adults is 18.2%, and lifetime prevalence in youth is 15% (nimh, 2011). many people suffer from both disorders and the intercorrelations between self-report measures of anxiety and depression are particularly high in youth populations (stark & laurent, 2001). this points to a considerable degree of symptom overlap between anxiety and depressive disorders, and there are indeed notable similarities in the way the two are manifested. according to the diagnostic and statistical manual of mental disorders (4th ed., text rev; dsm-iv-tr; american psychiatric association, 2000) anxiety and depression are both characterized by high subjective distress, poor concentration, and somatic symptoms. instead of separating anxiety and depression into conceptually distinct disorders, clark and watson (1991) proposed a tripartite model to account for both the unique and shared variances of anxiety and depressive symptoms. the tripartite model has found support in adult populations. however, research on its utility in youth samples is scarce (anderson & hope, 2008). the current investigation extended this line of research by  ruifan zeng, m.a., and shauna kushner, m.a., department of psychology, university of toronto; jennifer l. tackett, ph.d., department of psychology, university of toronto. ruifan zeng is now at the department of counseling and clinical psychology, teachers college, columbia university. jennifer l. tackett is now at the department of psychology, university of houston. correspondence concerning this article should be addressed to ruifan zeng at 235 e. 40 street 8i, new york, ny 10016. email: rrz2103@columbia.edu. examining the relevance of the tripartite model in explaining anxiety and depression symptoms in a community sample of non-clinical youths. anxiety and depression: overview past research has demonstrated the considerable overlap between self-report measures of anxiety and depressive symptoms in youth (for a detailed review, see brady & kendall, 1992). this high overlap in symptomatology and poor discriminant validity of measures is problematic, as anxiety and depression have traditionally been categorized as distinct diagnostic classes and theoretical constructs (akiskal, 1985). high symptom overlap in self-report measures has made it difficult to identify pure groups of depressed and anxious youth and to compare them to non-clinical youth in a valid way (laurent & ettelson, 2001). rates of comorbid anxiety and depression diagnoses are approximately 28% to 62% in clinically-diagnosed samples (brady & kendall, 1992). in fact, the highest comorbidity rates between anxiety and depression exist not among adults, but among adolescents (ollendick, shortt, & sander, 2005). comorbid anxiety and depression has also been associated with increased rates of suicidal ideation, suicide attempts, and completed suicide among clinical and community samples (mineka, watson, & clark, 1998). this increased risk denotes the augmented severity of comorbid cases, and calls for further research into the causes of such high rates of diagnostic overlap. it remains unclear whether depressive and anxious disorders should be conceptualized as distinct. further, research is needed to determine how different disorder conceptualizations might affect treatment strategies. clearly, there are both theoretical and clinical implications for enhancing our understanding of the dimensional versus discrete nature of anxiety and depression. there is some evidence suggesting that anxiety disorders in fact may lead to the onset of concurrent depression zeng, kushner, & tackett 38 (anderson & hope, 2008; brady & kendall, 1992; chorpita & daleiden, 2002; finch, lipovsky, & casat, 1989). it is unclear whether this co-occurrence reflects the fact that anxiety and depression are distinct constructs yet strongly inter-related, or rather are different manifestations of the same disorder represented by a single underlying dimension (feldman, 1993). recent research has shown that subfactors of internalizing symptoms were not differentiated in middle childhood, but that personality factors may distinguish anxiety/fear from depression/distress symptoms, suggesting some differentiation within childhood psychopathology (kushner, tackett, & bagby, 2011). the seminal tripartite model proposed by clark and watson (1991) has formed the basis for subsequent dimensional models of anxiety and depression, which can better explain the disorders’ underlying nature. clark & watson’s tripartite model clark and watson (1991) developed a tripartite model to explain both the similarity and distinctiveness of depressive and anxiety disorders. the tripartite model is a dimensional approach which posits that there are both shared components of the two disorders, as well as distinguishing factors that can separate comorbid diagnoses. clark and watson (1991) examined mood as well as anxious symptoms in both clinical and non-clinical adult samples, and suggested that a nonspecific distress factor, negative affect (na), forms the core component of both syndromes (clark & watson, 1991). na refers to the extent to which a person feels unpleasantly engaged or upset, and includes negative mood states such as “angry,” “guilty,” “sad,” “disgusted,” and “worried.” absence of na is characterized by “calm” and “peaceful” mood states. in contrast, positive affect (pa) is best defined by the degree to which a person feels enthusiasm, pleasurable engagement, and energy. this positive affectivity is captured by descriptors such as “active,” “delighted,” “proud,” and “enthusiastic.” a deficiency in pa is also characterized by somatic terms, such as “sluggish” (clark & watson, 1991). positive affect and na are not opposites and function independently of each other: pa is related to measures of social activity and pleasant events, while na is correlated with health complaints, stress, and unpleasant events. clark and watson (1991) also cite tellegen’s (1985) factor analysis of self-report measures of pa, na, anxiety, and depression, which demonstrated that anxiety was more highly associated with na, while low pa best characterized depression. the third construct in the tripartite model is physiological hyperarousal (ph). this construct reflects somatic symptoms and autonomic arousal, such as muscle tension, shortness of breath, dizziness, lightheadedness, and indigestion (clark & watson, 1991). clark and watson (1991) found that the items on the hamilton rating scale of anxiety (hamilton, 1959) that best differentiated depressed patients from those with panic attacks were physiologically based. these items included measures of cardiovascular, autonomic, and respiratory symptoms. they noted that the physiological hyperarousal associated with generalized anxiety disorder (gad) and panic attacks seemed to be specific to anxiety,. overall, clark and watson (1991) concluded that high levels of na persist in both anxious and depressed patients and act as an indicator of these disorders, yet they offer little in the way of discerning between the two. positive affect and ph may play a pivotal role as factors distinguishing between depressive and anxious disorders. though substantial empirical support has been found for pa as relatively unique to youth depression and na as a shared component, (for a detailed review, see anderson & hope, 2008), results from research on ph has been rather mixed in terms of whether it is unique to anxious or to depressive symptoms (chorpita & daleiden, 2002; jacques & mash, 2004; laurent et al., 2004). due to the model’s origins in clinical adult populations, further research on the tripartite constructs in youth is necessary to determine its applicability with a younger population. applicability of the tripartite model in youth populations research so far on the tripartite model has supported its utility in differentiating between anxiety and depression in a variety of populations (anderson & hope, 2008). in a nonclinical sample of undergraduate students, factor analyses showed that anxiety and depression symptoms were best separated using a three-factor solution including pa, na, and ph (joiner, 1996). in otherwise non-clinical substance abusers, symptoms of anxiety and depression were better discriminated by measures of pa and ph, consistent with the tripartite model (watson et al., 1995). the application of the tripartite model to community samples demonstrates its efficacy at discerning between anxious and depressive symptoms, even when these symptoms do not reach clinical levels. though the model was originally developed to account for adult populations, a number of studies with child and adolescent samples have since demonstrated its application in differentiating anxiety and depression symptoms among youths. lonigan and colleagues (1994) showed that low pa distinguished children with depressive disorders from those with anxiety disorders in a clinical sample, as measured by the children’s depression inventory (cdi; kovacs, 1980, 1981) and the revised children’s manifest anxiety scale (rcmas; reynolds & richmond, 1985). research with non-clinical children and adolescents has also established the utility of a three-factor model for children in grades three, six, and nine, as measured by items selected from the cdi and rcmas (turner & barrett, 2003). overall, there is support for the tripartite constructs in youth populations despite the fact that considerably less research has thus far been conducted with children and adolescents in comparison to that with adult populations (anderson & hope, 2008). on the other hand, there have been debates over whether there is a developmental change in the differentiation between anxious and depressive disorders. cole et al. (1997) found that a single factor model (anxiety-depression) fit data from tripartite model of anxiety and depression 39 third-grade students equally as well as a two-factor model (anxiety and depression), but that a two-factor model was a better fit for data from sixth graders. however, in a separate study, turner and barrett (2003) found no differences in terms of model fit between the grade 3, 6, and 9 groups, with a three-factor model best characterizing the data for all groups. researchers also concluded that within a combined sample of general population and clinically-referred 8-14 year olds, there is a dual-construct distinction between anxiety and depression across the whole age range (de bolle, decuyper, de clercq, & de fruyt, 2010). cannon and weems’ (2006) study also found no support for gradual developmental differentiation, and found that a three-factor model was the best fit for both groups of 6-11 year olds and 12-17 year olds. they did, however, note that there may be differences in the predominance of anxious versus depressive symptoms across development, as opposed to the separation of a single syndrome (cannon & weems, 2006). unlike the affective factors (i.e., pa and na) of the tripartite model which have received ample support, the somatic factor, (ph) has not been given adequate empirical attention (anderson & hope, 2008). three-factor structures consistent with the tripartite model seem to operate in child and adolescent samples as originally outlined in adult samples (chorpita & daleiden, 2002). it has also been suggested that ph may not be evenly related to all anxiety disorders. for instance, studies of adult outpatients suggest that ph is positively related to symptoms of panic disorder, but not to other anxiety disorders (brown, chorpita & barlow, 1998). this observation is contrary to the tripartite model’s supposition that ph is common to various anxiety disorders. empirical results of the discriminatory power of ph have been mixed: one study showed that although ph was correlated with depression, it had no incremental predictive value for depressive symptoms after accounting for the effect of pa and na in a non-clinical youth sample (laurent, catanzaro, & joiner, 2004). in addition, ph scales were found to be negatively correlated with pa scales in both parentand child-reports suggesting the two factors may not be independent as proposed by the tripartite model (clark & watson, 1991). on the other hand, a study of outpatient adolescents showed that the relationship between ph and anxiety is stronger than the relationship between low pa and depression, suggesting that ph may indeed be a better construct for differentiating anxiety and depression (dia, harrington, & silverman, 2010). the current investigation the current study aimed to expand the literature on the applicability of the tripartite model in youth populations (anderson & hope, 2008). we examined the relationships between the tripartite model constructs and depression/anxiety symptoms, in a community sample of children and adolescents. further, we also examined whether the constructs function differently in children (6-11 years old) versus adolescents (11-17 years old). the comparison of younger versus older youth would help explore whether anxiety and depression differentiate from a unitary construct over time (e.g., cole, 1997; turner & barrett, 2003). further validation of the tripartite model in youth populations would support a shift toward a dimensional approach to child and adolescent psychopathology similar to the shift in conceptualizations of adult pathology, especially with the advent of the dsm-5. several studies have also found that there are discrepancies between child and parent reports in the correlations of depression, anxiety and the tripartite factors. for example, chorpita and daleiden (2002) found that children reported more concurrent anxiety and depression symptoms than observed by their parents. there is also evidence that parent reports of anxiety and depression in their children were often not associated with the children’s own endorsements of na (philips, lonigan, driscoll, & hooe, 2002). explanations for convergence and discrepancies in cross-informant reports of ph remain unclear. if children do not vocalize particular somatic complaints such as headaches, the measures of ph would be likely lower in parent reports than those in child report. such differences could account for discrepancies in parent and child ratings of ph levels in relation to the child’s anxious/depressive symptoms. in the current study, both selfand parent-reports were obtained about the same individual, in order to obtain a better understanding of the nature of the tripartite factors. we used trait measures of pa and na instead of generally used state measures, such as the positive and negative affect scale for children (panas-c; laurent et al., 1999). we believed that trait measurement scales would serve a better instrument in capturing affective functioning in non-clinical samples such as the one used in the current study. we also focused on ph, which has consistently shown associations with anxiety, depression, and the other tripartite factors that are relatively contrary to the original model. somatic problems (sp) scales were used as a measure of ph (see measures for details). overall, the elucidation of these relationships through the current study can advance our understanding of the syndromes in general, as well as reduce the risk of artificial diagnostic ‘splitting’ when assessing patient populations so that the comorbidity, or possible unitary nature of anxiety and depression, can be properly addressed in both diagnosis and treatment. method we attempted to replicate the tripartite model in a youth population. we hypothesized that: (1) pa and na would be negatively correlated (though not independent constructs, low pa is expected to be unique to depression which is also characterized by high na); (2) sp would be positively correlated with na and not correlated with pa; (3) sp would be positively correlated with anxiety symptoms but not depression symptoms; (4) na would be positively correlated with both anxiety and depression; and (5) pa would be negatively correlated with depression, but not anxiety. in general, we expected that similar patterns of correlations zeng, kushner, & tackett 40 would be found in both self-reports and parent reports, but that correlations between the constructs would be higher for youth self-reports than for parent reports. participants participants were a community sample of 153 youth aged between 6 and 17 years. adult caregivers completed measures of mood and behavior for all participants. selfreports were obtained from participants aged 11 and older. in total, we collected 153 parent reports, 55 of which were paired with youth reports (for those children who were 11-17 years old). participants were not pre-screened for clinical disorders (i.e., previous or current diagnoses of mood/anxiety disorders) in order to include a wide range of possible symptomatology and severity. exclusion criteria were lack of fluency in english and the presence of developmental disorders (such as autism and down’s syndrome), which we assessed by asking the child’s parent during phone screenings. measures parents completed the 51-item inventory of children’s individual differences (icid; halverson et al., 2003). the positive emotions subscale was used as a measure of pa, which includes items such as “is a joy to be with,” “is sweet,” and “is loving.” the icid’s negative affect subscale was used to measure na, which includes items such as “is irritable”, “is quick-tempered”, and “gets angry easily”. parents also completed the child behavior checklist (cbcl; achenbach, 1991), a measure of their children’s observed social behaviors and competencies. anxiety symptoms were measured by the anxious/depressed scale, which included items such as, “fears going to school”, “nervous, highstrung, or tense”, and “worries”. symptoms of depression were assessed by the cbcl withdrawn/depressed scale. items include descriptions such as, “there is very little he/she enjoys,” “underactive, slow moving, or lacks energy,” and “unhappy, sad, or depressed.” finally, our measure of ph was approximated by the cbcl somatic problems (sp) scale. this scale was used due to the measures being administered as part of a larger study which did not include a specific measure of ph. the cbcl sp scale includes items such as “feels dizzy or lightheaded,” “overtired without good reason,” and “nausea, feels sick.” although these items do not assess the autonomic arousal component of ph, it is parallel with the somatic tension associated with ph (i.e., items assessing nausea, dizziness, chronic aches). children’s self-report consisted of ratings on the youth self-report (ysr; achenbach, 1991). items on the questionnaire are analagous to those on the cbcl, and participants completed the anxious/depressed scale, withdrawn/depressed scale, and the somatic problems scale. procedure youth and adult participants were recruited by phone from a database of families that had previously expressed interest in participating in psychological studies. some participants were also recruited by flyers posted in the metropolitan and greater toronto area, as well as advertisements in local newspapers. participants were mailed a package containing the questionnaires, and were asked to send them back in separate, sealed envelopes in order to ensure confidentiality. parents with children under the age of 11 were asked to fill out a set of questionnaires about their child. parents with children over the age of 11 were asked if their child would be willing to fill out a set of questionnaires about themselves, and these parents were also asked to complete a corresponding set of questionnaires about their child. the current investigation included data from families in which one primary caregiver had completed the cbcl & icid and their child over the age of 11 had completed the ysr. in 6-17 year old youth, we examined data from all parents who had completed the cbcl and icid about their child. upon receipt of the completed questionnaires each participant was compensated with a small honorarium (e.g., $10 gift-certificate). results youth selfand parent-report results of correlational analyses (pearson’s r) using spss statistical software of 55 parent and youth dyads (youth 11 years and older) are depicted in tables 1 and 2. we compared parent-reported na, pa, & sp to parentand youth-reported anxiety and depression. in both youthand parent-reports, the tripartite constructs na and pa were significantly negatively correlated, and sp was not significantly correlated with pa (p > .05). also in both youthand parent-reports, sp was significantly positively correlated with withdrawn/depressed scores and anxious/depressed scores. however, the youth self-reports indicated that anxiety was more highly correlated with sp than was depression. negative affect was not associated with youth-reported anxious/depressed or withdrawn/depressed scores, while low pa was significantly correlated with parentbut not youth-reported anxious/depressed scores. table 1 correlations between tripartite constructs on parent & youth selfreport measures tripartite constructs positive affect (parent) negative affect (parent) somatic problems (parent) -.260 .288* somatic problems (youth) -.008 .103 positive affect (parent) 1 -.470** note. n = 55. data from youth 11 and older. *p < .05, two-tailed. **p < .01, two-tailed. tripartite model of anxiety and depression 41 table 3 correlations between tripartite constructs on parent report measures tripartite constructs pa (parent) na (parent) sp (parent) -.110 271** pa (parent) 1 -.394** note. n = 153. data from youth aged 6-17. *p<.05, two tailed. **p<.01, two-tailed. parent-report only results of correlational analyses of 153 parent reports of their children aged 6-17 are depicted in tables 3 and 4. negative affect was significantly negatively correlated with pa and significantly positively correlated with sp. negative affect was also significantly positively correlated with both anxiety and depression. somatic problems was significantly positively correlated with both anxiety and depression, and pa was significantly negatively correlated with depression. we observed pa to be negatively correlated with anxiety but it was not statistically significant (p > .05). discussion the aim of this study was to examine the conflicting literature surrounding the function of the tripartite model in youth. we investigated the application of the tripartite constructs in differentiating anxious and depressive symptoms in a nonclinical child and adolescent sample. we found that na was significantly correlated with both anxious and depressive symptoms and the amount of variance it explained in both disorders was comparable. this is consistent with previous findings of the relationship between na and the two disorders (anderson & hope, 2008), lending further support to the proposition of the tripartite model that na is an underlying, shared component of anxiety and depression (clark & watson, 1991). however, sp was found to be associated with both anxiety and depression, which challenges the discriminant validity of sp (and possibly ph) in predicting anxiety, as proposed by the model. indeed, previous studies on the association between ph and internalizing disorders have been mixed (e.g., chorpita & daleiden, 2002; jacques & mash, 2004; laurent et al., 2004) surprisingly, we found no significant correlations between na and anxious or depressive symptoms reported by adolescents themselves. this is contrary to the abundance of past literature demonstrating that negative affect strongly characterizes both anxiety and depression. the current findings may be due in part to the cross-informant issue. that is, for the older youth in the sample, ratings of na were obtained from parents only, and these ratings were compared against the youth’s own ratings of depressive and anxious symptoms. it is possible that children’s negative affectivity may be less apparent to parents. negative affect is characterized by more internal unpleasant engagement as opposed to the obvious, outward expressions of energy characteristic of pa (clark & watson, 1991), so parents may simply have less knowledge of their child’s feelings of sadness. there is also evidence that children and adolescents’ ability to verbalize their emotions are not well developed, and thus tend to present negative emotions as somatic symptoms (mahoney, kennard, & mayes, 2011). furthermore, for older adolescents beginning to assert their independence, displays of na towards their parents might not be evident in other domains of their lives. in the current study, parents might have rated table 4 correlations between tripartite constructs and depressive and anxious symptoms on parent and youth self-report measures tripartite constructs depression (parent) anxiety (parent) sp (parent) .506** .498** pa (parent) -.250** -.034 na (parent) .308** .350** note. n = 153. data from youth aged 6-17. *p<.05, two tailed. **p<.01, two-tailed. table 2 correlations between tripartite constructs and depressive and anxious symptoms on parent and youth self-report tripartite constructs depression (parent & youth) anxiety (parent & youth) sp (parent) p: .433** p: .412** sp (youth) y: .472** y: .757** pa (parent) p: -.480** p: -.081 y: -.053 y: .049 na (parent) p:.380** p: .488** y: -.080 y: .019 note. n = 55. data from youth 11 and older. *p < .05, two-tailed, **p < .01, two-tailed. zeng, kushner, & tackett 42 their teenagers highly on na based on their behavior displayed at home but may have little knowledge of their behavior in other settings. these negative behaviors at home might not be representative of their genuine feelings, leading to the observed lack of correlation between na and depression or anxiety. we found that pa was negatively correlated with depression in parent reports, but was not correlated with anxiety symptoms in both youth and parent reports. these results are consistent with the prediction of the tripartite model that pa is a factor unique to depression (clark & watson, 1991). some studies, however, have reported the negative association between pa and anxiety symptoms (e.g., jacques & mash, 2004). it has been suggested that the absence of positive emotions might be the most prominent in social phobia among anxiety disorders (watson et al., 2005). the anxiety measure used in the current study (i.e., cbcl) does not include symptoms of social phobia, which may have obscured this negative association. the sp measure included in the current study captured the somatic tension component of the ph construct, and was found to be positively correlated with both measures of anxiety and depression in both parent and youth reports. these results suggest that somatic tension problems are not exclusive to anxiety, which invalidates predictions of the tripartite model. though we were unable to measure and distinguish between specific anxiety disorders in the current study, perhaps ph is more highly correlated with panic disorder in youth populations. there is some evidence among adult outpatients that ph is positively correlated with panic symptoms, but not the other anxiety disorders (brown, chorpita & barlow, 1998). clark & watson (1991) noted that na comprised a component of psychosomatic distress, and as our current measure of ph focused on somatic complaints and tension, the similarity in correlations between our measure of ph and anxiety/depression may be a reflection of negative affect-related somatization. therefore, this can help identify, at the symptom level, which components of ph (i.e., autonomic arousal vs. chronic somatic tension) are more relevant to different types of anxiety disorders in the future. for example, autonomic arousal measures have been consistently shown to be more highly correlated with panic than any other anxiety disorder (anderson & hope, 2008), while generalized anxiety disorder reflects some similar somatic symptoms as depression (e.g., muscle tension, aches and pains; american psychiatric association, 2000). interestingly, in the older youth sample, the positive correlation between sp and anxiety appeared to be larger than that between sp and depression (although we did not test if this difference was statistically significant). however, this difference was not observed in the analyses that included the full age range of youth. perhaps in older adolescents, chronic aches and pains are more salient whereas younger children (for whom we only obtained parent report) are not able to adequately express or identify their physical complaints. alternatively, perhaps somatic complaints simply become more relevant to anxiety disorders than they are to depression as children grow up. future directions and limitations based on the findings discussed above, we proposed several directions for future research. it is important to address the validity of parent reports when investigating the affective components of the tripartite model, as they may not fully capture the child’s internal perspective. it is also necessary to investigate the relevance of ph in differentiating anxiety and depression, as the construct did not seem to adequately distinguish the two in the current study. because we used sp to approximate ph, future studies should include more items measuring the autonomic arousal component in order to better represent clark and watson’s (1991) original conception of ph. although sp did not separate the two syndromes in our study, such physiological symptoms appeared to be more highly correlated with anxiety compared to depression in youth. future research can examine age differences in the utility of somatic complaints as a distinguishing feature of anxiety and depression, and how different classes of symptoms may characterize subtypes of anxiety disorder. in the current study, we utilized trait measures of positive affect and negative affect, as opposed to the more commonly used state measures, and found trait affectivity to be as effective as state affectivity in predicting anxiety and depression. mccrae and john (1992) proposed that na is related to big five personality traits such as neuroticism and pa is related to extraversion. our results appear to support the connection of affect and personality in relation to anxiety and depression. some researchers have suggested a temperamental basis for both personality and psychopathology, with temperamental domains of negative affectivity and positive affectivity (clark, 2005). future studies can examine the relationships between affective dimensions in personality and anxiety/depression, and a closer exploration of trait versus state affectivity will enhance our understanding of how each functions in the two disorders. our study was limited by the fact that the sample was drawn from a community sample, and the nature of clinically significant anxiety and depression may be phenomenologically different from subclinical symptoms. further replication in a clinical population would be beneficial to advancing our understanding of the difference between clinical and subclinical anxiety and depression in terms of whether they differ in severity or presentation of symptoms. despite the methodological constraints, our study has shown that anxiety and depression are both characterized by na, and pa distinguishes the two groups of symptoms – findings which are consistent with predictions of the tripartite model. our results, however, do not support the model prediction that ph is uniquely assoicated with anxiety. our results support the utility of the tripartite model in understanding anxiety and depression in children and tripartite model of anxiety and depression 43 adolescents, and also provide direction for further validation/modification of the model. finally, the tripartite model is a dimensional model of psychopathology that corresponds to the current shift towards an integration of categorical and dimensional models in dsm-5. for example, watson (2005) has proposed empirically based structures of psychopathology that reflect similarities among disorders instead of separating them into different categories. watson posits that disorders with a primary distress component such as major depression and generalized anxiety belong in one class, while panic disorder and social phobia cluster in a separate class, therefore dividing anxiety disorders (i.e., panic and gad) which had been traditionally conceptualized within one category. alternatively, lahey et al. (2004) found that social phobia in children clustered with the distress disorders. this again demonstrates the need for further investigation into dimensional models of youth psychopathology or, as we have attempted to do with the tripartite model, further extensions of adult models to children. given the shift toward dimensional diagnoses of adult psychopathology, it is important to define highly comorbid disorders such as anxiety and depression (and their respective subtypes) in terms of the factors which they share and do not share. the tripartite model represents one such way of addressing the issues of comorbidity between anxiety and depression by positing a shared underlying component (na) and unique constructs (pa, ph) instead of splitting the two syndromes. the current study highlighted the importance of further illuminating the dimensional nature of anxiety and depression in youth populations in order to advance tools for assessment and treatment, as well as our overall understanding of the two syndromes. references achenbach, t. m. 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(1995). testing a tripartite model: ii. exploring symptom structures of anxiety and depression in student, adult, and patient samples. journal of abnormal psychology, 104, 15-25. doi:10.1037/0021-843x.104.1.15 interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 60 cognitive and functional deficits of alcohol abuse: a review nikita malakhov teachers college, columbia university due to the high prevalence of alcohol abuse and alcohol-related mortalities worldwide, it is important to investigate the impact of alcohol abuse on cognitive and functional deficits. the aim of this review is to synthesize the disparate research on cognitive and functional deficits due to alcoholism and delineate the different moderating factors that affect these deficits. the review of the literature suggests that the relationship between alcohol abuse and cognitive and functional deficits is multifaceted and is moderated by age, gender, dose, and prior treatment history. the review also indicates limitations of the cited studies and suggests multiple directions for future research.  alcoholism (i.e., alcohol use disorders) is the third leading cause of preventable death in the united states, and the lifespan of people who suffer from alcoholism is roughly 12 years shorter than their non-alcoholic counterparts (maddux & winstead, 2008). according to the world health organization (2008), alcohol use disorders cause 88 million deaths yearly. in addition, 125 million people worldwide are estimated to have alcohol use disorders. based on the diagnostic and statistical manual, 4 th edition (american psychiatric association [dsm-iv-tr], 2000) alcohol use disorders include both abuse and dependence. alcohol abuse refers to a maladaptive pattern of alcohol use that is manifested through recurrent alcohol use in dangerous situations (e.g., driving drunk, operating machinery while intoxicated), despite legal, social or interpersonal problems, and resulting in a failure to fulfill major role obligations. alcohol dependence is defined by a maladaptive pattern of alcohol use manifested by at least three of the following: tolerance, withdrawal, larger consumption of alcohol than intended, unsuccessful efforts to cut down use, a great deal of time spent on obtaining the alcohol or using it, important social/occupational/recreational activities being given up or reduced because of alcohol use, and continued use despite physical or psychological problems attributed to alcohol use. tolerance is described as the need for significantly increased amount of alcohol to achieve intoxication or desired effect and diminished effect with continued use of the same amount of alcohol. alcohol withdrawal symptoms include hand tremors, headache, seizures, vomiting, and nausea (lessa & scanlon, 2006). alcohol withdrawal is also characterized by the consumption of more alcohol or a substance similar to it in order to avoid withdrawal symptoms. recreational alcohol use does not involve a maladaptive relationship with alcohol like alcohol dependence and abuse. the author would like to thank derek eckert for his support and help. correspondence concerning this article should be addressed to nikhita malakhov, 2727 ocean parkway, apt. e-15, brooklyn, ny 11235. email: nm2495@tc.columbia.edu. chronic consumption of alcohol has been found to be associated with cognitive deficits, including difficulties learning new information (mcglinchey-berroth, fortier, cermak, & disterhoft, 2002; ryan & butters, 1980; schottenbauer, hommer, & weingartner, 2007), problems with retaining information over periods of long delay (rose, shaw, prendergast, & little, 2010), and impairment in prospective memory (heffernan, moss, & ling, 2002; ling et al., 2003), verbal and non-nonverbal contextual memory (sullivan, shear, zipursky, sagar, & pfefferbaum, 1997), short-term memory, general memory, and verbal memory (ryan & butters, 1980; rosenbloom, o’reilly, sassoon, sullivan, pfefferbaum, 2005; sullivan, rosenbloom, & pfefferbaum, 2000; sullivan, fama, rosenbloom, & pfefferbaum, 2002). it has also been found to be associated with functional deficits in the areas of visuospatial abilities, upper limb mobility, and gait and balance (sullivan et al., 2000; sullivan et al., 2002). in addition, alcohol abuse has been found to negatively impact executive functioning, decision-making, behavioral inhibition, task shifting, working memory, and problem solving (hildebrandt, eling, brokate, & lanz, 2004; leckliter & metarazzo, 1989; noel, bechara, dan, hanak, & verbanck, 2007; sullivan et al., 2000; sullivan et al., 2002), additionally, research suggests that abstinence allows for recovery of some cognitive impairments associated with alcohol abuse (e.g., brandt, butters, ryan, & bayog, 1983; bates, voelbel, buckman, labouvie, & barry, 2005; mann, gunther, stetter, & ackerman, 1999; rosenbloom, rohlfing, o'reilly, sassoon, pfefferbaum, & sullivan, 2007). bates et al. (2005) found a modest recovery in the cognitive domains of executive functioning, verbal processing speed, and verbal ability domains, and a medium recovery in the memory domain of abstaining alcoholics. rosenbloom and colleagues (2007) found improvements on measures of general memory and ataxia in abstaining alcoholics. brandt and colleagues (1983) showed that alcoholics with a prolonged period of abstinence (more than 5 years) improved in short-term memory and non-verbal memory skills. in addition, mann and colleagues (1999) found significant improvement on measures of perceptual-motor speed, verbal knowledge, nonmalakhov 61 verbal reasoning, and spatial imagination in alcoholics who abstained from alcohol for a 5-week period. the aforementioned studies will be explored in more details further along in this review. effects of alcoholism on memory prospective memory prospective memory is an important part of everyday cognitive functioning and is defined as the type of memory in which a person has to remember to do something in the near future, similar to a mental “to do” list (heffernan et al., 2002). there is evidence that individuals with heavy alcohol use have impaired prospective memory compared to individuals with low-level alcohol use. an alcohol abuser with deficits in prospective memory may forget to perform important tasks from their “to do” list, such as attending doctor’s appointments and completing work responsibilities. a study conducted by heffernan and colleagues (2002) investigated the effects of alcohol use on memory. the authors recruited a sample of 60 college students and asked them to complete the prospective memory questionnaire (pmq), a self-report measure that assesses prospective memory and effects of alcohol abuse. the alcohol-abusing group was found to have significantly impaired prospective memory functioning. the heavy alcohol use group selfreported significantly higher levels of prospective forgetting for short-term, long-term, and internally cued prospective memory. however, the authors cautioned about interpretation of the results obtained because the pmq is a self-report measure and can therefore be biased. similar to heffernan and colleagues (2002), ling and colleagues (2003) conducted an internet-based study to investigate prospective memory function in alcohol abusers. seven-hundred sixty-three participants completed the pmq, the everyday memory questionnaire (emq), and a demographic questionnaire. results indicated a significant impairment in long-term aspects of prospective memory with increased cognitive failures among the heavy alcohol abusing group, corroborating previous results by heffernan and colleagues (2002). findings by ling and colleagues (2003) add further support to the negative association between prospective memory deficits and alcohol abuse. contextual memory another avenue of research on memory deficits in alcohol abusers has been the assessment of contextual memory, which is defined as the memory for the source of information, the temporal positioning of information, and the context in which that information was presented (sullivan et al., 1997). sullivan and colleagues (1997) assessed contextual memory in alcoholics using an order recognition test of verbal and non-verbal items. in order to test their contextual memory, the participants were shown 233 nouns and then were asked the question, “which words did you see more recently?” (sullivan et al., 1997, p. 198). alcoholics were found to have significant deficits in contextual memory as compared to healthy controls. this study has important implications because it suggests that alcohol abuse has a negative impact on contextual memory. effects of alcoholism on executive functioning bechara and martin (2004) proposed that there is an underlying deficit in executive functioning components of working memory and decision-making in people who abuse substances. bechara and martin (2004) found performance differences between individuals with substance dependence and control participants on measures of working memory and decision-making with the substance dependent individuals performing significantly worse than controls. thus, the authors established evidence to support the notion that individuals who abuse substances have underlying working memory and decision-making deficits. hildebrandt and colleagues (2004) further explored executive functioning deficits in people with long-term, heavy alcohol consumption diagnosed with alcohol dependence according to the icd-10. hildebrandt and colleagues (2004) assessed executive functioning (i.e., working memory, behavioral inhibition, and task shifting) using a two-back paradigm; participants were instructed to watch a computer screen presenting double-digit numbers from 10 to 99 and to press a response key when the number was the same as the previous number, two numbers back. the authors found that people with a history of long-term heavy alcohol consumption showed no impairment in working memory as compared to the matched healthy controls, but showed deficits in behavioral inhibition and task shifting. these results suggest that subdividing executive functioning into its constituent parts should be an integral part in studying executive functioning deficits in alcohol abusers (hildebrandt et al., 2004). similarly, a study by noel and colleagues (2007) looked at the performance of individuals who met the criteria for alcohol dependence according to the dsm-iv on the iowa gambling task (igt) in comparison to healthy controls. igt is designed as a game in which four decks of cards, each of which has different rewards/punishments, are presented and the person has to choose one card out of a deck and they are either rewarded or punished for their choice. the goal of the task is for the participant to pick out the most riskavoidant card deck. results indicated that individuals with alcoholism had poor executive functioning, impairment in behavioral inhibition, and performed worse than control on the last 20 trials of igt. the authors suggested that individuals with alcoholism display difficulties with decision-making, especially when these decisions involve risk. moreover, the authors proposed that working memory in alcohol dependent individuals shows normal storage capacity, but the ability to manipulate information held in working memory is impaired. contrary to study findings by hildebrandt and colleagues (2004) that found no evidence of deficits in working memory among alcohol dependents, noel and alcohol abuse deficits 62 colleagues (2007) showed a partial deficit in working memory function among alcohol dependents. both studies found deficits in behavioral inhibition among alcohol abusers; however, the study by noel and colleagues (2007) indicated impairment in the manipulation of information component of working memory, whereas the study by hildebrandt and colleagues (2004) did not. more research is needed on the executive functioning of working memory. executive functioning, as was suggested by hildebrandt and colleagues (2004), should be divided into its constituent parts in order for researchers to be able to reach a consensus about executive function impairment in alcohol abusers. tests of premature-aging hypothesis and the relation to amount of lifetime alcohol consumption it has been hypothesized that the cognitive deficits seen in alcoholism are due to the premature aging of cognitive functioning caused by chronic alcohol consumption, a hypothesis known as the “premature-aging hypothesis” (ryan & butters, 1980). ryan and butters (1980) tested the “premature-aging” hypothesis by administering various learning and memory tasks to younger alcoholics (ages 3449), older alcoholics (ages 50-59), and age-matched controls. among the various tests administered by the researchers (ryan & butters, 1980), one was the four-word short-term memory test, in which participants are presented with four words and, following a distractor activity (i.e., count down from a three digit number by a certain number) are asked to recall these words. their results provided evidence for the premature-aging hypothesis, showing that younger alcoholics consistently performed at a level similar to the 10 years older normal controls. a study by holden, mclaughlin, reilly, and overall (1988) looked to expand these findings. using the wechsler adult intelligence scale (wais, 1955), which allows for discerning a person’s mental age alongside their chronological one, holden and colleagues (1988) tested participants who met the criteria for alcohol abuse or dependence according to the dsm-iii. the results of the study indicated that the mental age of the alcoholic sample was seven years older than their actual chronological one, as compared to the age-matched sample. these results are in accord with the findings of ryan and butters (1980) and provide further evidence for the premature-aging hypothesis. nichols, hochla and parsons (1982) further explored the premature-aging hypothesis in females that met the criteria for alcoholism and were currently in a residential treatment facility. they found that alcoholic women performed significantly better than elderly non-alcoholic women on neuropsychological tests. the researchers, however, found that a subsample of female alcohol abusers who reported more severe alcohol intake performed comparably to nonalcoholic females that were 20-years their elder. thus, the authors established partial support for the premature-aging hypothesis in females. shelton, parsons, and leber (1984) tested the prematureaging hypothesis by comparing the cognitive performance of middle-aged chronic alcoholics whose alcohol consumption was disruptive to their daily living to the performance of middle-aged controls and elderly controls. cognitive performance was measured using a paired-associate learning test consisting of separate verbal and visuospatial subtests. elderly controls were found to perform significantly worse than both the middle-aged controls and the middle-aged chronic alcoholics; middle-aged alcoholics performed on a similar level to middle-aged controls rather than the elderly controls. therefore, the premature-aging hypothesis was not supported in this study. schottenbauer and colleagues (2007) further tested the premature-aging hypothesis by looking at the performance on a selective reminding task (srt) of participants who met the dsm-iii-r criteria for alcohol dependence and comparing their performance to the performance of healthy controls. the authors described the srt as a measure of learning and memory impairment. alcoholics were found to have deficits in both learning and memory as compared to controls. results indicated that age significantly predicted memory deficits among alcoholics, but lost statistical significance after controlling for dose effect (i.e., years of heavy drinking). these findings suggest that dosage is an important predictor variable of cognitive deficits alongside age and should be taken into consideration in future studies. pfefferbaum and colleagues (1992) performed a brain imaging study using magnetic resonance imaging on participants who met alcohol dependence criteria on the research diagnostic criteria (rdc, spitzer, endicott, & robins, 1975) and discovered an age-related, not doserelated, structural damage in alcohol dependent individuals as compared to age matched healthy controls. age significantly predicted structural damage above and beyond lifetime dosage of alcohol consumption, suggesting that even when the levels of lifetime alcohol consumption are comparable between younger and older alcoholics, older alcoholics seem to manifest greater structural damage in their brains. the significance of the neuroanatomical study by pfefferbaum and colleagues (1992) lies in the finding of actual morphological differences in the brain structures among alcohol abusers contingent on their age and not dosage. age and chronic alcohol abuse, as separate or compounded factors, have been linked to cause neuroanatomical damage. the premature-aging hypothesis has been extensively researched (e.g., nichols hochla & parson, 1982; ryan & butters, 1980; schottenbauer et al., 2007; shelton, parsons, & leber, 1984). some studies provide support for the premature-aging hypothesis (holden, mclaughlin, reilly, & overall, 1988; ryan & butters, 1980), while others provide partial or no evidence for this hypothesis (nichols hochla & parson, 1982; shelton, parsons, & leber, 1984). even though researchers have not reached a consensus on the validity of the premature-aging hypothesis, age seems to have an effect on the cognitive and functional deficits associated with alcohol abuse. it also seems to have an effect on the malakhov 63 structure of the brain as has been found by pfefferbaum and colleagues (1992). dosage, likewise, seems to have an effect on the cognitive and functional deficits of alcohol abuse and will be explored further along in this review. more research is needed in order to pinpoint the mechanism by which age seems to have an effect on cognitive and functional deficits associated with alcohol abuse and the structural changes that are associated with it. effects of gender on the cognitive and functional deficits a study by sullivan and colleagues (2000) tested and compared the performance of 71 recently detoxified (1 month) alcoholic males on several neuropsychological measures to healthy male controls. all of the alcoholic males met the rdc criteria for alcohol dependence. study participants underwent a thorough neuropsychological evaluation, which assessed executive functioning using the wisconsin card sorting task, short-term memory and production using the brown-peterson distractor tests, upper limb mobility by measuring grip strength and fine finger movement, declarative memory by using the delayed wechsler memory scale stories, visuospatial abilities by the hidden figure test, and gait and balance by using the ataxia battery. consistent with previous research findings (e.g., bechara & martin, 2004; hildebrandt et al., 2004; noel et al., 2007; ryan & butters, 1980; schottenbauer et al., 2007), sullivan and colleagues (2000) found that recently detoxified alcoholic males exhibited deficits in measures of executive functioning, working memory, short-term memory, upper limb mobility, visuospatial abilities, and gait and balance as compared to healthy male controls. furthermore, alcoholic males were found to be more vulnerable to deficits in upper limb mobility when age was taken into consideration. this finding suggests that age, in combination with alcohol dependence, has a deleterious effect on functional deficits with older alcoholic males exhibiting more deficits in upper limb motor mobility as compared to younger male alcoholics. in addition, the authors found that age did not have an effect on cognitive functioning, but did have a predictive effect on deficits found in gait and balance, which is suggestive of age-related cerebellar damage due to alcohol abuse. sullivan and colleagues (2000) found a dosage effect of alcohol consumption on gait and balance, but not on cognitive functioning. this finding contrasts previous findings reported by schottenbauer and colleagues (2007) showing that lifetime alcohol consumption significantly predicted learning and memory performance as measured with srt. a study by sullivan and colleagues (2002) tested the performance of 43 detoxified (3.6 months) females on several neuropsychological measures and compared them to healthy female controls and the males from the sullivan and colleagues (2000) study. the study used the same neuropsychological measures as the sullivan and colleagues (2000) study. as compared to the nonalcoholic control females, the alcoholic females exhibited many of the same cognitive and functional deficits as the alcoholic males did in the sullivan et al. (2000) study such as deficits in verbal and non-verbal working memory, visuospatial processing, and gait and balance. sullivan and colleagues (2002), however, found that alcoholic females had a lifetime alcohol consumption that was 2.5 times lower than the alcoholic males in the sullivan and colleagues (2000) study. thus, female alcoholics who were detoxified for 3.6 months and had a lifetime consumption that was 2.5 times lower than the alcoholic males in the sullivan et al. (2000) study still exhibited many of the same cognitive and functional deficits, suggesting that there is a difference in the way alcohol consumption affects the cognitive and functional deficits in the two genders. females consume less alcohol, but still show the same signs of cognitive and functional deficits as males do, suggesting that alcohol has an especially deleterious effect on females. however, the findings of this study should be interpreted with caution because the sullivan and colleagues (2000) study was not aimed at investigating a gender difference in the way alcohol affects the two genders. in sullivan et al. (2002) study an ad hoc comparison was performed between the males and females from the two different samples and the authors cautioned about the interpretation of the results. more research is warranted in order to further understand the relationship between alcoholism and cognitive and functional deficits in the two genders. effects of treatment history and amount of alcohol consumption in a study with chronic alcoholics who met lifetime criteria for alcohol dependence, fein and landman (2005) compared alcoholic patients with and without history of alcohol treatment, the latter being referred to as treatment naïve alcoholics. retrospective information about the participants’ alcohol use was gathered using a lifetime follow-back interview procedure, in which subjects broke their drinking history into periods with consistent alcohol use. the two groups were further matched into pairs, based on the age at which they first met the criteria for heavy drinking. results indicated that, compared to treatment naïve alcoholics, those with treatment histories had higher dose alcohol consumption (58% for males and 68% for females) during the period since they first met the criteria for heavy drinking. the study by fein and landman (2005) suggests that treatment naïve alcoholics and alcoholics with treatment histories are distinct populations in terms of their alcohol use, with dosage being an important differentiating factor between the two groups. therefore, fein & landman (2005) cautioned against generalizing research findings found amongst alcohol abusers with treatment histories to those that have never had treatment. another study by fein, mcgillivrary, and finn (2006) compared a sample of 58 treatment naïve alcohol dependent (tnad) participants, who met dsm-iv criteria for current alcohol abuse deficits 64 alcohol dependence, to a matched sample of non-alcoholic controls (nac) on a simulated gambling task (sgt) that measures decision-making and behavioral inhibition. results indicated that the two groups did not differ with respect to decision-making. contrary to previous findings showing decision-making and behavioral inhibition impairment in alcohol abusing sample with treatment histories (noel et al., 2007), the study by fein and colleagues (2006) showed that treatment naïve young adults with alcohol dependence do not have global deficits in decision-making. the poor decisionmaking that treatment naïve young adults with alcohol dependence exhibit regarding their alcohol consumption seems to be more specific to drinking. the aforementioned findings were further supported by the smith and fein (2010) study, which compared a sample of tnad participants who met dsm-iv criteria for current alcohol dependence with a matched sample of nacs on performance in nine performance domains. the domains included attention, auditory working memory, verbal processing, abstraction/cognitive flexibility, psychomotor function, immediate memory, delayed memory, reaction time, and spatial processing. smith and fein (2010) did not find a significant difference between the two samples on any of the nine performance domains. the absence of any difference between the nac group and the tnad group, when most studies consistently reported discernible differences between alcoholics and healthy controls (e.g., sullivan et al., 2000; rosenbloom et al., 2005), further supports the findings of fein and landman (2005), which suggested that treatment naïve alcoholics and alcoholics with treatment histories are different populations. therefore, future research must continue to investigate these two groups, the treatment naïve alcohol dependents and the non-alcoholic controls. improvements with abstinence and potential clinical implications a large study by brandt and colleagues (1983) of 134 alcoholics with at least a 10-year history of daily alcohol consumption and at least 1-month abstinence at testing time revealed that alcoholics showed improvements on measures of short-term memory and psychomotor skills, but not longterm memory. at the follow-up phase of the study, the authors grouped the alcoholic abstainers into three groups: the “short-term abstinence” group, including participants who were abstinent between 1 and 2 months; the “long-term abstinence” group, including those who were abstinent between 1 and 3 years; and the “prolonged abstinence” group, for those who were sober for at least 5-years. the authors found no significant difference between prolonged abstainers and non-alcoholic controls in terms of their short-term memory function, suggesting a recovery of short-term memory function among prolonged abstainers. the researchers, however, found a significant difference between prolonged abstainers and normal controls on measures of attention, perceptual speed, motor speed, visual scanning, and memory suggesting the irreversibility of the deficits in these areas even after prolonged abstinence. in addition, the researchers did not find a significant difference between prolonged abstainers and normal controls on a measure of non-verbal memory skills indicating recovery of these skills with prolonged abstinence. a study by rosenbloom and colleagues (2007) using various neuropsychological measures determined that alcoholics who met the dsm-iv criteria for alcohol dependence and were abstinent for 2 to 2.5 years showed significant improvement on measures of memory, and gait and balance as compared to controls. the alcoholic participants were self-reported abstainers. the participants were sober for over 4-months as they were tested at baseline. the authors (rosenbloom et al., 2007) were also able to find structural changes in the brain of the abstaining participants with abstaining alcoholics showing a significantly decreased lateral ventricular volume as compared to relapsing alcoholics. rosenbloom and colleagues (2007) concluded that both memory and ataxia could improve with sustained sobriety alongside structural changes in the brain. a study by bates and colleagues (2005) looked at the recovery of cognitive abilities of alcoholics who were in treatment for 6-weeks. the participants underwent a large neuropsychological evaluation before and after the 6-week treatment period. a modest recovery was reported in the domains of executive functioning, verbal processing speed, verbal ability domains, and medium recovery in the memory domain. bates and colleagues (2005) cautioned that the improvements observed (with the exception of improvements in memory function) might be too minor to be of clinical relevance. a study by mann and colleagues (1999) investigated the pattern of cognitive deficits and their time-dependent recovery in a sample of 49 males who met the dsm-iii-r criteria for alcohol dependence using a test-retest design. the authors also included a healthy sample of 49 males who were also tested and retested after a 5-week interval. the researchers (mann et al., 1999) established significant improvement on measures of perceptual-motor speed, verbal knowledge, non-verbal reasoning, and spatial imagination. however, the authors did not find improvement in the area of short-term verbal memory. this is an interesting finding because it is in contrast to the findings of brandt and colleagues (1983), who found that short-term memory recovers with abstinence and long-term memory does not. an explanatory factor for the results that mann and colleagues (1999) observed is that perhaps not enough time passed between test and retest in order for the authors to be able to observe an improvement in short-term memory. the abstainers in the brandt and colleagues (1983) study were abstinent for over 5-years and in the mann and colleagues (1999) study the participants were only abstinent for 5weeks. the clinical implications of the recovery of some of the cognitive and functional deficits of alcohol abuse could potentially provide the ability for mental health practitioners malakhov 65 to tailor treatments for specific populations of alcohol abusers, as pointed out by bates and colleagues (2005). the development of risk factor profiles that differentiate the cognitive and functional recovery among abstaining alcohol abusers can have a significant effect on how treatment is disseminated for the different profiles (bates et al., 2005). the treatment process can be stifled if the treatment information is disseminated in such a way that an alcohol abuser with cognitive and functional deficits cannot assimilate it (bates et al., 2005). the inability to assimilate the information that is disseminated as part of the therapeutic technique can influence the treatment outcome for people that suffer from alcohol abuse. the implication that the recovery of cognitive and functional deficits of alcohol abuse has is that specific therapeutic techniques can be better tailored to the needs of the people suffering from alcohol abuse. findings from longitudinal studies a prospective study focusing on males was conducted in denmark with 20-, 30-, and 40-year follow-ups. the sample of participants was chosen from a large copenhagen birth cohort. at the 20-year follow-up of this cohort, drejer, theikjaard, teasdale, schulsinger, and goodwin (1985) established that high-risk (i.e., having a father who is an alcoholic) 18and 19-year-old males differed significantly from age-matched controls on measures of vocabulary, tests of categorizing ability, organization, and planning. this is an important finding, as the authors pointed out, because other researchers found these problems with prolonged alcohol abuse (e.g., sullivan et al., 2000, 2002) and the results from this study show that it seems that high-risk males already have many of the deficits that were found in alcoholics prior to prolonged alcohol abuse. the 30-year follow-up studies on this cohort of high-risk males focused on the influence of genetic and environmental components of alcoholism (knop et al., 1993) and the predictor variables of future alcoholism (goodwin et al., 1994). the follow-up studies did not employ the use of neuropsychological batteries and therefore the results of the 20-year follow-up, which established that the high-risk males differ from age-matched controls on several neuropsychological measures, were not further explored. in a follow-up analysis by knop and colleagues (2003), the authors concluded that the premorbid differences between the high and low-risk groups were only modestly related to problem drinking and alcohol dependence at age 30. discussion the research on cognitive and functional deficits of alcohol abuse has been extensive and there seems to be a consensus amongst researchers that alcohol abuse includes cognitive and functional deficits in: learning, general memory, prospective memory, contextual memory, visuospatial abilities, upper limb mobility, gait and balance, executive functioning, decision-making, behavioral inhibition, behavioral inhibition, task shifting, working memory, and problem solving. however, there are some areas such as working memory, on which research has been inconclusive. hildebrandt and colleagues (2004) did not find deficits in working memory among alcohol abusers, but other researchers determined that indeed there are deficits in working memory (noel et al., 2007; sullivan et al., 2000; sullivan et al., 2002). thus, more research is necessary in order to clarify how alcohol abuse impacts working memory. this can be done through clearly delineating working memory from executive functioning, as in the study by hildebrandt and colleagues (2004), and classifying it in a way that would lead to consensus among different researchers. the research on age and severity of cognitive and functional deficits of alcohol abusers seems to also fall into the area of inconclusive research findings. researchers have found evidence to support the premature-aging hypothesis (holden et al., 1988; nichols hochla & parsons, 1982; ryan & butters, 1980) and neuroanatomical studies have reported age-related neuroanatomical damage even when dosage is controlled for (pfefferbaum et al., 1992). the study by schottenbauer and colleagues (2007) found that age had a predictive effect on the srt performance of alcoholics, but this effect was significantly reduced once dose was entered into the equation. this suggests that age and dosage may have effects on cognitive functions and more research is needed to delineate what these effects are. however, some researchers (e.g., sullivan et al., 2000) found that age and dosage did not have an effect on the cognitive functioning of alcoholics, but did have an effect on their functional capacities such as gait and balance. in addition, findings by sheldon and colleagues (1984) did not provide support for the premature-aging hypothesis in their study of alcoholic males. these contrasting findings suggest that more research into this topic is imperative. there are few studies covering the gender differences in cognitive and functional deficits of alcoholics. however, the study by sullivan and colleagues (2002), which compared female alcoholics to male alcoholics, yielded important findings. the study showed that women tend to consume smaller amounts of alcohol for over a shorter period of time, but seem to exhibit many of the same cognitive and functional deficits as men do, such as upper limb strength, executive functioning, and speed. while these findings suggest that alcohol has a different effect in the two genders, more research is needed to further extrapolate what the differences between the genders are in terms of sensitivity to alcohol’s deleterious effects. fein and landman (2005) explored an avenue of research by noticing that researchers have focused on a convenience population (i.e., alcoholics in treatment or with a history of treatment) and did not focus on the larger population (i.e., naïve alcoholics or alcoholics who have not received treatment). fein and colleagues (2006) and smith and fein (2010) did not report any cognitive or functional alcohol abuse deficits 66 differences between treatment naïve alcoholics and normal non-alcoholic samples, when directly comparing these two groups. these findings expand upon previous research that only examined alcoholics who have received treatment by including a sample of treatment naïve alcoholics. further research is warranted in order to pinpoint at what level of consumption alcohol begins negatively impacting cognitive functioning. also, research should be conducted to identify patient characteristics that distinguish treatment naïve alcoholics from alcoholics with treatment histories. this type of research can be enlightening because it can add other dimensions to understanding the differences between alcoholics with treatment and treatment naïve alcoholics. research in cognitive and functional deficits of alcohol use disorders can substantially benefit from longitudinal studies, which follow participants over time. by following participants with alcohol use disorders over time and conducting multiple sequential assessments of cognitive and functional deficits, longitudinal studies allow researchers to identify predictors and moderators of these deficits and distinguish between shortand long-term effects. the aforementioned danish prospective study by dreijer and colleagues (1985) was unique in that it employed a longitudinal design. however, none of the subsequent follow-up assessments (e.g., goodwin et al., 1994; knop et al., 1993) assessed participants’ neuropsychological functioning, significantly limiting how much information regarding cognitive and functional deficits of alcohol abuse could be obtained from this prospective study. thus, it is difficult to pinpoint what the cognitive and functional deficits of alcohol abuse are from this particular prospective study. another limitation of the danish cohort study was that it only focused on males, which limits the external validity of this study, since there appears to be a difference between how the genders respond to alcohol abuse (sullivan et al., 2002). the danish prospective study was ideal for discerning what the risk factors and predictors for alcohol abuse and dependence are, (e.g., knop et al., 2003), but not the cognitive and functional deficits of alcohol abuse. therefore, new prospective studies with both female and male cohorts are needed in order to disentangle what the cognitive and functional deficits of alcohol abuse are. the findings presented in this review should be interpreted with caution because the nature of these studies is not of true experimentation. therefore, the establishment of a causal relationship between alcohol abuse and cognitive and functional deficits was stifled. likewise, the directionality of the deficits is hard to pinpoint. are the cognitive and functional deficits seen in alcohol abusers a result of alcohol abuse or are they what led to the alcohol abuse in the first place? one way that the causal relationship and directionality between alcohol abuse and cognitive and functional deficits can be established is through true experimentation with animals. random selection and random assignment can be accomplished in animal research and the internal validity of these types of studies would be quite strong. on the other hand, the external validity of such research would be thwarted because of the differences between humans and animals. even with limited external validity, experimental studies with animals have a huge potential for elucidating the causal relationship between alcohol abuse and functional and cognitive deficits, and are therefore needed. another important limitation of the studies reviewed refers to the heterogeneous use of diagnostic criteria for alcohol dependence and abuse. diagnosis of alcohol dependence or abuse was given based on a variety of diagnostic manuals, such as the icd-10, dsm-iii, dsm-iv, and rcd, which may account for the lack of consensus among different studies. additionally, the cited studies did not always specify the longevity and the severity of the alcohol dependence or abuse. future studies should agree on “gold standard” diagnostic criteria for alcohol dependence and abuse, in order to reach reliable and conclusive findings about the cognitive and functional deficits of alcohol abuse. in addition, research that focuses on the recovery of cognitive and functional deficits of alcohol abuse is a very important avenue of research because it has implications for clinical practice. it is a necessary endeavor to establish the profile of risk factors that predict differences in cognitive recovery between individuals, as bates and colleagues (2005) suggested. establishing risk factors profiles can guide therapeutic interventions that could be better tailored for specific populations. thus, more research is needed in order to identify the risk factors that predict differences in cognitive recovery of individuals. further research in the area of recovery of functional and cognitive deficits of alcohol abuse can inform therapeutic work and help people with alcohol abuse recovery. conclusion the relationship between alcohol abuse and cognitive and functional deficits may seem elementary on the surface; the more a person drinks the more deficits they exhibit. the results of numerous research studies, however, speak largely to the contrary. there are multiple variables that affect the cognitive and functional deficits of alcohol abusers including age, gender, treatment history, and dosage. there is documented recovery of some of the cognitive and functional deficits with abstinence and treatment. more encompassing research is needed in order to fully grasp and discern the effects of the aforementioned factors on cognitive and functional deficits of alcohol abusers. the details of this research could enlighten 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(2008). the global burden of disease: 2004 update. who, geneva, switzerland. body dysmorphic disorder and ocd graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university obsessive compulsive related disorders: a new classification for the dsm-v lauren m. mancusi, m.a. teachers college, columbia university there is concern surrounding the classification of obsessive compulsive disorder (ocd) for the next edition of the diagnostic and statistical manual of mental disorders (dsm). the dsm-v workgroup for ocd related disorders and researchers alike suggest removing ocd from the anxiety disorders category of the dsm, and placing it under the heading of obsessive compulsive related disorders (ocrd). this paper provides a review of current literature examining three popular candidates (body dysmorphic disorder, trichotillomania, and tourette’s disorder) for inclusion in the ocrd category. recommendations for future research are made. the classification of obsessive compulsive disorder (ocd) has undergone considerable change since the initial compilation of the diagnostic and statistical manual of mental disorders (dsm). in the dsm-ii, ocd was categorized as “obsessivecompulsive neurosis,” while obsessive compulsive disorder received a new classification in the dsm-iii as an anxiety disorder. currently, ocd remains classified as an anxiety disorder in the dsm-iv-tr (montgomery, 1993); however, the classification of ocd continues to be a topic of controversy for the dsm-v. researchers have recently suggested that the current classification of ocd is mainly symptom based. specifically, obsessive thoughts increase anxiety which is moderated by compulsive behaviors (bartz & hollander, 2006). as such, anxiety presents as a byproduct of the disorder and not an underlying feature (mataix-cols, pertusa, & leckman, 2007). additionally, the current classification fails to account for the differences among ocd and the remaining anxiety disorders, mainly in the sphere of repetitive behaviors and an inability to resist impulses. several other disorders (e.g., body dysmorphic disorder, trichotillomania, and tourette’s disorder) that are not included in the anxiety disorders category also display the compulsive and impulsive behaviors present in ocd. thus, the research planning agenda for the dsm-v workgroup on obsessive compulsive-related disorders suggests removing ocd from the anxiety disorders category and placing it under the title of obsessive compulsive related disorders (ocrds) (hollander, braun, & simeon, 2008). other recent work has proposed a multidimensional model of ocd that recognizes the heterogeneity among causes and presenting symptoms across ocd and related disorders (castle & phillips, 2006; mataix-cols, 2007). it is suggested that ocd and related disorders be classified along a continuum for future editions of the dsm. the ocd spectrum is subdivided into three distinct clusters; (1)1 preoccupations with body sensations or image (e.g., body correspondence: lauren mancusi, lmm2176@columbia.edu dysmorphic disorder), (2) impulse disorders (e.g., trichotillomania), and (3) neurological based disorders (e.g., tourette’s disorder). these seemingly unrelated disorders display consistency across (1) symptomology (e.g., compulsivity and impulsivity), (2) neurobiology (e.g., fmri data), and (3) responses to psychosocial (e.g., cognitive behavioral therapy) and pharmacological (selective serotonin reuptake inhibitors) treatments (castle & phillips, 2006; rossi, 2006). further, hollander (1993) suggests a “compulsive-impulsive” dimension, with compulsive disorders (e.g., ocd) on one end of the spectrum (compulsive) and impulse control disorders (e.g., trichotillomania) at the other end of the spectrum (impulsive). in this case, compulsivity reflects harm avoidance, whereas impulsivity reflects risk seeking. obsessive compulsive symptoms are present in various disorders besides ocd. these disorders include tourette’s disorder (td), body dysmorphic disorder (bdd), and trichotillomania (tmm) (castle & phillips, 2006). while these disorders are primary candidates for ocrds, eating disorders, autism, and depersonalization disorder, along with certain neurological disorders such as parkinson’s and sydenham’s chorea, are also under consideration for inclusion within the oc domain (castle & phillips, 2006; hollander, 1993). what is more, recent literature revealed that the dsm-v workgroup on obsessive compulsiverelated disorders labored over whether or not to include behavioral addictions, such as pathological gambling, kleptomania, and pyromania within the ocrds. the workgroup concluded these behavioral addictions will not be classified as ocrds, but rather will be included in a parallel category of behavioral and substance addictions. the behavioral and substance addictions category will include existing as well as new (compulsive buying, internet addiction, and compulsive sexual behavior) impulse/control disorders as well as substance addictions (bartz & hollander, 2006). this paper aims to elaborate on the process of the new classification proposed for the ocrds by examining the 12 obsessive-compulsive disorder 13 three contending disorders (body dysmorphic disorder, trichotillomania, and, tourette’s disorder) with regard to the symptom domain, the neurobiological and genetic domain, and the treatment domain. suggestions for future research are recommended as well. body dysmorphic disorder and ocd the symptom domain body dysmorphic disorder is currently classified as a somatoform disorder, and is marked by an excessive preoccupation with a perceived body defect which is usually non-existent or minimal (american psychiatric association, 2000; mckay, neziroglu, & yaryura-tobias, 1997). the experienced preoccupations are believed to be similar to the obsessions experienced in ocd; obsessions in ocd and bdd tend to be intrusive and persistent. additionally, individuals with these disorders recognize the obsessions as excessive. however, unlike individuals with ocd, individuals with bdd do not view their obsessions as unreasonable (hollander, braun, & simeon, 2008). this may be due to the lack of global insight often seen in individuals with bdd as compared to those with ocd who tend to have more insight and recognize their obsessive thoughts as excessive and harmful (phillips et al., 2007). as evidenced in ocd, individuals with bdd engage in compulsive behaviors (e.g., mirror checking) and reassurance seeking in attempts to reduce the stress surrounding the preoccupation. the repetitive behaviors often are expressed in a ritualized form and may follow a certain sequence. furthermore, this sequence is repeated if interrupted or until a desired aim is achieved (phillips, mcelroy, keck, pope, & hudson, 1994). in both groups, the compulsions are not inherently gratifying or pleasurable, but rather distressing and socially debilitating. while both individuals with ocd and bdd engage in compulsive behaviors, these activities are less likely to reduce anxiety, behaviors, or compulsions in individuals with bdd (hollander, braun, & simeon, 2008), which might be attributed to the poorer insight observed in individuals with bdd. mckay, neziroglu, and yaryura-tobias (1997) examined the overlapping symptom domains of ocd and bdd. a sample of 22 ocd outpatients and 23 bdd outpatients were administered a variety of psychological measures assessing ocd, bdd, overvalued ideation, depression, physical symptoms of anxiety, and cognitive symptoms of anxiety. the researchers found that bdd is a more severe variation of ocd. participants with bdd reported higher levels of overvalued ideas when compared to those with ocd. additionally, the bdd participants exhibited more severe obsessive and compulsive symptoms than the ocd participants. the two groups were statistically equivalent on other measures of depression and physical symptoms of anxiety; however, there was a significant difference between the two groups on the measure of cognitive symptoms of anxiety, with the ocd participants reporting higher incidences. these results suggest a difference in the experience of anxiety associated with each disorder, on the one hand, while, on the other, that those with ocd and bdd similarly experience obsessive and compulsive symptoms. the relatedness between the two disorders in the symptom domain provides evidence in favor of an ocd spectrum. more recently, phillips and colleagues (2007) conducted a comparison study of clinical features of ocd and bdd. the researchers administered the structured clinical interview and a variety of psychological measures assessing symptoms of ocd, bdd, beliefs, and depression with 210 ocd participants, 45 bdd participants, and 40 comorbid ocd/bdd participants. a comparison of subjects’ characteristics showed ocd and bdd did not significantly differ in regard to demographic traits such as age, race, gender, age of onset, illness duration, most functioning measures, and most comorbidity. findings suggest that subjects with bdd were more likely to suffer from lifetime major depression or another mood disorder. however, the symptom severity of these disorders did not differ significantly among the groups, suggesting that bdd may be a good candidate for the ocrds within the symptom domain. the neurological and genetic domain the brain circuitry within ocd patients is characterized by hyperactivity in the orbital frontal cortex, caudate nucleus, thalamus, and the anterior cingulated nucleus (bartz & hollander, 2006). researchers have noted that the prefrontal regions of the brain, specifically, the frontalstriatal region including the basal ganglia, have been linked with the intrusive thoughts associated with ocd (stein, 2000). unfortunately, few neuroimaging studies in bdd are available for comparison (mataix-cols & van den heuvel, 2006). researchers conducted a morphometric study with 8 women with bdd and 8 female controls, and results showed a significantly different asymmetry in the caudate nucleus with a leftward shift in the bdd group. the activity in the caudate nucleus suggests that a similar brain region is active in both ocd and bdd (mataix-cols & van den heuvel, 2006); however, research in this area is sparse and requires replication. bienvenu et al. (2000) examined the relationship among ocd and prospective spectrum disorders. the researchers found that cases of bdd were significantly higher in case probands than controls. bdd was also shown to be transmitted in families of patients with ocd, while bdd rates were higher in families with patients of ocd. the researchers suggest developing phenotypic definitions for future genetic research of ocd spectrum disorders (bienvenu et al., 2000). mancusi 14 the treatment domain obsessive compulsive disorder and body dysmorphic disorder both respond to psychosocial and psychopharmacological treatments (hollander et al., 2008). the leading psychosocial treatments for ocd are cognitive and behavioral-based therapies that focus on exposure and response prevention (erp). erp is considered the preferred psychosocial treatment for ocd (castle & phillips, 2006; wilhelm et al., 2005). one study suggests that 63% of ocd patients respond positively to erps; however, 20% to 30% remain resistant or refuse erp due to the anxiety provoking exposure (wilhelm et al., 2005). while ocd responds favorably to erp alone, the cognitive component of cognitive behavioral therapy (cbt) has also been efficacious (castle & phillips, 2006). wilhelm and colleagues (2005) examined the effects of a purely cognitive treatment for individuals with ocd. participants received 12 weekly 50-60 minute individual sessions of cognitive therapy. the cognitive therapy included psychoeducation, procedures according to beck’s cognitive model (e.g., socratic dialogue and identification of cognitive errors), and relapse prevention strategies. the researchers found that all participants improved across ocd symptoms as well anxiety symptoms and maladaptive beliefs. while results support the efficacy of cognitive treatment alone, this was the first study to examine purely cognitive techniques with an ocd sample, and further work is needed to make more conclusive statements regarding this therapeutic approach. the treatment approach for bdd is based on the treatment of ocd (neziroglu & khemlani-patel, 2003), such as psychosocial interventions that include a cognitive component as well as exposure and response prevention treatment to lessen anxiety and ritualistic behaviors (buhlmann, reese, renaud, & wilhelm, 2008; castle & phillips, 2006). while the literature on bdd remains fairly limited, the available research suggests that bdd responds to similar psychosocial treatments as ocd (neziroglu, 2008). neziroglu, mckay, and yaryura-tobias (1996) presented a case series in which 17 patients with bdd received daily 90-minute cbt sessions over the course of 1 month. results showed a 50% reduction in symptoms in more than half the participants (n = 12). veale and colleagues (1996) conducted a randomized study assessing the effectiveness of cbt with individuals with bdd. nineteen individuals with bdd were randomly assigned to either the treatment group or the waitlist control group. participants in the treatment group attended weekly 1-hour sessions of cbt for 12 weeks, and those that received treatment improved significantly more than those in the waitlist condition. in a 6-week intensive treatment of bdd using exposure response and prevention (without a cognitive component), 10 participants received five 90-minute sessions a week. the results indicated that participants improved on measures of bdd symptoms, avoidance, depression, and anxiety, while follow-up data showed that improvements remained stable over a 6-week period (mckay et al., 1997). with regard to psychopharmacological treatments, ocd and bdd respond favorably to selective serotonin reuptake inhibitors (ssris) (castle & phillips, 2006; hollander et al., 2008). in a meta-analysis of treatments employing long-term medication for ocd, researchers found that ssris were, overall, effective over time and also helpful in relapse prevention. data suggest that paroxetine, escitalopram, and fluoxetine are the most effective ssris in relapse prevention of ocd (fineberg, pampaloni, pallanti, ipser, & stein, 2007). studies to date often report that ssris are also efficacious for bdd (phillips, didie, feusner, & wilhelm, 2008). in a 12-week double-blind study (n = 67), fluoxetine was significantly more efficacious than placebo for bdd beginning at 8 weeks and continuing at 10 and 12 weeks and with participants receiving a relatively high dose of the medication (77.7 +/8.0 mg/d) (phillips, albertini, & rasmussen, 2002). this finding is in accordance with previous reports that psychopharmacological treatment of bdd often has a longer delay in ssri response and requires higher ssri doses (neziroglu & khemlani-patel, 2003). literature shows similar information for the delay in ssri response and effective treatment dose with ocd (castle & phillips, 2006; hollander et al., 2008). trichotillomania the symptom domain trichotillomania (ttm) is currently classified as an impulse control disorder characterized by repetitive hair pulling (american psychiatric association, 2000). while ttm is not distinctly marked by obsessions, they are sometimes present in the disorder. when obsessions are present, they often are not associated with an intrusive thought, but rather with the compulsive desire to pluck one’s hair, and this urge is recognized as unreasonable as intrusive thoughts are to individuals with ocd (hollander et al., 2008). the ritualized and repetitive hair pulling associated with ttm is parallel to compulsions expressed in ocd. much like compulsive behaviors exhibited in ocd, the compulsive hair plucking often reduces anxiety and is influenced by an individual’s need for symmetry in the hair pattern (hollander et al., 2008). often the compulsive behavior is rigid and repeated until the desired outcome is achieved; hair plucking is a tension reducing response to the urge to pluck one’s hair. furthermore, hair plucking is distressing and socially debilitating as seen in ocd, and, while both hair pulling and ocd compulsions reduce anxiety, hair pulling is gratifying (castle & phillips, 2006). to the author’s knowledge, few studies exists directly comparing observable behavior of ocd to ttm in terms of symptomology. bohne, savage, deckersbach, keuthen, and wilhelm (2008) compared motor inhibition abilities in ttm and ocd patients. reaction times were measured using a gonogo task among 25 ttm, 21 ocd, and 26 control obsessive-compulsive disorder 15 participants. the researchers reported no significant difference in reaction times among the ttm, ocd, and healthy control groups; however, there was a small portion of the ttm group that performed either “fast and inaccurate” or “slow and accurate.” this portion of the ttm group was associated with an earlier age of onset, suggesting a subgroup of ttm sufferers that experience increased motor inhibition. with that said, overall, findings do not represent a significant difference in reactions between individuals with ttm and ocd, and further work exploring motor inhibition in ttm and ocd is warranted. the neurological and genetic domain the neuroimaging data on ttm is limited (mataix-cols & van den heuvel, 2006; stein, 2000). researchers suggest the caudate nucleus, a brain structure implicated in ocd, is not significantly involved in trichotillomania. stein and colleagues (1997) compared caudate nucleus volumes in 13 ocd participants, 17 ttm participants, and 12 healthy controls. results showed no significant differences among the groups. in a study with 10 women with ttm, researchers found clomipramine (a tricyclic antidepressant often used in ocd) was negatively correlated with anterior cingulated and orbitofrontal metabolism. additionally, findings suggest that symptom severity of hair pulling is correlated with decreased perfusion in the frontal, partial, and strautum brain regions stein et al., 2002). these findings agree with prior neuroimaging work on ocd, suggesting that both ttm and ocd involve activity in similar brain regions, mainly the frontal regions (mataix-cols & van den heuvel, 2006; stein et al., 2002). bienvenu et al. (2000) found that cases of ttm were significantly higher in case probands than controls. ttm was shown to be transmitted in families of patients with ocd, and the disorder was the most prevalent in patients whose family members exhibited ocd. the researchers provided a lifetime prevalence of oc spectrum disorders for patients with ocd; ttm (4%) exhibited one of the highest lifetime prevalences (hollander, 1993). the treatment domain the leading psychosocial and psychopharmacological interventions for ttm are habit reversal therapy (hr), ssris, and clomipramine (bloch et al., 2007). bloch and colleagues (2007) conducted a meta-analysis assessing the individual effectiveness of hr for ttm participants as compared to controls. the researchers found a significant difference between the hr and waitlist/control group. these results are consistent with current literature concerning psychosocial treatment for ttm (hollander et al., 2008). in another study, 22 participants with ttm were involved in an open trial of individual cbt with an emphasis on relapse prevention. treatment was administered in two phases. the first phase consisted of active treatment in which individuals were provided with psychoeducation, strategies of competing responses training, and cognitive restructuring. this phase included cbt once a week for 8 weeks. the second phase consisted of four bi-weekly sessions focusing on relapse prevention. results showed that 77% of participants were classified as “treatment responder” and 32% were classified as “excellent responders.” results remained consistent at a 6-week follow up, with 66% of participants classified at “treatment responders,” and 32% considered “excellent responders” (tolin, franklin, diefenbach, anderson, & meunier, 2007). the results revealed that ttm, like ocd, responds positively to cognitive and behavioral treatments. in terms of psychopharmacological treatment, ssris appear to be an effective treatment for ttm. in a 12-week open-label trial of treatment with escitalopram, (ssri), 20 women were administered 10-30 mg/d of the medication. researchers found a 50% reduction from baseline in symptom severity (gadde, wagner ii, connor, & foust, 2007). however, based on a meta-analysis, bloch and colleagues (2007) suggest that there is little evidence for the efficacy of ssris for ttm when compared to controls. additionally, these researchers examined the effectiveness of clominpramine (a medication often used in the treatment of ocd) when compared to placebo control groups. results suggest that clominpramine is more effective when compared to the placebo control group. on whole, research has yielded mixed results regarding the similarities and differences of ttm and ocd in their response to ssri treatments. tourette’s disorder the symptom domain currently, tourette’s disorder (td) is classified based on diagnosis in infancy, childhood, or adolescence. td is marked by multiple motor and/or one or more vocal tics (american psychiatric association, 2000). the most familiar associated symptoms of td are obsessions and compulsions. obsessions are not present in all diagnosis of td; however, when present, obsessions tend to be similar to ocd, and might include obsessions of symmetry or exactness. compulsions are more persistent and, as in ocd, they are not pleasurable, but rather, are experienced as distressing and socially debilitating (american psychological association, 2000; hollander et al., 2008). in addition to a shared symptomology, motor stereotypy, a defining feature of td, is frequently also manifested in ocd (korff, stein, & harvey, 2008). the neurological and genetic domain the frontal-striatal cortex has been indicated in various disorders, including ocd and other perspective ocrds, such as td (mataix-cols & van den heuvel, 2006; stein, 2000). the basal-ganglia, caudate nucleus, and thalamus have been implicated in ocd and td (bartz & hollander, mancusi 16 2006; mataix-cols & van den heuvel, 2006). peterson and colleagues (2003) measured basal ganglia volumes using structural mris in 154 participants with td, including individuals with comorbid ocd under the condition that td preceded ocd, and 130 healthy controls. the researchers assessed regional specificity and abnormal asymmetries in the basal ganglia. results showed reduced volume in the caudate nucleus of the basal ganglia in participants with td when compared to controls. furthermore, individuals with comorbid td and ocd exhibited even smaller caudate nucleus volume than those with td alone. participants with comorbid td and ocd also showed an increase in tic symptom severity, suggesting that a similar brain region may be active in both ocd and td. using structural mris, peterson and colleagues (2001), examined prefrontal, parieto-occipital, and inferior occipital brain regions in 155 td and 131 health control participants. results were consistent with the previously mentioned study, showing decreased volume in the prefrontal region of the brain in participants with td. additionally, increased symptom severity was correlated with decreased volume in these regions. one of the most pertinent comparisons of td and ocd may be with respect to the neurochemistry of these disorders. research often points to the effectiveness of ssris and the role of the serotonin neurotransmitter system in ocd, however, the dopamine neurotransmitter system offers insight into the relationship between td and ocd, especially in regard to stereotypic behaviors (stein, 2000). korff, stein, and harvey (2008) examined stereotypic behaviors in deer mice to assess the role of the serotonin and dopamine neurotransmitter systems in ocd. the stereotypic behaviors were observed and baseline data was recorded. deer mice were then administered high and low doses of fluoxetine (an ssri). dopamine d2 receptor agonists were administered as well. results showed a significant decrease in stereotypic behavior in deer mice that received both high and lose doses of fluoxetine; the dose of the ssri was positively correlated with the decrease in symptom severity. additionally, states of spontaneous stereotypic behavior were lessened by dopamine d2 receptor agonists. on whole, results indicate that both the serotonin and dopamine neurotransmitter system may have an effect on the stereotypic behavior expressed in ocd and often in td. these results may also aid in psychopharmacological treatment of these disorders. tourette’s disorder is genetically transmitted through families (american psychiatric association, 2000). stein (2000) makes note that there is a strong genetic overlap between ocd and td. tics are seen more frequently in families of ocd probands, and ocd is more common in families with individuals with td than in control subjects. another study presents three case studies in which individuals with comorbid ocd and td expressed a similar chromosome 18 breakpoint; the breakpoint localized to the same chromosomal band in each of the cases presented (cuker, state, king, davis, & ward, 2003).while the sample size (18) used in this study was small, the data provide a promising start, and further research with individuals with comorbid ocd and td seems appropriate. the treatment domain while psychopharmacological treatments have been shown effective and are most often employed in the treatment of td, many patients refuse or discontinue medication (wilhelm et al., 2003). researchers have examined the effectiveness of psychosocial therapeutic approach such as habit reversal therapy. a randomized controlled study assessed the effectiveness of habit reversal therapy versus supportive therapy. participants with td were randomly assigned to 14 sessions of either habit reversal therapy (n = 16) of supportive therapy (n = 13). habit reversal contained awareness training, self-monitoring, relaxation, competing response training, and contingency management. all participants received weekly individual therapy sessions for the first 8 weeks, while the remaining sessions were administered bi-monthly. hr patients exhibited significantly lower tic severity scores than supportive therapy patients; tic symptoms in the supportive therapy group remained largely unchanged, while symptom severity was significantly reduced in the hr group. furthermore, hr participants showed significantly less functional impairment at 10-month follow-up compared to the supportive therapy group (wilhelm et al., 2003). in a replication of this study, deckersbach and colleagues (2006) found results similar to the initial experiment, further evidencing the effectiveness of hr for individuals with td. while hr is not explicitly employing all the components of cbt, it does implement behavioral strategies (e.g., selfmonitoring) utilized in cbt and erp. thus, both td and ocd respond well to treatments with a behavioral component. the leading psychopharmacological treatment for td is dopamine agonists, including haloperidol and pimozide; however, other dopamine antagonists, such as metoclopramide have proven efficacious in double-blind studies as well (nicolson, craven-thuss, smith, mckinlay, & castellanos, 2005). more recently, researchers examined the effects of aripiprazole, a partial dopamine agonist. in a pilot study, 14 children and adolescents with td were administered aripiprazole over the course of 8 weeks starting with a dose of 5 mg and increasing the dose by 5 mg every 1 to 2 weeks. results showed that more than half of the participants experienced at least a 30% improvement in tic severity, providing a positive foundation for future work which might also include other age groups. as mentioned above (td-the neurobiological domain), the stereotypic behaviors displayed in ocd appear to be related to the dopamine neurotransmitter system, and it does respond well to dopamine agonists, especially in the reduction of td like behaviors. obsessive-compulsive disorder 17 discussion the proposal of an obsessive compulsive related disorders category for the next edition of the dsm has significant implications for treatment and classification (castle & phillips, 2006). there exists a systematic approach in examining the proposed disorders in relation to ocd, mainly assessing similarities and differences in the (1) symptom domain, (2) the neurobiological domain, (3) and the treatment domain. while this approach elucidates similarities among ocd and the prospective ocrds, conclusive research is lacking. while ample research ties together the similarities between ocd, bdd, ttm, and td, as outlined above, findings rely heavily on observable symptoms. a variety of disorders not included in the prospective ocrds (e.g., impulse control disorder) display obsessions, compulsions, or both, and yet, are not under consideration for ocrd classification (hollander et al., 2008). similarly, as noted above, two of the more popular contenders for the ocrds, tmm and td, rarely include obsessions in their clinical presentation. additionally, demographic parameters, such as comorbidity and age of onset, may lack sufficient strength as a defining ocrd criterion. while ocd shares these features with many of the perspective ocrds, they are present with other anxiety disorders as well (bartz & hollander, 2006; hollander, et al., 2008). neurobiological studies lend to the comprehensive review of ocd and related disorders. however, a variety of brain regions are affected in ocd, and while ocd shows brain region abnormalities similar to bdd, ttm, and td, it shares abnormalities with existing anxiety disorders as well. for example, both ocd and social phobia express abnormalities in the limbic region of the brain (mataix-cols & van den heuvel, 2006). similarly, effective treatments for ocd such as cbt, erp, and ssris, have also proven to be efficacious for other anxiety disorders (bartz & hollander, 2006). the future classification ocrds proposes a spectrum model. yet, a more productive approach may be to consider symptomology, neurobiology, and treatment on a continuum as opposed to categories in which similarities and differences with ocd are dichotomously placed (castle & phillips, 2006). the current method of studying ocrds is to examine the similarities and differences between ocd and another disorder, and place the results into a “fix” or “no fix” category. if a continuum of symptomology, neurobiology, and treatment responses were created prior to conducting further research studies, perhaps data on the ocrds for the dsm-v would be more conclusive. conclusion the classification of ocd has undergone considerable changes over the past editions of the dsm. in fact, classification remains a concern for future editions of the dsm. researchers have offered evidence both in support of and against a new classification of this disorder (mataix-cols et al., 2007). however, the majority of current research is heavily focused on the prospective ocrds. in order to conclusively and confidently remove ocd from the anxiety disorders category, research comparing and contrasting ocd to both anxiety disorders and ocrds is warranted. further research on the classification of ocd as a spectrum disorder is recommended, especially since the literature remains preliminary and inconclusive. researchers have found similarities among ocd and the proposed oc spectrum disorders across various domains. while ocd and bdd appear to share the most putative symptoms, there still lacks conclusive evidence for the inclusion of this and other disorders such as, trichotillomania and tourette’s disorder in the oc spectrum. to develop a spectrum of disorders based on the symptom domain alone appears to be an oversimplification which neglects other possibilities. the existing research serves as a phenomenal starting point and needs to be built upon, especially in the areas of psychological and psychopharmacological treatment. for classification as a spectrum disorder, researchers need to replicate the studies that find biological, neurological, and treatment response similarities between ocd and the recommended ocd spectrum disorders. currently, there are few research studies directly comparing ocd to an ocrd. rather, ocd and ocrds are often indirectly connected through the comparison of separate research studies, and future work should employ samples consisting of both ocd and ocrd patients. a consistent methodology would offer a more accurate comparison of ocd and ocrds. continued research is needed to explore the many aspects of ocd and how these features are expressed across other potential ocd spectrum disorders. references american psychiatric association. 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(2005). effectiveness of cognitive therapy for obsessivecompulsive disorder: an open trial. journal of cognitive psychotherapy: an international quarterly, 19(5), 173179. 31 graduate student journal of psychology 2022, vol. 19 copyright 2022 by the department of counseling and clinical psychology teachers college, columbia university parents’ psychological adaptation after receiving a fetal diagnosis: a systematic review catherine r. gaspar, teachers college, columbia university a fetal diagnosis places an unexpected psychological burden on parents and triggers a complex pregnancy experience. parents who choose to continue the pregnancy have unique perspectives as they prepare for birth. it is crucial to understand these families’ experiences to inform their care and support. this qualitative systematic review explored the psychological adjustment of parents who continued gestation after they received a fetal diagnosis. a systematic database search was conducted with subsequent thematic analysis of fourteen included studies. parents experienced intense initial emotionƺǹ�ȗǔƺljƞǩȅǿș�ƞȅ�ƞǧǔ�ǐǩƺǡǿȅșǩș�ǩǿljǹȣǐǩǿǡ�șǧȅljƿ�ƺǿǐ�ǡȗǩǔǟॹ�ǟȅǹǹȅλǔǐ�ljρ�ƺ�ljȅǿȓǹǔπ�ȓȗȅljǔșșǩǿǡ�ȓǔȗǩȅǐ�ǩǿмȣǔǿljǔǐ�ljρ�ȓǔȗșȅǿƺǹ� ƺǿǐ�șȅljǩƺǹ�ǟƺljƞȅȗșঀ�eǧǔ�йǿǐǩǿǡș�ǐǔǿȅǿșƞȗƺƞǔ�ƺ�ǿǔǔǐ�ǟȅȗ�ǩǿȓȗȅκǔǐ�ǿȣǹƞǩǐǩșljǩȓǹǩǿƺȗρ�ȓƺȗǔǿƞƺǹ�șȣȓȓȅȗƞ�ǟȅȗ�ǟƺǿǩǹǩǔș�λǧȅ�ȗǔceive a fetal diagnosis and add rationale for the addition of psychological services to the care teams of prospective parents. keywords: prenatal, fetal diagnosis, pregnancy, parents, emotions, process pregnancy is a time of major life adjustment for any parent. parents who undergo typical pregnancies experience changes in lifestyles, emotions, and identities (edvardsson et al., 2011). pregnancies that receive a fetal diagnosis place an additional psychological burden on prospective parents, especially at the time ȅǟ� ǩǿǩƞǩƺǹ� ǩǐǔǿƞǩйljƺƞǩȅǿ� শκƺǿ� ǐǔȗ� ^ƞǔǔǿ� ǔƞ� ƺǹঀॹ� �ষঀࢷࢲࢱࢳ these stressors continue after birth as the family shifts into living daily life with the infant and their specific developmental needs (woolf-king et al., 2017). due to advances in technologies, such as noninvasive methods, prenatal screenings have become standard in much of the developed world (pös et al., 2019; who, 2012). these screenings are generally accepted and perceived as necessary by parents (aune & möller, 2010, ekelin et al., 2016), and receiving positive, on-track information about their unborn child’s development can contribute to a positive pregnancy experience (richter et al., 2020; wittman et al., 2016). however, the widespread use of modern screening technologies also means greater detection of prenatal conditions such as birth defects or genetic disorders (carlson & vora, 2017). reports show that about one in 33 births is complicated by a birth defect (cdc, 2008) which can often result in physical or mental disabilities (boyle & cordero, 2005). due to advances in technologies, such as noninvasive methods, prenatal screenings have become standard in much of the developed world (pös et al., 2019; who, 2012). these screenings are generally accepted and perceived as necessary by parents (aune & möller, 2010, ekelin et al., 2016), and receiving positive, on-track information about their unborn child’s development can contribute to a positive pregnancy experience (richter et al., 2020; wittman et al., 2016). however, the widespread use of modern screening technologies also means greater detection of prenatal conditions such as birth defects or genetic disorders (carlson & vora, 2017). reports show that about one in 33 births is complicated by a birth defect (cdc, 2008) which can often result in physical or mental disabilities (boyle & cordero, 2005). � �� ǟǔƞƺǹ� ǐǩƺǡǿȅșǩș� ǩș� ǐǩгljȣǹƞ� ǿǔλș� ǟȅȗ� ǟƺǿǩǹǩǔș� to receive. while many families decide to terminate these pregnancies (hawkins et al., 2012), some families decide to continue. in recent years, rates of continued pregnancy after receiving a fetal diagnosis have increased (madeuf et al., 2016). the decision to continue a pregnancy is multifaceted. for many parents it is an ethical dilemma, with worries over playing god and wanting the pregnancy to occur naturally, or they feel a sentimental attachment to the fetus (winn et al., 2018). the timing of diagnosis also matters. parents farther along in gestation have a greater likelihood of choosing to continue the pregnancy (madeuf et al., 2016; michalik & preis, 2013; winn et al., 2018). additionally, diagnosis severity and other variables play a role, where less severe fetal diagnoses and conditions with a history of greater postnatal success have a higher likelihood of pregnancy continuation (hawkins et al., 2012; madeuf et al., 2016; winn et al., 2018). other socio-contextual factors such as parental education, race, ǡǔȅǡȗƺȓǧǩlj� ǹȅljƺƞǩȅǿॹ�ƺǿǐ�йǿƺǿljǔș�ƺǹșȅ� ǩǿȓƺljƞ�ƞǧǔ�ǐǔcision (hawkins et al., 2012; michalik & preis, 2013). for parents, the decision to continue pregnancy rather than terminate may improve their psychologǩljƺǹ�ȅȣƞljȅǿǔș� শ�ȅȓǔ� ǔƞ� ƺǹঀॹ� �ষॹࢶࢲࢱࢳ ƺ� ljȗȣljǩƺǹ�ljȣаǔȗ� ƺș� prospective parents already face vulnerabilities to their 32 mental health during pregnancy (cindy-lee et al., 2017; condon et al., 2004; davalos et al., 2012). in typical pregnancies, factors such as lower socioeconomic șƞƺƞȣșॹ�йǿƺǿljǩƺǹ�ǧƺȗǐșǧǩȓșॹ�ρȅȣǿǡǔȗ�ǿƺƞǔȗǿƺǹ�ƺǡǔॹ�ƺǿǐ� histories of prior mental health struggles, put women at an increased risk for mental health conditions such as depression (rich-edwards et al., 2006). lower social support is also a risk factor; parents with low social support may lack social networks which can provide advice, information, and reduce negative emotions that may result from stressors (bedaso et al., 2021). however, many factors can act protectively for prospective parents’ psychological health, such as high social support which may promote psychological well-being (corno et al., 2022). a qualitative study on public health clinics found that pregnant mothers utilized friendships to manage stress and relieve tension through venting and laughing together (abdou et al., 2010). similarly, relationship quality and partner support act as protective factors. involved partners and șƞȗȅǿǡ� ȗǔǹƺƞǩȅǿșǧǩȓș� ǧƺκǔ� ljǔǔǿ� ǟȅȣǿǐ� ƞȅ� ljǔǿǔйƞ�ǿƺternal well-being for mothers undergoing typical pregnancies (rini & dunkel schetter, 2010). other literature on typical pregnancies has demonstrated that social support, family functioning, and relationship șƺƞǩșǟƺljƞǩȅǿ� ljȣаǔȗǔǐ� ǹǩǿƿș� ljǔƞλǔǔǿ� șƞȗǔșșǟȣǹ� ǔκǔǿƞș� and depression (divney et al., 2012). in recent work ȅǿ�șȓǔljǩйlj�șƞȗǔșșǟȣǹ�ǹǩǟǔ�ǔκǔǿƞșॹ�șȣljǧ�ƺș�ƞǧǔ��kt2�েࢺࢲ� pandemic, support from partners, social networks, ƺǿǐ�ǧǔƺǹƞǧljƺȗǔ�ȓȗȅκǩǐǔȗș�λƺș�ǩǐǔǿƞǩйǔǐ�ƺș�ȓǹƺρǩǿǡ�ȓȗȅtective roles in the mental health of pregnant women (khoury et al., 2021; vacaru et al., 2021). further support can stem from parents’ mindsets. pregnant women who engaged in emotion-focused coping in early and middle pregnancy had lower distress (huizink et al., 2002), and those with more positive cognitive appraisal in stressful life events like covid-19 had less mental health problems (khoury et al., 2021). utilization of belief systems like religion or spirituality as a source of guidance or comfort has also been suggested as helpful factors (abdou et al., 2010). further support of mental health vulnerabilities in pregnancy may be the receipt of psychological services (kinser et al., 2021; urizar et al., 2019), yet currently, many prospective parents undergoing typical pregnancies struggle to access adequate psychological services (schwartz et al., 2021). pilot intervention programs have been implemented to facilitate access to services (slade et al., 2021), yet less is known about ȣǿǩκǔȗșƺǹ�ȅȗ�ljȗȅƺǐǔȗ�ǔаȅȗƞșঀ�^ȣȓȓȅȗƞǩǿǡ�ƞǧǔ�șȓȗǔƺǐ�ȅǟ� information, the internet has helped aid parents to access informational resources (fleming et al., 2014) recent years have seen the development and utilization of e-mental health tools, where parents use web-based strategies for the delivery or enhancement of mental health information and services (fonseca et al., 2016). for high-risk pregnancies, including those with fetal diagnoses, formal social supports (e.g., targeted support networks within peers or practitioner-facilitated ǡȗȅȣȓșষ� ƺȗǔ� ƺǹșȅ� ǐȅljȣǿǔǿƞǔǐ� ƺș� ǔаǔljƞǩκǔ� ȗǔșȅȣȗljǔș� শ�ȅаǿƺǿ� ૭� [ƺρॹ� �আࢳࢱࢱࢳ ?ȣǡǹǔȗ� ૭� 'ƺȗǿǔȗॹ� �ষঀࢶࢲࢱࢳ it is important to note that culture is an important factor when considering the emotional well-being, coping, and resources of parents (cindy-lee et al., 2017; dunkel schetter, 2011). the availability of resources and reasons for seeking support varies across cultures and geographic regions (baron et al., 2015; dunkel schetter, 2011; tol et al., 2018), yet further knowledge is needed on parent emotional processing and use of supports across cultures. similarly, much of the work on the emotional well-being, emotional processing, and subsequent resources for prospective parents has been performed with typical pregnancies, however, less is known on these topics for those with high-risk pregnancies such as fetal diagnoses. these parents may have unique needs and experiences (van der steen et al., 2016), thus further exploration of their emotional process and ƞǧǔ� ǟƺljƞȅȗș� λǧǩljǧ� ǩǿмȣǔǿljǔ� ƞǧǩș� ȓȗȅljǔșș� ǩș� ǿǔǔǐǔǐঀ� a prenatal diagnosis vastly shifts parents’ perspectives of pregnancy (horsch et al., 2013). other reviews have explored this phenomenon, but none have focused solely on the emotional processing and acclimation of parents who decided to continue their pregnancy. lou and colleagues (2017) completed a thorough review of parent responses to prenatal diagnosis that included studies with both continued and terminated pregnancies. johnson and colleagues (2020) performed a comprehensive review of prospective parǔǿƞșঢ়�κǩǔλș�λǧǔǿ�ƺ�ǟǔƞƺǹ�ƺljǿȅȗǿƺǹǩƞρ�λƺș�ǩǐǔǿƞǩйǔǐ�ljȣƞ� focused solely on anomalies detected via ultrasound and included insights from healthcare professionals. � xȗǩȅȗ� ȗǔκǩǔλș� ȅаǔȗ� ǩǿȓȅȗƞƺǿƞ� ǩǿșǩǡǧƞș� ȅǿ� ȓƺȗents and prenatal diagnosis, but additional work is ǿǔǔǐǔǐ�ȅǿ� ƞǧǔ�ȓșρljǧȅǹȅǡǩljƺǹ� șƞƺƞǔ� ƺǿǐ� ǔπƞǔȗǿƺǹ� ǩǿмȣences for parents who continue these pregnancies to gaspar 33 parent psychological adaptation better understand parents of infants with atypical development. as such, the present systematic review aimed to synthesize the prenatal emotional adjustment of parents who continued pregnancy after reljǔǩκǩǿǡ�ƺ� ǟǔƞƺǹ�ǐǩƺǡǿȅșǩș�ƺǿǐ� ƞȅ� ǩǐǔǿƞǩǟρ� ǟƺljƞȅȗș� ǩǿмȣencing their emotional responses to the diagnosis. methods search procedures this review was conducted in accordance with the preferred reporting items for systematic reκǩǔλș� ƺǿǐ� eǔƞƺ৉�ǿƺǹρșǔș� শx[2^e�ষ� ǡȣǩǐǔǹǩǿǔșঀ� the search strategy utilized spider, a search tool for qualitative research (cooke et al., 2012). spi��[� ǩǐǔǿƞǩйǔș� ƞǧǔ� শ^ষ� șƺǿȓǹǔ� șƞȣǐǩǔǐ� শ৚ȓƺȗǔǿƞșॹ� prospective parents”), (pi) phenomenon of interest (“prenatal diagnosis, prospective pregnancy”), (d) targeted study design (“interview, survey”), (e) evaluation of the phenomenon (“experiences, perceptions”), and (r) type of research (“qualitative”). inclusion criteria included studies were peer-reviewed original empirical works from any country that focused on the experiences of current or prospective parents (e.g., mother, father, familial caregivers) who continued their pregnancy after receiving a fetal diagnosis. included studies focused on the prenatal period during and after the diagnosis, but prior to birth. if studies included both preand post-natal diagnoses, only prenatal data was used. fetal diagnosis was conceptualized as an abnormality which would impact the child’s post-birth functioning, development, or health. parents were conceptualized as any primary caregiver of the child in the perinatal period. studies needed to utilize parent-reported qualitative data (e.g., solely qualitative articles or qualitative sections of articles using mixed methods) and be written in english. exclusion criteria studies were excluded if they used solely quantitative methods or were not published in a peer-reviewed journal. studies with quantitative data were excluded from the present review as the focus was to provide an in-depth synthesis of parent experiences and emotions, a level of depth often better captured by qualitative data as it highlights lived experiences of participants while quantitative approaches aim to quantify and order participant data (ponterotto, 2002). studies with samples that included only stakeholders and no primary caregivers were excluded. studies that included parent perspectives of terminated or miscarried pregnancies, or postnatally administered diagnoses, were also excluded. studies were excluded that only focused on parents’ postnatal experiences, or only detailed parǔǿƞșঢ়�ȓȗǔǿƺƞƺǹ�ǔπȓǔȗǩǔǿljǔș�ȓȗǩȅȗ�ƞȅ�ƺǿ�ȅгljǩƺǹ�ǐǩƺǡǿȅșǩșঀ� study selection study selection is summarized in table 1. the selection process consisted of two stages. first, databases were searched using search terms and screened based on titles and abstracts. next, full texts of eligible studies were read and eligibility criteria were applied, resulting in the inclusion of ten publications. a manual search of reference lists and library ȗǔșȅȣȗljǔș� ǩǐǔǿƞǩйǔǐ� ǟȅȣȗ� ǿȅȗǔ� ǔǹǩǡǩljǹǔ� ȓƺȓǔȗșॹ� ȗǔsulting in the inclusion of 14 total publications. quality appraisal methodological quality of included studies was assessed by the author using the critical appraisal skills programme (casp) qualitative appraisal tool (critical appraisal skills programme, 2018). the casp tool evaluates based on criteria from three sections consisting of a total of ten items: a) are the results of the study valid? (e.g., items 1) was there a clear statement of the aims of the research? 2) is a qualitative methodology appropriate? 3) was the research design appropriate to address the aims of the research? 4) was the recruitment strategy appropriate to the aims of the research? 5) was the data collected in a way that addressed the research issue? 6) has the relationship between the researcher and participants been adequately considered?), b) what are the results? (e.g., items 7) have ethical issues been taken into considerƺƞǩȅǿঁ� �ষ�vƺșࢹ ƞǧǔ� ǐƺƞƺ� ƺǿƺǹρșǩș� șȣгljǩǔǿƞǹρ� ȗǩǡȅȗȅȣșঁ� �ষ�2ș�ƞǧǔȗǔ�ƺ�ljǹǔƺȗ�șƞƺƞǔǿǔǿƞ�ȅǟ�йǿǐǩǿǡșঁষॹ�ƺǿǐ��ষ�vǩǹǹࢺ the results help locally? (e.g., item 10) how valuable is the research?). each item was rated yes, can’t tell, or no. after rating, each item was assigned a point value (i.e., yes = 2, can’t tell = 1, no = 0) and items were totaled with 20 as the maximum possible score. studies receiving a score of 17 or higher were classiйǔǐ� ƺș� ǧǩǡǧ� ǿǔƞǧȅǐȅǹȅǡǩljƺǹ� ȕȣƺǹǩƞρॹ� șljȅȗǔș� ljǔƞλǔǔǿ� 16 and 14 as moderate methodological quality, and 13 or below as lesser methodological quality. no stud 34 ies were excluded because of the appraisal (table 1). data synthesis this review utilized thematic analysis (thomas & harden, 2008) which allowed results of the included ȓȣljǹǩljƺƞǩȅǿș�ƞȅ�ljǔ�șρǿƞǧǔșǩφǔǐঀ�^ȓǔljǩйljƺǹǹρॹ�ƞǧǔ�ƺǿƺǹρsis procedures employed a thematic synthesis approach outlined by thomas and harden (2008) which allows ǟȅȗ�ƺǿ�ǔаǔljƞǩκǔ�ƞȗƺǿșǹƺƞǩȅǿ�ȅǟ�ljȅǿljǔȓƞș�ƺǿǐ�ljȅǿǿǔljƞǩȅǿ� ȅǟ�ȕȣƺǹǩƞƺƞǩκǔ�ȗǔșǔƺȗljǧ�йǿǐǩǿǡșঀ�eǧǔ�ƞǧǔǿƺƞǩlj�șρǿƞǧǔșǩș� guidelines were used to generate and identify themes and subthemes. first, included studies were read multiple times and notes were taken of initial ideas for coding. next, the qualitative results sections of each study were reviewed and coded into a set of initial, broad codes. data relevant to each code was extracted and sorted under the respective code. codes were inductively developed and added to as needed, resulting in a set of overarching themes (e.g., initial reactions, processing period, social factors, and coping stratǔǡǩǔșষ�λǧǩljǧ�λǔȗǔ� ljǧǔljƿǔǐ� ǟȅȗ�йƞ�λǩƞǧ� ƞǧǔ�ǐƺƞƺ� ƞǧǔǿ� ǐǔйǿǔǐ�ƺǿǐ�ǿƺǿǔǐঀ�'ȗȅǿ�ǧǔȗǔॹ�ǐƺƞƺ�ȣǿǐǔȗ�ǔƺljǧ�ƞǧǔǿǔ� was reviewed and sorted further into narrower subthemes under each broader theme. subthemes were ȗǔκǩǔλǔǐ�ƺǿǐ�ȗǔйǿǔǐ�ǟȅȗ�йƞ�λǩƞǧǩǿ�ƞǧǔ�ljȗȅƺǐǔȗ�ƞǧǔǿǔșঀ results the 14 included studies were conducted in a range ȅǟ�ljȅȣǿƞȗǩǔșॸ�йκǔ� ǟȗȅǿ�ƞǧǔ�hǿǩƞǔǐ�^ƞƺƞǔșॹ� ƞǧȗǔǔ� ǟȗȅǿ� australia, two from sweden, one from denmark, one from ireland, one from south korea, and one from the united kingdom. the studies included a total of 251 primary caregivers, including 173 mothers, 67 fathers, nine grandparents, and two undisclosed sexes. while included studies varied in aims, qualitative design, and distinct focus, all examined parents’ insight and experiences after receiving a prenatal diagnosis. based on the thematic analysis (thomas & harden, 2008), the synthesized results show that emotional adjustment to a fetal diagnosis was an ongoing process characterized by two main timepoints: initial diagnosis and processing period. table 2 details a summary of themes and corresponding studies. parents experiǔǿljǔǐ� ǐǩаǔȗǔǿƞ� ȓǔȗșȓǔljƞǩκǔș� ǐǔȓǔǿǐǩǿǡ� ȅǿ� ƞǧǔ� ƞǩǿǔpoint. they reported early emotions at the time of diagnosis, then shifted emotions as they underwent the processing period. while families consistently reacted strongly to the initial diagnosis, these emotions were not homogenous and shifted as parents adjusted to the news. individual parent experiences of the ȅκǔȗƺǹǹ� ƺǐǵȣșƞǿǔǿƞ� ȓȗȅljǔșș� λǔȗǔ� ǩǿмȣǔǿljǔǐ� ljρ� ƞλȅ� main factors: interactions with others and coping strategies. figure 2 models parents’ emotional process. initial reactions. parents reported a range of ǔǿȅƞǩȅǿș� λǧǔǿ� ƞǧǔρ� йȗșƞ� ȗǔljǔǩκǔǐ� ƞǧǔ� ǟǔƞƺǹ� ǐǩƺǡǿȅsis. most parents described intense shock when they received the news (carlsson et al., 2017; clark et al., �আ�(ȅаࢲࢲࢱࢳ�আ��ȉƞǔে�ȗșǔǿƺȣǹƞ�૭��ǔǿǿǔρে?ȅǔǹșljǧॹࢱࢳࢱࢳ et al., 2013; hickerton et al., 2011; how et al., 2019; im et al., 2018; johnson et al., 2018; lokmic et al., 2017; mckechnie & pridham, 2012; o’connell et al., �ষ�ƺǿǐ�ǐǔșljȗǩljǔǐ�ǧȅλ�ƞǧǩș�șǧȅljƿ�ǿƺǐǔ�ǩƞ�ǐǩгljȣǹƞࢺࢲࢱࢳ to grasp the diagnosis (carlsson et al., 2017). shock λƺș� ǔșȓǔljǩƺǹǹρ� șƺǹǩǔǿƞ� ǩǿ� йȗșƞেƞǩǿǔ� ǿȅƞǧǔȗș� শkঢ়�ȅǿnell et al., 2019). parents also reported grief, sadness, and mourning (carlsson et al., 2015; carlsson et al., 2017; clark et al., 2020; côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011; how et al., 2019; im et al., 2018; johnson et al., 2018; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019). they described intense ǔǿȅƞǩȅǿƺǹ� șȣаǔȗǩǿǡ� ƺǿǐ� ǐǔκƺșƞƺƞǩȅǿ� শ�ƺȗǹșșȅǿ� ǔƞ� ƺǹঀॹ� 2015; clark et al., 2020; im et al., 2018; mckechnie & pridham, 2012; o’connell et al., 2019), and felt a deep sense of loss surrounding their original expectations for the child and pregnancy (côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011; johnson et al., 2018; lou et al., 2020; mckechnie et al., 2015). � �� ȓȅȗƞǩȅǿ� ȅǟ� ȓƺȗǔǿƞș� ǟǔǹƞ� ƺǿǡǔȗ� λǧǔǿ� ƞǧǔρ� йȗșƞ� ǧǔƺȗǐ�ƞǧǔ�ǐǩƺǡǿȅșǩș�শ�ƺȗǹșșȅǿ�ǔƞ�ƺǹঀॹࢸࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹ� 2013) while others felt confused (carlsson et al., 2015; hickerton et al., 2011; im et al., 2018; mckechnie & xȗǩǐǧƺǿॹ� �ষঀࢶࢲࢱࢳ eǧǔρ� ȕȣǔșƞǩȅǿǔǐ� λǧρ� শ(ȅа� ǔƞ� ƺǹঀॹ� 2013; mckechnie & pridham, 2012) and felt the diagnosis did not make sense (carlsson et al., 2015; im et al., 2018). many parents also reported fear and anxiety (carlsson et al., 2015; im et al., 2018; johnson et al., 2018; lokmic et al., 2017; lou et al., 2020; mckechnie et al., 2015). some were fearful of fetal loss or worsening of the condition (carlsson et al., 2015; mckechnie et al., 2015), while others experienced panic about the future (im et al., 2018; lou et al., 2020). parents also reported feelings of guilt (carlsson et al., 2017; clark et al., 2020; côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011; im et al., 2018; lokmic et al., 2017). many felt guilt for potentially causing the gaspar 35 parent psychological adaptation anomaly (carlsson et al., 2017; côté-arsenault & denney-koelsch, 2011; lokmic et al., 2017), while others felt moral guilt in considering whether to terminate the pregnancy (im et al., 2018; hickerton et al., 2011). for some parents, guilt was compounded with other emotions, like guilt about their sadness or hope for a false-positive diagnosis (carlsson et al., 2017; clark et al., 2020; côté-arsenault & denney-koelsch, 2011). overall trends during the processing period. adjusting to the diagnosis was a process for parents. they overwhelmingly reported gratitude in receiving the diagnosis prenatally versus postnatally (carlsson et al., 2015; carlsson et al., 2017; clark et al., 2020; �ȉƞǔে�ȗșǔǿƺȣǹƞ�૭��ǔǿǿǔρে?ȅǔǹșljǧॹࢲࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹ� 2013; hickerton et al., 2011; how et al., 2019; im et al., 2018; johnson et al., 2018; lokmic et al., 2017; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019) as this gave them time to prepare. however, after receiving the diagnosis, parents felt they needed time to digest the ǿǔλș�শ�ǹƺȗƿ�ǔƞ�ƺǹঀॹࢱࢳࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢴࢲࢱࢳ�আ�/ȅλ�ǔƞ�ƺǹঀॹ� 2019; mckechnie & pridham, 2012). in this processing period, they shifted their thoughts and feelings toward the future (carlsson et al., 2015; carlsson et al., �আ�/ǩljƿǔȗƞȅǿࢴࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢱࢳࢱࢳ�আ��ǹƺȗƿ�ǔƞ�ƺǹঀॹࢸࢲࢱࢳ et al., 2011; how et al., 2019; im et al., 2018; johnson et al., 2018; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015). as they looked ahead, most described an acceptance of the diagnosis (carlsson et al., 2015; carlsson et al., 2017; clark et al., �আ�/ȅλࢲࢲࢱࢳ�আ�/ǩljƿǔȗƞȅǿ�ǔƞ�ƺǹঀॹࢴࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢱࢳࢱࢳ et al., 2019; im et al., 2018; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015). many felt having time to process emotions helped their acljǔȓƞƺǿljǔ� শ�ǹƺȗƿ� ǔƞ� ƺǹঀॹ� �আ�/ȅλࢱࢳࢱࢳ ǔƞ� ƺǹঀॹ� �আ�(ȅаࢺࢲࢱࢳ et al., 2013; mckechnie & pridham, 2012), and used this time to reframe their original expectations of the child, future parenting, and life milestones (hickerton et al., 2011; mckechnie et al., 2015). parents began to celebrate and see their unborn baby as any other child, with individuality, personality, and hardships that all ȓƺȗǔǿƞș� ǟƺljǔ� শ(ȅа�ǔƞ� ƺǹঀॹ� �আ�/ȅλ�ǔƞࢴࢲࢱࢳ ƺǹঀॹ� �আࢺࢲࢱࢳ 2ǿ� et al., 2018; lou et al., 2020; mckechnie et al., 2015). despite acceptance of their future child and circumstances, most parents reported ongoing anxieties during the processing period (carlsson et al., 2015; �ƺȗǹșșȅǿ� ǔƞ� ƺǹঀॹ� �আ��ǹƺȗƿࢸࢲࢱࢳ ǔƞ� ƺǹঀॹ� �আ�(ȅаࢱࢳࢱࢳ ǔƞ� ƺǹঀॹ� 2013; hickerton et al., 2011; how et al., 2019; im et al., 2018; johnson et al., 2018; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019). worries focused on the current pregnancy and the remaining gestational development of their child (carlsson et al., 2017; how et al., 2019; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015). other fears revolved around the future. parents were uncertain about the outlook for themselves and their child (carlsson et al., 2015; �ƺȗǹșșȅǿ� ǔƞ� ƺǹঀॹ� �আ��ǹƺȗƿࢸࢲࢱࢳ ǔƞ� ƺǹঀॹ� �আ�(ȅаࢱࢳࢱࢳ ǔƞ� ƺǹঀॹ� hickerton et al., 2011; 2013; johnson et al., 2018; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015). they worried about navigating the new ǩǿмȣπ� ȅǟ� ǩǿǟȅȗǿƺƞǩȅǿ� ƺǿǐ� ǿǔǔƞǩǿǡ� ƞǧǔǩȗ� ljǧǩǹǐঢ়ș� ǟȣture needs, such as medical and other support services (carlsson et al., 2017; clark et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015). many felt societal pressures such as the expectation to produce a healthy child (im et al., 2018), the impact of a child with a disability on family functioning (carlsson et al., �আ�@ȅȣ�ǔƞࢴࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢸࢲࢱࢳ�আ��ƺȗǹșșȅǿ�ǔƞ�ƺǹঀॹࢶࢲࢱࢳ al., 2020), and their child’s future social experiences including stigma and social milestones (clark et al., 2020; johnson et al., 2018; lou et al., 2020; mckechnie et al., 2015). parents also reported uncertainty in their social functioning, especially when interacting λǩƞǧ�ȓƺȗǔǿƞș�ȅǟ� ƞρȓǩljƺǹǹρ�ǐǔκǔǹȅȓǔǐ�ljǧǩǹǐȗǔǿ�শ(ȅа�ǔƞ� al., 2013; hickerton et al., 2011; johnson et al., 2018). though anxious, parents reported a newfound bond with their unborn child (carlsson et al., 2017; côté-arsenault & denney-koelsch, 2011; im et al., 2018; lou et al., 2020; mckechnie et al., 2015; o’connell et al., 2019). as they accepted their child, they described a strong sense of love and attachment and felt an increasing connection that strengthened their parental duty and commitment (carlsson et al., 2017; im et al., 2018; lou et al., 2020; mckechnie et al., 2015; o’connell et al., 2019). they saw their baby as an individual, and desired for others to view their child the same way (côté-arsenault & denney-koelsch, 2011; how et al., 2019; im et al., 2018; o’connell et al., 2018). filled with acceptance and love, parents reported feelings of positivity and hope as they progressed through the pregnancy (clark et al., 2020; im et al., 2018; mckechnie & pridham, 2012; mckechnie et al., 2015). � 2ǿмȣǔǿljǩǿǡ� ǟƺljƞȅȗș. despite consistent overall trends, parents did not all follow the same rate of adjustment during the processing period. some had 36 a slower adjustment and others rebounded from the ǐǩƺǡǿȅșǩș�ȕȣǩljƿǹρঀ�^ȅǿǔ�ǧƺǐ�ƺ�ȓȅșǩƞǩκǔॹ�ǟȣǹйǹǹǩǿǡ�ȓȗǔǡnancy, while others felt more cynical and distanced. emergent themes evidenced that experiences were shaped by outside factors. throughout included studies, parents mentioned multifaceted details in social interactions and coping strategies which contributed to their pregnancy experience and acclimation process. social interactions with others medical professionals. medical professionals ranged from doctors, nurses, doulas, and other pregǿƺǿljρ� șȣȓȓȅȗƞ� șƞƺаঀ� ^ȅǿǔ� ȓƺȗǔǿƞș� ǐǔκǔǹȅȓǔǐ� ljǹȅșǔ� relationships with their healthcare professionals and communicated with them frequently after receiving the diagnosis (mckechnie & pridham, 2012; mckechnie et al., 2015). these parents had a select few which they trusted and looked to for support (carlsson et al., �আ�@ȅȣ�ǔƞࢲࢲࢱࢳ�আ�/ǩljƿǔȗƞȅǿ�ǔƞ�ƺǹঀॹࢴࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢶࢲࢱࢳ al., 2020). they appreciated their knowledge and advice relating to the pregnancy and diagnosis (carlsson et al., 2015; côté-arsenault & denney-koelsch, 2011, hickerton et al., 2011; how et al., 2019; im et al., 2018; mckechnie et al., 2015; o’connell et al., 2019). parǔǿƞș�λǔȗǔ�ǔșȓǔljǩƺǹǹρ�șƺƞǩșйǔǐ�λǧǔǿ�ǿǔǐǩljƺǹ�ȓȗȅǟǔșșǩȅǿals listened and supported their decisions and felt most at ease getting continuous care from their trusted team (carlsson et al., 2015; hickerton et al., lou et al., 2020). however, many parents in included studies overwhelmingly reported negative experiences with medical professionals after the diagnosis. they reported that healthcare professionals had pessimistic attitudes and delivered diagnostic news poorly (carlsson et al., 2015; clark et al., 2020; côté-arsenault & denǿǔρে?ȅǔǹșljǧॹ� �আࢲࢲࢱࢳ (ȅа� ǔƞ� ƺǹঀॹ� �আࢴࢲࢱࢳ /ǩljƿǔȗƞȅǿ� ǔƞ� al., 2011; im et al., 2018; johnson et al., 2018; lokmic et al., 2017; lou et al., 2020; mckechnie et al., 2015; o’connell et al., 2019). parents felt providers held negative stereotypes about disabilities and routinely pushed for a termination of pregnancy, often ǿƺƿǩǿǡ�ȗǔȓǔƺƞǔǐ�ljȅǿǿǔǿƞș�ƺljȅȣƞ�ƞǔȗǿǩǿƺƞǩȅǿ�শ(ȅа� et al., 2013; hickerton et al., 2011; how et al., 2018; johnson et al., 2018; lokmic et al., 2017; lou et al., 2020). many parents described medical professionals as grim, unemotional, and uncompassionate in their ljƺȗǔ� শ�ǹƺȗƿ� ǔƞ� ƺǹঀॹ� �আ�(ȅа�ǔƞࢱࢳࢱࢳ ƺǹঀॹ� �আ�@ȅȣ�ǔƞࢴࢲࢱࢳ ƺǹঀॹ� 2020), and recounted hurtful, inappropriate remarks from providers about their babies and choices (johnson et al., 2018; mckechnie et al., 2015; o’connell et al., 2019). parents felt the professionals lacked crucial knowledge and resources about the diagnoses and were inconsistent in the advice and information they shared (carlsson et al., 2015; carlsson et al., 2017; côté-arseǿƺȣǹƞ�૭��ǔǿǿǔρে?ȅǔǹșljǧॹࢲࢲࢱࢳ�আ�(ȅа�ǔƞ�ƺǹঀॹࢴࢲࢱࢳ�আ�=ȅǧǿson et al., 2018; lokmic et al., 2017; lou et al., 2020). often, unannounced specialists attended appointments, which made parents increasingly anxious and distrustful (johnson et al., 2018; lokmic et al., 2017). friends and family. family and friends ranged from immediate and extended family to circles of friends. parents’ social networks were important sources of support during the pregnancy (carlsson et al., 2017; clark et al., 2020; côté-arsenault ૭� �ǔǿǿǔρে?ȅǔǹșljǧॹ� �আࢲࢲࢱࢳ (ȅа� ǔƞ� ƺǹঀॹ� �আࢴࢲࢱࢳ /ǩljƿerton et al., 2011; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019). parents retreated to their trusted, inner social circles after the diagnosis (clark et al., 2020; mckechnie & pridham, 2012; o’connell et al., 2019), and relied on them to listen and help with practical needs (carlsson et al., 2017; mckechnie & pridham, 2012). however, not all of the parents’ social groups were accepting or helpful (carlsson et al., 2017; clark et al., 2020; côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011; how et al., 2019; mckechnie et al., 2015; o’connell et al., 2019). parents felt family and friends were not always supportive (côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011; mckechnie et al., 2015). parents received insensitive remarks and felt pressured by others to terminate the pregnancy (hickerton et al., 2011; how et al., 2019; o’connell et al., 2019). many friends and family members were unsure how to respond to the diagnosis, while others refused to accept the pregnancy or unborn baby (clark et al., 2020; côté-arsenault & denney-koelsch, 2011; hickerton et al., 2011). parents felt lonely, isolated, and stigmatized, and felt others could no longer relate to them (côté-arsenault & denney-koelsch, 2011; mckechnie et al., 2015, o’connell et al., 2019). they underwent a great divide in their personal and social experiences and reported the distancing and changing of friendships (carlsson et al., 2017; côté-arsenault & denney-koelsch, 2011; mckechnie et al., 2015). gaspar 37 parents’ coping strategies research and information-gathering. most ȓƺȗǔǿƞș�ǟǔǹƞ�ƺ�ǿǔǔǐ�ƞȅ�йǿǐ�ǩǿǟȅȗǿƺƞǩȅǿ�ȅǿ�ƞǧǔ�ǐǩƺǡǿȅsis, which they did through personal research. they tried to educate themselves and build their knowledge as much as possible so they could be prepared for the future (carlsson et al., 2015; carlsson et al., 2017; clark et al., 2020; im et al., 2018; johnson et al., 2018; lokmic et al., 2017; lou et al., 2020; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019). some found this strategy helpful and attained valuable information on their baby’s condition (carlsson et al., 2015; im et al., 2018; lou et al., 2020; mckechnie & pridham, 2012), while others found it overwhelming and confusing due to the large quantity of resources, much of it negative or outdated (carlsson et al., 2015; clark et al., 2020; lokmic et al., 2017; mckechnie & pridham, 2012; mckechnie et al., 2015). experiential knowledge. parents also relied on the experiences of other families with the same diagnoses. some parents connected with these families ƞǧȗȅȣǡǧ� ƞǧǔǩȗ� ȗǔșǔƺȗljǧ� ǔаȅȗƞșॹ� λǧǩǹǔ� ȅƞǧǔȗș� ȗǔƺljǧǔǐ� out to families they already knew. for some, the experiences of others caused fear and distress, especially in cases with poor outcomes (carlsson et al., 2015; carlsson et al., 2017; mckechnie et al., 2015). but for many, the experiences of other parents helped them feel positive and reassured (clark et al., 2020; johnson et al., 2018; lokmic et al., 2017; mckechnie & pridham, 2012; mckechnie et al., 2015; o’connell et al., 2019). collaborating with others lessened their anxiety and reshaped expectations, especially when they saw children with similar conditions living happy lives (how et al., 2019; johnson et al., 2018). some parents also joined parent groups and disability organizations to extend their social support (johnson et al., 2018; mckechnie & pridham, 2012; mckechnie et al., 2015). healthcare planning. parents also took comfort in planning for the future. they focused on the logistical health consequences of the diagnosis, joined healthcare waitlists, and planned postnatal care so they could be actively involved in upcoming healthcare decisions (carlsson et al., 2015; johnson et al., 2018; mckechnie & pridham, 2012; mckechnie et al., �ষঀ�kƞǧǔȗșࢶࢲࢱࢳ ȗǔмǔljƞǔǐ� ȅǿ� ƞǧǔǩȗ� ȓǔȗșȅǿƺǹ� ǧǔƺǹƞǧ� ƺǿǐ� began eating better and exercising (im et al., 2018). perspective-taking. as another strategy, parents reexamined their perspectives of the diagnosis. some utilized religion and began to view their baby as ƺ�ljǹǔșșǩǿǡ�ǟȗȅǿ�ƺ�ǧǩǡǧǔȗ�ȓȅλǔȗ�শ(ȅа�ǔƞ�ƺǹঀॹࢴࢲࢱࢳ�আ�2ǿ� et al., 2013), while others actively worked to change their idealized future to better align with the diagnosis (clark et al., 2020; how et al., 2019; mckechnie et al., 2015). these parents emphasized gaining rather than losing and focused on the essential responsibility of raising the child, identifying themselves as parents and embracing their parental role (how et al., 2019; lou et al., 2020; mckechnie et al., 2015). discussion this systematic review of 14 qualitative studies explored the psychological processes of prospective parents after receiving a fetal diagnosis. the review found that receiving a prenatal diagnosis marks a multiplex adjustment period for parents and adds an unexpected psychological burden as they absorb the news. at the initial diagnosis, parents often experienced mourning and shock. past work suggests that these reactions are common for parents, and they are not alone in these feelings (staham et al., 2000) as the initial diagnosis is the most emotionally challenging time for parents শ�ǧƺȓǹǩǿ�ǔƞ�ƺǹঀॹࢶࢱࢱࢳ�ষঀ��ǔρȅǿǐ�ƞǧǔ�йȗșƞ�ǐǩƺǡǿȅșǩșॹ�ȓƺȗents in the present review progressed through a multiǟƺljǔƞǔǐ�ƺǐǵȣșƞǿǔǿƞ�ȓȗȅljǔșș�йǹǹǔǐ�λǩƞǧ�ǐρǿƺǿǩljॹ�ljȅǿplicated emotions. consistent with prior work, parents ǩǿ� ƞǧǔ� ȓȗǔșǔǿƞ� ȗǔκǩǔλ� ǐǩаǔȗǔǐ� ǩǿ� ȓȗȅljǔșșǩǿǡ� ƞǩǿǔ� ƺș� they accepted the child as an individual (chaplin et al., 2005; lou et al., 2017) and oriented themselves to how the diagnosis shaped their present and future (johnson et al., 2020; statham et al., 2000). outside factors including social support and coping strategies ǩǿмȣǔǿljǔǐ�ȓƺȗǔǿƞșঢ়�ǩǿǐǩκǩǐȣƺǹ�ƺǐǵȣșƞǿǔǿƞ�ƞȗƺǵǔljƞȅȗǩǔșঀ� a mental shift is common for prospective parents. past work has shown that the transition to parenthood lowers new parents’ psychological well-being, even for those with typically develop pregnancies and high self-esteem prior to becoming a parent (chen et al., 2020). however, parents who receive a fetal diagnosis are at an especially increased mental health risk (cole et al., 2016) as they shift their mindsets and prepare for the future. given the emotional adjustment occurring in ƞǧǔșǔ� ȓȗǔǡǿƺǿljǩǔș� ƺǿǐ� ƞǧǔ� ǩǿмȣǔǿljǔ� ȅǟ� ǔπƞǔȗǿƺǹ� ǟƺljtors documented in the present review, parents may ljǔǿǔйƞ� ǟȗȅǿ� ƺȓȓȗȅȓȗǩƺƞǔ� ljƺȗǔ� ƺǿǐ� șȣȓȓȅȗƞ� ǐȣȗǩǿǡ� ƞǧǩș� ȓǔȗǩȅǐ� ƞȅ� ljȅȅșƞ� ȓȅșǩƞǩκǔ� ǩǿмȣǔǿljǩǿǡ� ǟƺljƞȅȗș� parent psychological adaptation 3838 gaspar the present review. strengthening protective factors in this population is especially imperative as parents may be at risk for long-term psychological distress as children born with a fetal abnormality have an increased risk of altered developmental outcomes and disabilities throughout their lifespan (liu et al., 2016; love et al., 2011) and parents of children with disabilities often show decreased psychological health (olsson & hwang, 2008). one possibility for a reinforced protective support is through healthcare providers. the present review and past literature show that parents with fetal diagnoses often experience negative, insensitive, and uninformed medical care (chaplin et al., 2005; stock et al., 2019), but literature suggests that healthcare providers may be ill-prepared and receive little training in parent practices post-diagnosis (johnson et al., 2020; luz et al., 2017). despite this, parents strongly rely on and desire genuine, trusting relationships with their healthcare team (oulton et al., 2020), and parents in the present review who received supportive care from their healthcare team felt more comfortable and prepared. to address gaps in provider quality, health organizations may want to consider updating and expanding parent resources and encourage healthcare professionals to partake in additional professional development and training on parent support practices and fetal abnormalities to better support families in the perinatal period. as evidenced in the present review and priȅȗ� λȅȗƿ� শ�ȅаǿƺǿ� ૭� [ƺρॹ� �আࢳࢱࢱࢳ ?ȣǡǹǔȗ� ૭� 'ƺȗǿǔȗॹ� �ষॹࢶࢲࢱࢳ ƞƺȗǡǔƞǔǐ� șȅljǩƺǹ� ǿǔƞλȅȗƿș� ƺǹșȅ� ȅаǔȗ� ƺ� ȓȗȅǿǩșing route for a bolstered protective role. in addition ƞȅ� ȓƺȗǔǿƞșঢ়� ǩǿǿǔǐǩƺƞǔ� șȅljǩƺǹ� ljǩȗljǹǔșॹ� йǿǐǩǿǡș� șȣǡǡǔșƞ� advantages to participation in formal social outlets such as support groups, especially those with similar perinatal experiences. parents in past literature who participated in parent groups described these relationships as imperative for their adjustment to parenthood as it provided a space to discuss their shared experiences and challenges with new parenting (glavin et al., 2017). parents who receive fetal diagǿȅșǔș�ǿƺρ�ljǔǿǔйƞ� ǟȗȅǿ� șȣljǧ� șȅljǩƺǹ� ȅȓȓȅȗƞȣǿǩƞǩǔș� ƞȅ� connect with other families with shared experiences. a third, innovative approach to strengthening protective factors is the addition of psychological professionals to prospective parents’ support teams. literature suggests that parents are best supported by a multidisciplinary team of healthcare and psychological professionals (catlin et al., 2008; statham ǔƞ� ƺǹঀॹ� �ষॹࢱࢱࢱࢳ ƺǿǐ� ƺș� șȣljǧ� ȓƺȗǔǿƞș� ǿƺρ� ljǔǿǔйƞ� ǟȗȅǿ� psychological support as they process the diagnosis. recent work on mindfulness interventions (reid et al., 2016), group prenatal care (ickovics et al., 2019), grief support (navidian et al., 2017), and other psychological counseling (rohde et al., 2008) indicate promising results for perinatal parent populations. pretest counseling has also been demonstrated as ljǔǿǔйljǩƺǹ� ƞȅ� ǧǔǹȓ� ǔǿȅƞǩȅǿƺǹǹρ� ȓȗǔȓƺȗǔ� ȓƺȗǔǿƞș� ǟȅȗ� prenatal screening results (dorner et al., 2020). limitations and conclusion there are some limitations in this review. first, λǧǩǹǔ�ǔаȅȗƞș�λǔȗǔ�ǿƺǐǔ�ƞȅ�ljȅǿǐȣljƞ�ƺ�ƞǧȅȗȅȣǡǧॹ�ljȅǿprehensive search and selection of literature, additional studies may have been published since the initial searches were performed and were not included in the present selection. similarly, the analysis process ǿƺρ�ǐǩаǔȗ�ljǔƞλǔǔǿ�ȗǔșǔƺȗljǧǔȗșঀ��ǹƞǧȅȣǡǧ�ȓȗȅljǔǐȣȗƺǹ� steps are detailed, it is possible that others may utilize ǐǩаǔȗǔǿƞ� ljȅǐǩǿǡ� ƺȗȗƺǿǡǔǿǔǿƞș� ƺǿǐ� ǵȣǐǡǔǿǔǿƞșঀ� �ǐditionally, although qualitative studies were included in the present review, quantitative data may also provide valuable insights. future work in this area may λƺǿƞ� ƞȅ� ȓǔȗǟȅȗǿ� ƺǿ� ƺǿƺǹρșǩș� ȅǟ� ȕȣƺǿƞǩƞƺƞǩκǔ� йǿǐǩǿǡș� or synthesize a combination of both qualitative and quantitative literature. studies in this review covered a wide range of countries. it is important to note the ǩǿмȣǔǿljǔ�ȅǟ�ljȣǹƞȣȗǔ�ǩǿ�ǔƺljǧ�ƞƺȗǡǔƞ�ȓȅȓȣǹƺƞǩȅǿॹ�λǧǩljǧ� may shape study results including individual responses, coping, and perspectives. future reviews may ljǔǿǔйƞ� ǟȗȅǿ�ǿƺȗȗȅλǩǿǡ� ƞǧǔ� ǟȅljȣș� ƞȅ� ƺ�ǿȅȗǔ�ǧȅǿȅǡenous selection of countries, while further empirical work is needed to explore fetal diagnoses and available resources across cultures and geographic regions. receiving a fetal diagnosis is life-altering news for families. the present review suggests that prospective parents have similar initial reactions to prenatal diagnosis, but the subsequent adjustment process ǩș� șǧƺȓǔǐ�ljρ� κƺȗǩȅȣș� ǩǿмȣǔǿljǩǿǡ� ǟƺljƞȅȗș� ƺǿǐ� ǔπƞǔȗǿƺǹ� characteristics. parents who have strong protective factors, such as supportive social networks and sensitive, informed healthcare support may have improved experiences and adjustment. findings suggest the benǔйƞ� ȅǟ� ȓȗȅκǩǐǩǿǡ� ǩǿȓȗȅκǔǐ� ǿǔǐǩljƺǹॹ� ȓșρljǧȅǹȅǡǩljƺǹॹ� and social resources to parents after a fetal diagnosis. eƺƿǔǿ� ƞȅǡǔƞǧǔȗॹ� ƞǧǔșǔ� йǿǐǩǿǡș� ȓȗȅκǩǐǔ� ǐǔǔȓǔȗ� ȣǿ39 parent psychological adaptation derstanding of parent experiences and related factors and indicate directions for future parent support. references abdou, c. m., schetter, c. d., jones, f., roubinov, d., tsai, s., jones, l., lu, m., & hobel, c. 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(2012). screening the genes. bulletin of the world health organization, 90(8):557–632. retrieved november 4th, 2020, from https://www.who.int/bulletin/volumes/90/8/12-030812/en/ parent psychological adaptation 44 gaspar 45 parent psychological adaptation 46 gaspar 47 parent psychological adaptation 48 gaspar graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 3 the mental health needs of unaccompanied immigrant children: lawyers’ role as a conduit to services charles d. r. baily teachers college, columbia university schuyler w. henderson new york university amanda r. taub fordham university glynnis o’shea teachers college, columbia university honora einhorn teachers college, columbia university helen verdeli teachers college, columbia university unaccompanied immigrant children are a highly vulnerable population, but research into their mental health and psychosocial context remains limited. this study elicited lawyers’ perceptions of the mental health needs of unaccompanied children in u.s. deportation proceedings and their mental health referral practices with this population. a convenience sample of 26 lawyers who work with unaccompanied children completed a semi-structured, online survey. lawyers surveyed frequently had mental health concerns about their unaccompanied child clients, used clinical and lay terminology to describe symptoms, referred for both expert testimony and treatment purposes, frequently encountered barriers to accessing appropriate services, and expressed interest in mental health training. the results of this study suggest a complex intersection between the legal and mental health needs of unaccompanied children, and the need for further research and improved service provision in support of their wellbeing. the mental health needs of unaccompanied immigrant children: lawyers’ role as a conduit to services under the terms of 6 u.s.c. § 279(g)(2), federal law defines an unaccompanied alien child as any child or adolescent under the age of 18 who is in the united states without lawful immigration status and does not have a parent or other legal guardian present to provide custody. of the 14,299 unaccompanied children detained by the department of homeland security between october 2008 and september 2010, 91% were from latin america (mostly central america), 70% were between the ages of 15 and 17, and 73% were male (byrne & miller, 2012). due largely to increasing violence and insecurity in central america, in recent years there has been a dramatic rise in the number of apprehensions. in 2013, u.s. immigration authorities detained 21,537 unaccompanied children from guatemala, honduras, and el salvador alone (united nations high commissioner for refugees, 2014). psychosocial stressors the available literature suggests that unaccompanied youth are at high risk for repeated exposure to psychosocial stressors before, during, and after their migration to the united states (baily, henderson, taub, ricks, & verdeli, 2011). children may be fleeing gangs, evading forced recruitment by military and paramilitary organizations, escaping war or civil unrest, avoiding coercion into child labor or prostitution, or facing displacement following natural disasters (chavez & menjívar, 2010). they can spend months traveling alone to the united states in treacherous conditions, and during the journey they are vulcorrespondence concerning this article should be addressed to: charles d. r. baily; department of counseling and clinical psychology, teachers college, columbia university. horace mann room 328, 525 west 120th street. new york, ny, 10027, usa. email address: cdb2123@tc.columbia.edu 4 nerable to abuse and physical and sexual exploitation by bandits, smugglers, and local officials (bhaba & schmidt, 2008; casillas, 2006; fazel & stein, 2002; seugling, 2004). although government guidelines have been created to protect unaccompanied children apprehended by u.s. immigration, they may be detained in prison-like conditions for extended periods of time prior to release to family members or other less restrictive settings (women’s refugee committee, 2009). once released to less restrictive settings, they still face a long period of instability and insecurity while they await immigration proceedings to determine whether they will be deported, during which they may also experience acculturation issues and discrimination within the local culture (perez foster, 2001). mental health needs despite the well-documented psychosocial stressors faced by unaccompanied children migrating to the united states, there has been limited research on their mental health needs. research to date has largely taken the form of reports and papers by legal and human rights researchers and advocacy groups, has focused predominantly on children living in detention (as opposed to children reunified with family members in the community), has relied predominantly on qualitative interviews with key informants, and has discussed children’s experiences broadly rather than focusing on mental health specifically. nevertheless, several papers have documented high rates of posttraumatic stress disorder (ptsd), other anxiety conditions, depression, aggression, psychosomatic complaints, and suicidal ideation among unaccompanied children (bhaba & schmidt, 2008; chavez & menjívar, 2010; women’s refugee commission, 2009). to the authors’ knowledge, only two empirical studies have used standardized instruments to assess the mental health status of unaccompanied children in the united states, both of which looked at very specific populations of unaccompanied children, and had very targeted research questions. porte and torney-purta (1987) examined the relationship between different types of foster care and depression and academic achievement in unaccompanied indochinese children. geltman and colleagues (2005) looked at ptsd and its relationship to overall functioning among unaccompanied sudanese youth. the majority of empirical research on the mental health of unaccompanied children has been conducted in northern europe, and has found that these children are at high risk for exposure to traumatic events (bean, derluyn, eurelings-bontekoe, broekaert, & spinhoven, 2007b), have elevated rates of psychopathology (e.g., derluyn, broekaert, & schuyten, 2008; hodes, jagdev, chandra, & cunniff, 2008; lustig, kia-keating, & knight, 2004), and have limited access to psychological care (bean, eurelings-bontekoe, mooijaart, & spinhoven, 2006). however, the generalizability of these findings to unaccompanied children in the united states is likely limited, given differences in the countries of origin, migration experiences, legal systems, and resettlement conditions of unaccompanied youth in these european countries compared to america. legal context in contrast with unaccompanied children’s mental health needs, the legal challenges they face have been widely documented (e.g., byrne, 2008; georgopoulos, 2005; nafziger, 2006). these include lack of access to counsel, difficulty meeting the high evidentiary standards required to obtain legal relief, and the legal system’s failure to consistently apply a “best interests of the child” standard when making decisions in their cases. however, a sustained legal advocacy campaign over the last 30 years has led to an expansion in the types of immigration relief for which unaccompanied children may be eligible, and increased access to legal services to help them prepare their cases (byrne, 2008). unaccompanied children may be eligible for a variety of forms of immigration relief, including special immigrant juvenile status, asylum, and petitions under the victims of trafficking and violence protection act (byrne & miller, 2012). these cases can take years to resolve, during which children are placed in the temporary custody of family members residing legally in the united states or, when such an option is not available, in government-sponsored foster care or residential facilities (women’s refugee commission, 2009). lawyers’ advocacy role during this period often includes connecting children to a variety of services (e.g., academic, social, health) in support of their cases and overall wellbeing (baily et al., 2011). in baily, henderson, taub, o’shea, einhorn, verdeli 5 particular, legal and mental health advocacy frequently overlap: each of the major forms of immigration relief available to unaccompanied children requires evidence of psychosocial stress, and lawyers frequently refer clients for assessment and documentation of mental health difficulties to be provided to the court as expert testimony in support of their cases (baily et al., 2011). however, there has been little formal study of the intersection of mental health and legal needs in unaccompanied children in the united states. conceptual rationale in this exploratory study, lawyers completed a survey about their perceptions of the mental health needs of their unaccompanied child clients and referral practices with this population. the goal was to provide qualitative, descriptive information about the experiences of the lawyers surveyed, as opposed to quantitative data from which to draw inferences about the overall experiences of lawyers working with unaccompanied children or the mental health needs of these youth. the study was intended to provide a first step towards more extensive research to address the gap in the literature on the mental health needs of unaccompanied children in the u.s. immigration system. this line of research was initiated following requests from several new york city lawyers to help them find mental health referrals for their unaccompanied child clients. discussions with these lawyers suggested that they have concerns about the mental health of many of these clients, and often seek psychological referrals, but have difficulty finding services appropriate to their clients’ needs. the lawyers mentioned a variety of reasons for mental health referrals: for psychological evaluations and expert testimony that lend weight to children’s immigration petitions; for treatment to support children through a stressful legal process that frequently requires recounting of traumatic experiences; and because they are concerned more generally for children’s psychological welfare (baily et al., 2011). these rationales mirror those reported in the wider legal literature (e.g., galowitz, 1999; price & mccreary, 1976) as reasons lawyers request psychological services for clients. the current survey explored whether the concerns raised by lawyers during these preliminary discussions were shared by other new york city lawyers who represent these youth. given the emotionally and legally vulnerable status of unaccompanied children, it seemed that an anonymous survey with an informed third party (as opposed to a study with unaccompanied children and their families directly) would be the least intrusive and most ethically appropriate point of departure for our research. this is consistent with the ethical principles of beneficence and nonmaleficence in conducting research with vulnerable populations (american psychological association [apa], 2010). the study was also intended to generate initial information about the feasibility of conducting research on this topic, and to gain information about questions such as recruitment, protection of subjects, and data issues (e.g., reliability, generalizability, qualitative versus quantitative methodology) in research on unaccompanied children. thus, this research sought both to generate hypotheses for future study and inform subsequent research methodology. the use of key informants in research with immigrant children is complicated by these children’s diverse histories and experiences, as well as inconsistent reporting due to varying cultural and experiential perspectives (suárez-orozco & suárez-orozco, 2001). the decision to use lawyers as informants in this study was based on multiple rationales. from an information-gathering point of view, lawyers are often the professionals who know these children best: lawyers see their unaccompanied child clients at multiple time points during their often protracted immigration processes; in the course of developing immigration petitions, lawyers take detailed histories of these children’s backgrounds (including their exposure and reactions to psychosocial stressors); and their unique role as children’s advocates may help establish a relationship of trust within an otherwise confusing and intimidating system. from a service-provision perspective, lawyers are frequently charged with helping children access other services and resources, and the study sought to understand lawyers’ role as a conduit to mental health services, to provide data on how mental health professionals can support them in this role, and to generate initial information about the possibility of developing a more unaccompanied child mental health: lawyers’ role 6 systematic mental health referral pathway for unaccompanied children via their legal processes in the future. from a research standpoint, this study with lawyers sought to contribute to the growing literature on the inter-relationship between unaccompanied children’s mental health and legal needs (e.g., derluyn & broekaert, 2008; nugent, 2006). of note, the survey was not intended to provide epidemiological data about psychopathology in unaccompanied children. accurately identifying psychological difficulties in their clients is outside attorneys’ professional expertise and role, and was beyond the scope of this study. the specific aims of this study were to investigate whether participating lawyers were observing mental health problems in their unaccompanied child clients, how lawyers characterized these problems, their referral practices with this population, barriers they encountered to service access, and their interest in further mental health training. method measure a 71-question survey titled “mental health referral practices of lawyers representing unaccompanied immigrant minors” was developed to assess lawyers’ perceptions of their unaccompanied child clients’ mental health needs, their mental health referral practices, and their mental health training and experience. the survey content was informed by a review of the available literature on the psychological needs of unaccompanied children and lawyers’ mental health referral practices, and then refined through consultation with a lawyer member of the research team with experience representing unaccompanied children. the format and structure of the survey was revised through consultation with researchers from the new york state psychiatric institute with expertise in public health research and the assessment of child mental health. the survey combined selected-response, likertstyle, and open-ended questions. lawyers were asked to give some basic demographic information (e.g., number of years in legal practice, primary area of legal practice etc.), to provide information on their attitudes towards mental health diagnosis and referrals (e.g., “in what ways does a diagnosis of a mental health problem in unaccompanied minors typically influence immigration proceedings?”), to rate their mental health knowledge (e.g., “do you feel confident in your ability to identify mental health problems in your unaccompanied minor clients?”), and to describe areas of interest for further mental health training. for their three most recent clients, whether or not they were referred for mental health services, lawyers were asked to describe any behavior, emotions, or thoughts that made them concerned for the client’s mental health. for their three most recent clients referred for mental health services, lawyers were asked about the reasons for referral and any barriers to obtaining services. participants were given the opportunity to write optional additional comments pertaining to each of the above topic areas. the survey was hosted at surveymonkey, a service for web-based questionnaires that employs secure sockets layer (ssl) encryption to secure the data provided by participants. it took approximately 30-40 minutes to complete. participants study participants were lawyers practicing in new york city who had represented at least one unaccompanied child client in immigration proceedings within the last five years (n=26). the data concerning the types of legal organizations for which respondents worked, their primary areas of legal practice, and the number of unaccompanied children they had represented are presented in table 1. broadly speaking, the participants fell into one of two categories: a majority of lawyers worked for private law firms and other organizations specializing in corporate law, and had represented a small number (<5) of unaccompanied children as a minor portion of their practice; a smaller group of lawyers worked for nonprofit legal services organizations, specialized in immigration law, and had represented a large number (>50) of unaccompanied children. procedure a pool of potential participants was recruited via outreach to legal advocacy programs that work with unaccompanied children. these included catholic charities and the legal aid society, nonprofit orgabaily, henderson, taub, o’shea, einhorn, verdeli 7 nizations that provide free legal services to unaccompanied children, as well as kids in need of defense (kind), a national organization that arranges legal representation for unaccompanied children by pro bono lawyers. representatives from these organizations sent an email describing the study and providing a link to the survey to their listservs of new york city lawyers representing unaccompanied children. neither the contact details of lawyers on these listservs nor any other identifying information about them was provided to the research team. approximately 150-200 attorneys were contacted via this method. in addition, participants were invited to forward the survey link to other lawyers who work with unaccompanied children. this methodology, known as snowball sampling, is common to many survey studies. in particular, it has been used in studies concerning vulnerable populations with heightened confidentiality and anonymity concerns (e.g., kendall et al., 2008). these procedures were intended to recruit a convenience sample of lawyers who could describe their experience of the mental health issues involved in representing unaccompanied children. the sample and data collected were not intended to be representative of or generalizable to the wider population of lawyers representing unaccompanied children in new york city. the e-link to the survey contained a consent form completed by all participants prior to completing the study. participation was anonymous and voluntary, and neither the recruitment process nor the survey itself required lawyers to provide identifying information about themselves, their clients, or their places of work. the study was approved by the internal review boards of the new york state psychiatric institute and teachers college, columbia university. data analysis: due to the descriptive nature of this study, the nature of the sample, and the types of questions asked, the data were primarily analyzed qualitatively. for questions with a selected-response format, frequency data were collected. these data were intended to be used descriptively, rather than for the purposes of quantitative analysis. they are summarized in tables 1-5. variations in the n reported in the tables relate to differences in response rate for different survey questions. in some cases lawyers provided reasons for omitting questions, including privacy concerns (e.g., “i can’t comment (case in progress)”) and lack of knowledge in a particular area (e.g., “no experience”). in other cases, the reasons for omissions were unclear. the frequency data collected were used to supplement the qualitative data provided by lawyers’ open-ended responses. results mental health difficulties observed by lawyers the lawyers in this study were asked whether they had observed any behaviors, emotions, or thoughts in their last three unaccompanied child clients which had made them concerned about their mental health and, if so, to describe them. respondents were asked to comment separately on each of these clients, regardless of whether they were referred for mental health services. overall, lawyers reported concerning behaviors, thoughts, or emotions in about half of these youth. lawyers used a mixture of lay terminology (e.g., “frustration and sense of rejection,” “just hyper unaccompanied child mental health: lawyers’ role unaccompanied child mental health: lawyers’ role 34 table 1 participant demographics (n=26) n a legal organization type ( /26) private law firm 18 nonprofit legal services organization 5 solo practitioner 2 in-house counsel 1 government attorney 0 primary area of legal practice ( /24) corporate law 16 immigration law 7 family law 1 number of cases completed ( /26) < 5 17 6-10 1 11-20 3 21-50 0 50+ 5 a differences in n reflect variations in response rate between different demographic questions 8 anxiety,” difficulty sleeping,” “tearfulness,” “reports of stress”) and clinical terminology (e.g., “flat affect,” “depression,” “separation anxiety,” “delusional behaviors,” “schizophrenia”) to describe areas of concern. they noted a wide range of difficulties, including what appeared to be internalizing symptoms (e.g., “poor self-esteem,” “nightmares,” “seemingly despondent”) and externalizing symptoms (e.g., “behavioral problems,” “self-mutilation,” “suicide attempts”). in addition to apparent psychological symptoms, they also reported potentially psychosomatic symptoms (e.g., “sleepiness”) and contextual signs of distress (e.g., “poor school performance,” “difficulties with personal relationships”). in some cases, they identified specific psychological stressors, including traumatic stressors (e.g., “client expressed trouble sleeping, nightmares, [and] memory problems that appear to be related to trauma suffered in his home country”), family stressors (e.g., “not fully dealt with suicide of mother,” “severe depression related to rape by a family member,” “resentment against father for physical and emotional abuse”), detention-related stressors (“frustration at having spent nine months in federal custody,” “anger at family members for not stepping up to get minor released from custody,” “sense of rejection due to family not coming through for reunification”), and court-related stressors (“unwillingness to discuss journey to the u.s.” and “startle reaction to question by immigration judge”). in addition to the mental health concerns noted, several lawyers described resilience processes that appeared to protect children from developing psychological symptoms despite the psychosocial stressors they may have endured. some lawyers described protective individual characteristics in clients (e.g., “this kid was… very grounded”). others emphasized systemic factors contributing to resilience (e.g., “most of my [unaccompanied child clients] have family support in the u.s., though not the mother and father”). reasons for referral a little under half of the lawyers surveyed had referred unaccompanied child clients for mental health services. these lawyers were asked about the primary and other reasons for referral for the three most recent unaccompanied child clients they had referred to mental health services (these are combined in table 2). in almost half of the referred cases lawyers described, their primary reason for referral was to obtain expert psychological testimony in support of their clients’ legal cases. commenting more generally on their attitudes towards diagnostic evaluations, half of the lawyers surveyed agreed that having a mental health diagnosis typically assists in acquiring immigration relief. most of the lawyers in this study who had made mental health referrals indicated that the potential legal implications of having a mental health diagnosis had been a factor causing them to refer unaccompanied child clients. several lawyers’ comments suggested a complex and nuanced relationship between mental health diagnoses and immigration petitions. for example, one respondent mentioned that the influence of a mental health diagnosis on immigration proceedings “depends on the diagnosis; generally [it] helps more that [it] hurts,” while another suggested that a diagnosis’s utility “depends on its relation to the claim being asserted.” however, none of the lawyers surveyed agreed that the potential legal implications of having a mental health diagnosis had caused them not to refer a client for mental health services. among the lawyers surveyed who work for nonprofit legal service organizations that specialize in working baily, henderson, taub, o’shea, einhorn, verdeli unaccompanied child mental health: lawyers’ role 35 table 2 reasons for mental health referral in three most recent unaccompanied child clients referred (n=25) n a ( /25) reason behavior observed by lawyer 17 expert testimony 16 child self-reported difficulties 15 interference with legal process 11 behavior reported by third party 7 child’s request for help 3 caretaker’s request for help 1 a n reflects total number of clients in whom this was a reason for referral (some lawyers reported multiple reasons for referring a single client) 9 with unaccompanied children, all reported that they had referred clients to mental health services. within this highly experienced subset of respondents, all agreed that having a mental health diagnosis generally assists in acquiring immigration relief and that this had influenced their decision to make referrals. in many cases, lawyers referred for both expert testimony and ongoing psychological services. in almost half of the referral cases lawyers described, one reason for doing so was to assist with psychological difficulties affecting legal representation. one lawyer described a client’s “unwillingness to discuss the journey to the u.s.” another lawyer described a client from whom, “we needed the expert testimony for the case; also, i was concerned that i (as a lay-person) was not getting the full story from my client; that she was glossing over events that a professional would have been better placed to uncover.” the possible legal benefits of mental health assessment and treatment aside, lawyers also frequently referred children out of a more general concern for their wellbeing. one lawyer described being “deeply concerned about the [client’s] self-mutilation.” commenting more generally, another lawyer suggested “i find that youth will self-medicate and this is extremely disconcerting for the long term health and stability of the child.” lawyers frequently described making referrals for a combination of legal and mental health reasons. for example, one lawyer described referring a client, “to help the kid’s mental health and to help the case and document the abuse.” in the majority of cases where participating lawyers had referred one of their last three clients, they did so on the basis of concerning thoughts, feelings, or behaviors that they observed directly or that children reported to them. by contrast, a child or guardian’s direct request for help was a factor in less than a quarter of the cases lawyers described. one lawyer described a case in which the “child seemed like they wanted to speak to someone and i thought that they should speak to a qualified person,” alluding to the multiple needs lawyers may feel pulled to address. some lawyers appeared to refer clients routinely as a form of mental health screening. one reported, “i would assume they need an evaluation,” and another noted “i err on the side of referral… [there’s] no real downside to a single visit consultation.” barriers in obtaining mental health services lawyers were also asked about barriers to accessing mental health services for the last three clients they had referred (see table 3). in the great majority of these cases they encountered obstacles, and in almost half of the referral cases described, the clients ultimately did not receive services. the most commonly endorsed difficulties were cost of services, difficulty in finding services in the client’s/caretaker’s primary language, and distance/transportation issues. one lawyer described systemic issues in helping children to access affordable resources: “we need social workers to help children sign up for medical and education programs and get medicaid so they can pay for mental health treatment; for depressed clients (many) or those who are not motivated or savvy with adult bureaucracies in the us (most all), getting to a therapist is difficult.” other lawyers indicated a more fundamental lack of appropriate resources. as one lawyer suggested, “there are virtually no spanish speaking counselors.” another indicated, “i wish there were more free therapy sources that take medicaid and where therapists speak spanish.” several lawyers contrasted the availability of services when children are in detention versus out in the community. as one explained, “all of the detained children receive mental health services in the orr [office of refugee resettlement] custodial centers. very few of the released children have access to these services.” unaccompanied child mental health: lawyers’ role unaccompanied child mental health: lawyers’ role 36 table 3 barriers to mental health services encountered in three most recent unaccompanied child clients referred (n=25) n a ( /25) reason cost 18 language 14 distance/transport 11 confidentiality concerns 1 no barriers 3 a n reflects total number of clients for whom this was a barrier (some lawyers reported multiple barriers encountered by a single client) 10 lawyers appeared to have particular difficulty finding ongoing treatment services as compared to expert testimony evaluations. one lawyer stated, “i only refer for expert testimony because i can only find therapists able to provide that type of service. there are no programs for on-going therapy/care.” another indicated, “if there was a program/clinic providing service, i would refer independent of the legal case need…sadly, these programs do not exist.” faced with a lack of resources, some lawyers appeared to operate an informal triage system. one lawyer suggested, “i tend to only be able to get access to mental health services for the most high risk cases.” another commented, “i wish i could get counseling for all of the children i work with because many who do not openly express depression/anxiety are actually experiencing it.” almost half of the lawyers surveyed indicated that they would have referred more unaccompanied child clients if they had been aware of available mental health services. one lawyer stated, “if mental health services were more readily available, i would refer ever single client to services.” several lawyers mentioned stigma attached to mental health difficulties and treatment as a barrier to accessing services. one lawyer described a client who was “currently resisting assistance.” another reported, “one of the greatest challenges in working with youth is their reluctance to engage in treatment because of socio-cultural factors.” caregivers’ attitudes towards mental health issues may also pose a barrier to service access. one lawyer “did not press for follow up treatment because i believed the [caregivers] were not engaged and would not take follow up steps.” mental health stigma was not the only source of reluctance to engage in treatment. for example, one lawyer cited a client’s “mistrust of systemic actors” as a barrier to obtaining services. mental health services received lawyers were asked about the types of mental health services to which they had referred unaccompanied children (see table 4). private practice and community service/nonprofit organizations were the most common types of referrals. none of the lawyers surveyed had ever referred clients to the emergency room. lawyers had mixed feelings regarding the effectiveness of the services to which they had referred their clients. approximately half of the participating lawyers agreed that when they had referred unaccompanied child clients for mental health services it had been beneficial to them. concerns were raised about the mandated mental health services provided to children detained in government-sponsored facilities, however. one lawyer explained, “although detained minors ostensibly have access to mental health services in the shelters, there are real concerns about [the] confidentiality of those services, as well as whether the services are sufficiently rigorous to meet the needs of unaccompanied children.” lawyers’ mental health knowledge/training lawyers were asked to comment on their mental health knowledge and training. approximately half did not feel confident in their ability to identify mental health problems in their clients or confident knowing when to refer clients. one lawyer stated succinctly, “i am not a mental health professional, so [it’s] difficult to know when to refer.” most of the lawyers surveyed did not know where to refer clients. among the lawyers surveyed who worked in programs in nonprofit organizations specializing in representation of unaccompanied children, all but one had received training in mental health issues related to working with unaccompanied children (and baily, henderson, taub, o’shea, einhorn, verdeli unaccompanied child mental health: lawyers’ role 37 table 4 types of mental health services to which lawyers have referred unaccompanied child clients (n=14) n a ( /14) service type private practice 10 community service/npo organization 7 primary care provider 2 student mental health clinic 2 faith-based organization 1 support group 1 emergency room 0 a n reflects total number of lawyers who referred to this type of service (some lawyers reported making multiple types of referral) 11 in this subset of respondents, all but one felt confident in their ability to identify mental health problems in their clients and in knowing when to refer). by contrast, among the larger subset of corporate lawyers representing unaccompanied children pro bono, only one had received such training. describing a previous case, one such lawyer commented, “as a new practitioner in removal defense, at the time i wasn’t aware of the possibility or need of referring; and only one such behavior was exhibited, so i felt it was not a major issue. i might act differently now.” another lawyer implied that lack of awareness about psychological issues is a systemic problem: “probably the immigration bar generally needs to be better informed about health issues concerning unaccompanied minor clients and relevant resources.” the great majority of the lawyers surveyed agreed that it was within the scope of their role as lawyers to recommend mental health services for clients. all but two indicated that they would be interested in receiving further training. the most popular suggestions for future training were methods for interviewing unaccompanied children with a traumatic history, recognizing common mental disorder symptoms, and means of accessing mental health resources (see table 5). discussion derluyn and broekaert (2008) describe how differing legal and psychological perspectives on unaccompanied children may lead to neglect of their mental health, and suggest that the overall standpoint for understanding these children should be primarily psychological rather than legal (i.e., seeing them first and foremost as youth with specific developmental needs, not as “unaccompanied alien children”). the lawyers in this study find themselves in precisely this predicament, moving between legal and psychological responsibilities, addressing children’s mental health in both a legal context (e.g., requesting expert testimony to support clients’ immigration claims) and a psychological one (e.g., requesting treatment for clients’ emotional and behavioral concerns). given the legal context, one might imagine that lawyers would be primed to identify mental health difficulties such as anxiety, depression, and traumatic stress that could be seen as evidence of prior abuse and so might lend support to legal claims and bolster a case that a child needs further protections in the united states. similarly, one might anticipate that lawyers would less readily identify problematic behaviors that could present a negative impression of their clients in court. however, lawyers in this survey reported a wide range of symptoms in their clients, including some that might potentially be viewed less favorably, such as “anger and resentment,” “self-medication by drinking,” and “out of control teenage behavioral problems.” the range of mental health and behavioral problems noted by the lawyers in the survey mirrored symptoms found in previous studies with unaccompanied and other vulnerable immigrant children, including anxiety symptoms (derluyn & broekaert, 2007; fazel & stein, 2002; silove & steel, 1998; sourander, 1998), depression (derluyn & broekaert, 2007; fazel & stein, 2002; hodes et al., 2008; silove & steel, 1998), sadness (fazel & stein, 2002; silove & steel, 1998; sourander, 1998), withdrawal (ajdukovic & ajdukovic, 1998; fazel & stein, 2002; silove & steel, 1998), tearfulness (ajdukovic & ajdukovic, 1998), loss of interest (fazel & stein, 2002; silove & steel, 1998), sleep disturbances (fazel & stein, 2002; silove & steel, 1998), nightmares (ajdukovic & ajdukovic, 1998; fazel & stein, 2002; silove & steel, 1998), concentration problems (ajdukovic & ajdukovic, 1998; fazel & stein, 2002; silove & steel, 1998; sourander, 1998), hyperarousal (fazel & stein, 2002; silove & steel, 1998), psychosis unaccompanied child mental health: lawyers’ role unaccompanied child mental health: lawyers’ role 38 table 5 areas for future mental health training with lawyers (n=19) n a ( /19) topic interviewing unaccompanied children with trauma histories 16 recognizing symptoms of common mental disorders 14 means of accessing mental health resources 13 encouraging unaccompanied child clients to follow-up on referrals 10 presenting mental health concerns to children and their families 7 a n reflects total number of lawyers who expressed interest in this type of training (some lawyers reported interest in multiple topics) 12 (hodes & tolmac, 2005), suicidality (silove & steel, 1998), and behavioral problems (ajdukovic & ajdukovic, 1998; fazel & stein, 2002; sourander, 1998). the overlap between legal and mental health concerns was most apparent in the context of referrals. among the referral cases lawyers described expert testimony was the most commonly cited primary reason for referral, and most of the lawyers who had made referrals suggested that the possible legal benefits of a mental health diagnosis had factored into their decision to do so. however, the potential for clients’ psychological difficulties to have an impact on legal proceedings extends beyond giving expert testimony and providing mental health diagnoses. for example, posttraumatic stress can affect refugee petitioners’ ability to testify and the content of their testimonies (rousseau, crépeau, foxen, & houle, 2002). in this study, lawyers described enlisting mental health professionals to support children in disclosing traumatic histories that were important to their cases but that they might otherwise have been unable to report. similarly, some lawyers referred children to help them combat posttraumatic symptoms associated with appearing in court. the contrast between legal and psychological perspectives on unaccompanied children can create the impression that it is impossible to balance the two. however, lawyers in this survey frequently expressed great concern for their clients’ well-being, over and above any potential relevance of the child’s psychological presentation to their immigration cases. likewise, in their great majority, the lawyers surveyed suggested that advocating for their clients’ mental health needs was part of their role. the surveyed lawyers’ difficulty in accessing appropriate services for their clients was one of the most salient findings of the survey. the main barriers to care that lawyers described were similar to those commonly described in previous studies assessing access to mental health services for unaccompanied refugee children and adolescents in europe (derluyn & broekaert, 2008). although, for reasons of confidentiality, the survey did not include any questions about clients’ ethnicity, most unaccompanied children are from latin america (byrne & miller, 2012) and barriers to care lawyers reported were similar to those described elsewhere in the literature on latino mental health care access (e.g., aguilar-gaxiola, loera, méndez, & sala, 2012): lack of affordable options, lack of local resources, and language difficulties. these same factors of course hinder service access for immigrants from many parts of the world (apa, 2012). some lawyers surveyed also cited stigma towards mental health issues and clients’ wariness of treatment seeking as barriers to care, again mirroring the wider literature on immigrant mental health service utilization (e.g., ishikawa, caedemil, & falmagne, 2010; sue, fujino, hu, li-tze, & takeuchi, 1991). in latino immigrants, reluctance to seek mental health assistance has been linked to cultural values such as marianismo, which encourages females to be self-sacrificing and not to talk about personal problems, and machismo, which encourages males to show strength and not to demonstrate vulnerability (workgroup on adapting latino services [wals], 2008). in addition, unaccompanied children often live in communities in which many people are undocumented and there is a culture of mistrust towards professional institutions, and this may dissuade them from seeking mental health services (aguilar-gaxiola et al., 2012; ter kuile, rousseau, munoz, nadeau, & ouimet, 2007; wals, 2008). however, further research is required to understand how these and other factors influence treatment-seeking in this socio-culturally diverse population of youth. future directions although this is small study with a convenience sample, the responses of the lawyers surveyed are suggestive of a need for more systematic identification of unaccompanied children in need of mental health services, more comprehensive and cohesive referral pathways, and greater availability of services appropriate to their needs. with few exceptions, the lawyers surveyed were the only source of referral for their unaccompanied child clients. lawyers may represent one potential pathway into services, and training should be provided to support them in this role. however, in order to provide a more comprehensive approach to meeting unaccompanied children’s needs, other mental health care pathways for unaccompanied children should be developed, such as schools (hodes et al., baily, henderson, taub, o’shea, einhorn, verdeli 13 2008; kataoka et al., 2003) and primary health care clinics (rousseau, measham, & nadeau, 2013). as several of the lawyers surveyed noted, the only unaccompanied children who routinely receive mental health services are those mandated to do so because they are detained in government-sponsored detention facilities (women’s refugee commission, 2009). the fact that provision of services is determined more by children’s custodial status than their particular mental health needs is, as derluyn and broekaert (2008) note, a clear example of the favoring of a legal over a psychological framework for their care. the lawyers surveyed consistently voiced the need to increase the availability of appropriate and feasible mental health services for their unaccompanied child clients. the fact that more respondents had referred clients to private practitioners than to other types of mental health care that more typically serve immigrant communities, such as community-based service organizations (wals, 2008), speaks to the lack of programming currently available to unaccompanied children and, presumably, other undocumented immigrant youth. in the absence of such services, lawyers may look to private practitioners to provide services on an occasional, pro bono basis. however, this type of provider is unlikely to be able to respond to a high service demand, or to lead to the development of specialized mental health programming for unaccompanied children. when surveyed lawyers were successful in finding care for their clients, they had mixed opinions regarding the effectiveness of the services they accessed. in particular, several respondents’ comments echoed concerns raised in previous studies about the consistency (united states department of health and human services, 2008) and confidentiality (byrne, 2008) of the services provided to detained unaccompanied children. taken together, the surveyed lawyers’ comments suggest a need for an improved mental health infrastructure for unaccompanied children. such an approach might include aspects of the child advocacy center (cac) model for victims of abuse, which emphasizes the coordination of investigation and intervention services (e.g., law enforcement, child protective services, prosecution, victim advocacy, medical care, and mental health services) to care for children and minimize the number of times they have to retell their stories. the cac model has been shown to improve the effectiveness and efficiency of responding to child abuse cases while reducing harm and discomfort to children and their families (e.g., smith, witte, & fricker-elhair, 2006; jones, cross, walsh, & simone, 2007). community collaborative care models, whereby mental health providers with specialized cultural expertise in the patient population work with other providers (e.g., primary care and social service professionals) to offer sensitive care to vulnerable children and families, have also been proposed as a way of addressing the challenges faced in delivering psychological services to immigrant and refugee children (rousseau et al., 2013). expanding mental health training for lawyers should be prioritized as an important part of any integrated program of services for unaccompanied children. almost all of the lawyers surveyed indicated that they would be interested in further training in mental health considerations when working with unaccompanied children. the large percentage of lawyers who represent unaccompanied youth on an occasional pro bono basis (as opposed to working for a nonprofit organization specializing in work with this population) may benefit particularly from mental health education: this subset of respondents was less likely to have received mental health training, had represented fewer unaccompanied clients, expressed less confidence in identifying these clients’ mental health needs and knowing when to refer, and appeared less aware of the possible benefits of mental health assessment and treatment for their clients’ legal cases. future training should, as respondents suggested, include areas such as identifying common psychiatric symptoms in children, interviewing traumatized children, and facilitating mental health referrals. regardless of the topic area, training should be framed within a child-centered perspective, that takes into account children’s needs, experiences, and developmental (i.e., physical, cognitive, social) processes (nugent, 2006; steinberg, woodhouse, & cowan, 2002). developments in programming for unaccompanied children and the professionals who serve them should go hand in hand with research examining the mental health needs of these youth. the methunaccompanied child mental health: lawyers’ role media 14 odology used in this study (combining outreach via legal organizations and snowball sampling) provided an anonymous and confidential format through which respondents could ethically disclose sensitive and informative details about their cases. the detailed qualitative data provided by respondents suggest that unaccompanied children are a population with complex and frequently unmet psychological needs. further study should investigate children’s psychological needs directly (i.e., through interviews with children and their caregivers). this research should seek to examine risk and resilience processes in this population, and differences in experiences and need between different subsets of unaccompanied children (e.g., youth living in detention versus in the community). research should also investigate the feasibility of different pathways into care (e.g., via primary care, schools, and child welfare services) and different models of service provision. wherever possible, research and programming should seek to enhance a psychological perspective and to identify unaccompanied children’s individual differences, as opposed to their common legal status and predicament (henderson, baily, & weine, 2010). finally, future research and programming should place a strong emphasis on children’s strengths and protective factors, in addition to the challenges they face. limitations this study had a small number of respondents. due to the recruitment procedure, it was not possible to ascertain the survey response rate or how representative the participants were of the general population of lawyers serving this population. of particular relevance for this study, lawyers who chose to participate may have been more invested in mental health referrals and may have been more likely to have observed mental health problems in their unaccompanied child clients than lawyers who chose not to. differential response rates for different survey questions may have created additional bias. furthermore, a survey may not provide the best format in which to inquire about certain sensitive questions, such as the potential legal benefits of a mental health diagnosis. all of these factors limit the generalizability of the findings. new contribution to the literature this is, to the authors’ knowledge, the first study to investigate the mental health needs of immigrant youth from lawyers’ perspectives. it is intended as a first step in research to help address the gap in the literature on the psychological needs of unaccompanied children in the united states. it is also intended to inform psychoeducational interventions for lawyers working with unaccompanied children. the long-term goal of this research is to contribute to the development of feasible, appropriate, 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(2009). halfway home: unaccompanied children in immigration custody (research report). retrieved from women’s refugee commission website: http://www.womenscommission.org/reports/ cat_view/68-reports/71-detention-a-asylum?start=10 interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 39 who are we? social identity and psychological well-being steven pirutinsky and alfred f. mancuso georgian court university social identification – the perception of the self as an exemplar of a social category – forms an essential part of an individual’s identity. previous studies have found a relationship between various forms of social identity (e.g., ethnic, religious, national) and psychological well-being. the current research examines whether strength of social identification, regardless of specific identity and pattern of acquisition, correlates with life satisfaction, self-esteem, depression, anxiety, and stress. one hundred and two participants completed an internet survey including the multicomponent social identity scale and multiple measures of psychological well-being. results indicated that the strength of social identification predicted life satisfaction and self-esteem, controlling for demographic and clinical (i.e., depression, anxiety, and stress) variables. possessing a strong social identity of any type appears to be an important correlate of life satisfaction and selfesteem. potential implications for clinical work are discussed. erikson (1975) defined identity as a subjective sense of personal sameness and continuity in which numerous given aspects of the self, such as appearance, temperament, and abilities, combine with chosen roles, occupations, and relationships. even casual observation of human behavior, however, reveals that beyond an individuated conception of personal identity, lays a collective or social identity to which individuals are emotionally committed and act to preserve (brewer, 1991). these social identities―whether ethnic, national, religious, or occupational―shift focus away from the characteristics that differentiate us from others, and ―towards the perception of self as an interchangeable exemplar of some social category‖ (turner, hogg, oakes, riecher, & wetherell, 1987, p. 50).  early social theorists explored these ideas empirically, finding that self-categorization accentuates perceived similarities between in-group members, exaggerates differences from out-group members, and encourages preference for the in-group (tajfel & turner, 1986; turner et al., 1987). thus, they concluded that social categorization forms an essential part of an individual’s identity. this process appears to be so innate and fundamental that even arbitrary categorization of participants, an experimental procedure known as the minimal group paradigm, elicits these effects (diehl, 1990). despite focusing primarily on inter-group consequences, such as conflict, stereotyping, and preference (brewer, 1991; dosie, 1988; hogg, 1996), many social theorists also endeavor to link social identity with psychological wellbeing. for instance, social identity theory initially proposed that in-group identification and preference results in enhanced self-esteem (hogg & abrams, 1988). others correspondence concerning this article should be addressed to steven pirutinsky, teachers college, columbia university, department of counseling and clinical psychology, box 303, 525 west 120th street, new york, ny 10027. email: sp2813@columbia.edu. suggest that group identification reduces uncertainty by prescribing who individuals are, how they should behave, and how others may react to them (hogg, sherman, dierselhuis, maitner, & graham, 2007). social identity has also been theorized to provide meaning (abrams & hogg, 1988), a sense of belonging (baumeister & leary, 1995), increased self-regulation (twenge, baumeister, tice, & stucke, 2001), protection from death anxiety (solomon, greenberg, & pyszczynski, 1998), and an optimal level of distinctness (brewer, 1991). taken in aggregate, these theories suggest that social identity may be related to overall psychological well-being, which has been generally defined as including increased positive-hedonic indicators, such as self-esteem and life satisfaction, and decreased negative indicators such as depression, anxiety, and stress (e.g., ahren & ryff, 2006; mcdaniel & grice, 2008). however, prior empirical investigation primarily explored the basic mechanisms and motivations of social identity formation with limited consideration of the broader proposition that social identity enhances psychological well-being (greenfield & marks, 2007). moreover, previous research has been limited to exploration of specific social identities in particular theoretical frameworks, such as ethnic identity (mossakowski, 2003; negy, shreve, jensen, & uddin, 2003), religious identity (greenfield & marks, 2007; keyes & reitzes, 2007), national identity (zheng, sang, & wang, 2004), and athletic identity (brewer, 1993). thus, the current research aims to integrate these perspectives and findings by examining if the strength of an individual’s social identity, regardless of type, is correlated with psychological wellbeing, specifically life satisfaction, self-esteem, depression, anxiety, and stress. previous research suggests that social identity is particularly related with the positive facets of psychological well-being (ahren & ryff, 2006). the present study examined if social identity would correlate with life satisfaction and self-esteem beyond the influence of pirutinsky & mancuso 40 depression, anxiety, and stress. specifically, we hypothesized that 1) the strength of an individual’s salient social identity would correlate positively with satisfaction with life and self-esteem (h1); 2) social identity would predict satisfaction with life and self-esteem above the effects of relevant background variables and depression, anxiety, and stress (h2); 3) social identity would predict satisfaction with life and self-esteem, regardless of whether an individual was born into their identity or chose it later in life (h3); 4) all types of social identities (e.g., religious, ethnic, occupational) would equally predict satisfaction with life and self-esteem (h4); and finally, 5) social identity would relate with satisfaction with life and self-esteem among those reporting high and low levels of depression, anxiety, and stress (h5). method participants one hundred and two participants were recruited for a study of ―social identity and psychological well-being‖ through a variety of internet sources including 17 randomly selected newsgroups and several websites listing online psychological research projects. participants ranged in age from 18 to 75 years (m = 35.65, sd = 14.92) with females representing 63% (n = 64) and males 37% (n = 38). fiftynine percent (n = 60) of participants were married and 41% (n = 42) were single. measurement of socio-economic status consisted of education, 46% (n = 58) of the sample reported having a bachelors degree, and income which had a median of $25,001 $50,000 (iqr = less than $25,000 through $75,000). the majority of participants self-reported their ethnicity as caucasian (86%, n = 88), while others reported hispanic (2%, n = 2), african-american (4%, n = 4), nativeamerican (1%, n = 1), and other (6%, n = 6). the vast majority of participants reported residing in the u.s. (70%) with additional participants from a variety of countries including indonesia, uruguay, russia, and israel. instruments to identify participants’ most salient social identity, participants were asked: people often define themselves by the different groups – gender, ethnic, religious, occupational, and social – that they belong to. for example, some may say: ―i am an african-american‖, ―i am an accountant‖, ―i am muslim‖, or ―i am a college student‖. how would you complete the following sentence? ―i am a _________.‖ because individuals are often members of multiple social groups, participants were then asked to complete the statement ―i am a _______.‖ for as many groups as they could, and to select the particular social identity most important to them. subsequently, to assess the strength of their chosen identity, participants completed the multi-component social identity scale (mcsis; leach et al., 2008) referring to their self-selected most salient identity. this 14-item scale draws extensively on previous research (e.g., doosje, 1998; ellemers, kortekaas, & ouwerkerk, 1999; luhtanen & crocker, 1992) and includes a variety of theoretically and empirically derived aspects of social identity, such as individual self-stereotyping, in-group homogeneity, selfinvestment, solidarity, satisfaction, and centrality. items include, ―i think that [in-group] have a lot to be proud of.‖, ―i feel a bond with [in-group].‖, and ―[in-group] people are very similar to each other.‖ these items were rated on a likert-type response scale ranging from 1 (strongly disagree) to 7 (strongly agree). the mcsis has shown both construct, predictive, and discriminant validity across diverse group identities (leach et al., 2008) and was ideal for measuring the diversity of social identities examined in the current research. it was internally consistent (α = .91) in the current sample. in addition, participants indicated if they were born into or chose their salient social identity. to assess psychological well-being, participants completed the satisfaction with life scale (diener, emmons, larsen, & griffin, 1985; swls), the rosenberg (1986) selfesteem scale (ses), and the depression, anxiety, and stress scales short-form (lovibond & lovibond, 1995; dass). these measures are widely used, likert-type scales, and have previously demonstrated reliability and validity (see citations above). in the current sample, these scales were internally consistent with the following cronbach alphas: swls (.91), ses, (.84), dass-depression (.79), dass-anxiety (.73), dass-stress (.76). procedure participants were directed to the survey website, which explained the nature of the study, and asked them to give informed consent in order to proceed. after giving consent, participants were asked to provide demographic information such as age, gender, income (selected from a pre-defined list), occupation, ethnicity (selected from a pre-defined list), and religious affiliation (selected from a pre-defined list). once complete, the participants were directed to choose a salient social identity and completed the mcsis, swls, ses, and dass. upon completion of all survey items, the participants were given contact information for the researchers and the georgian court university institutional research review board, which approved this study. participants were not reimbursed. results social identity selected participants chose a variety of social identities, however, several common themes emerged accounting for 76% of the salient identities. these were family role (e.g., mother and father; 28%), occupation (18%), religion (16%), gender (8%), and nationality (6%). age was unrelated to choice between these categories (f(4, 72) = .10, p = .98), as was income (f(4, 69) = 1.20, p = .32), college degree (χ 2 (4, n = 77) = 3.68, p = .45), gender (χ 2 (4, n = 77) = 6.96, p = .14), religion (χ 2 (12, n = 57) = 9.82, p = .63), and ethnicity (χ 2 (12, n = 73) = 11.56, p = .48). married individuals were significantly social identity and psychological well-being 41 more likely to choose family role and less likely to choose occupational identity (χ 2 (4, n = 77) = 12.84, p = .01). social identity and psychological well-being this study assessed the strength of each participant’s most salient, self-selected social identity (using the mcsis), as well as multiple aspects of psychological well-being. to test our hypothesis that social identity would be related to these outcome variables (h1), we conducted a series of pearson correlations. results indicate that while strength of social identity significantly correlated with swls and ses, it did not correlate with depression, anxiety, or stress (see table 1). depression, anxiety, stress, swls, and ses were all significantly correlated with each other. regressions on satisfaction with life and self-esteem we further hypothesized (h2) that although previous research suggests that stress, anxiety, and depression are important correlates of swl and ses, strength of social identity would positively predict swls and ses, beyond these effects, and beyond relevant background variables. to test this hypothesis, a hierarchal regression analysis was conducted (tabachnick & fidell, 1996) and results are presented in table 2. model 1 included only background variables (i.e., age, gender, income, college degree, and married), which predicted a non-significant portion of the variance (swls, p = .22; ses, p = .19), suggesting that these variables were unrelated to swls and ses in our sample. model 2 introduced the three dass subscales―depression, anxiety, and stress―and the overall model significantly predicted both swls (p < 0.001) and ses (p < 0.001). due to a high degree of co-linearity, individual coefficients for depression, anxiety, and stress could not be interpreted. model 3 added strength of social identity (mcsis), and accounted for a significant amount of variance beyond models 1 and 2 for both swls (p < 0.001) and ses (p = 0.02). these results support our hypothesis (h2) that social identity strength uniquely relates with both swls and ses, above the effects of background variables and negative affect. additionally, h3 suggested that social identity would be an equally important predictor of swls and ses, for both table 1 correlations between social identity, satisfaction with life (swls), self-esteem (ses), and dass 1 2 3 4 5 6 1. mcsis — 2. swls .28** — 3. ses .20* .37*** — 4. dass depression -.06 -.45*** -.47*** — 5. dass anxiety .03 -.36*** -.48*** .76*** — 6. dass stress .02 -.43*** -.45*** .79*** .77*** — note. * p < .05, ** p < .01, *** p < .001 table 2 hierarchical regression on satisfaction with life and self-esteem satisfaction with life self-esteem step/predictor δr 2 b se b β δr 2 b se b β model 1: background variables .07 .07 age -.02 -.07 -.03 .08 .06 .17 gender (1 = male, 0 = female) -3.04 1.71 -.19 .24 1.50 .02 college degree 1.70 1.77 .11 1.19 1.56 .09 income .52 .52 .11 .44 .46 .11 married 1.44 1.75 .09 -1.17 1.55 -.09 model 2: negative affect .21** .20** depression -.91* .41 -.38 -.32 .37 -.15 anxiety .17 .40 .07 -.46 .36 -.22 stress -.50 .41 -.21 -.32 .37 -.16 model 3: social identity .10** .05* mcsis .18** .05 .32 .11* .05 .24 note. * p < 0.05, ** p < 0.001 pirutinsky & mancuso 42 those who chose their identity and those who were born into it. an additional regression analysis examining this interaction was conducted. as per aiken and west (1991), ―born into‖ was dummy coded, (1 = born into, 0 = chosen), and then multiplied with the mcsis (centered) to yield an interaction term. both ―born into‖ and the interaction term (―born into x social identity‖) were then entered into the regression equation described above (model 3; table 3). results indicate that the addition of this interaction did not significantly increase the proportion of variance explained for swls (p = .15) or ses (p = .86), suggesting that social identities, both chosen and born into, equally relate with swls and ses. h4 stated that regardless of type (e.g., religious, ethnic, occupational), the strength of social identity would predict satisfaction with life and self-esteem. to test this hypothesis, membership in each of the five identified social identity categories was dummy coded, and multiplied with the mcsis (centered) yielding an interaction term for each identity type. we then added these interactions to the regression equation (table 3). results indicated that adding the interaction of social identity type and strength of identity did not significantly increase the proportion of variance explained for swls (p = .13) or ses (p = .67), indicating that social identities of all types equally predicted swls and ses. in regards to h5, social identity did not appear to interact with the level of depression, stress, and anxiety (table 3) and was an equally important predictor among both those with high and low levels of distress (swls p = .24; ses p = .38). discussion research suggests that social identity is an innate and fundamental psychological process with implications for psychological well-being. however, previous studies have focused primarily on inter-group processes and specific forms of identity (e.g., ethnic, religious, occupational). these findings can be integrated and suggest that social identities of any type are related to psychological well-being. accordingly, the current study examined the relationship between social identity, social identity type, and negative (depression, anxiety, and stress) and positive indicators of psychological well-being (life satisfaction and self-esteem). consistent with these ideas and the five specific hypotheses presented in this study, we found that individuals reporting strong social identities of any type (e.g., religious, occupational, gender), reported higher levels of both satisfaction with life and self-esteem (h1). this relationship remained significant even when background and clinical (i.e., depression, anxiety, and stress) variables were controlled for (h2). the relationship also held for both identities an individual was born into and those chosen later in life (h3), as well as for each of the diverse types of social identities selected (h4). social identity also equally predicted satisfaction with life and self-esteem for both individuals with high and low distress (h5). these results suggest that having a salient strong social identity significantly relates to both satisfaction with life and self-esteem independent of levels of depression, anxiety, and stress. this finding has important implications for clinical work with individuals struggling with social identity transformations (e.g., acculturation, academic and occupational transitions, disability, religious change, and divorce), since beyond targeting specific symptoms (e.g., depression and anxiety), clients may also benefit from the reacquisition of a strong positive social identity. although psychotherapy increasingly focuses on symptom relief (e.g., barlow, 2008), our results suggest that an additional consideration of identity and identity formation is relevant to improving positive-hedonic aspects of psychological wellbeing. in general, most research studies and theoretical models have focused on one aspect of social identity (e.g., race, gender, religion). while this approach highlights important table 3 interaction of mcsis with “born into,” social identity type, and distress satisfaction with life self-esteem step/predictor δr 2 b se b β δr 2 b se b β adding “born into” .01 .001 born into x mcsis -.16 .12 -.14 .03 .11 .03 adding social identity type .04 .05 family role x mcsis -.08 .15 -.06 -.22 .14 -.21 occupation x mcsis .14 .15 .11 -.13 .14 -.12 religion x mcsis .15 .13 .16 -.20 .13 -.12 gender x mcsis .09 .28 .03 -.57 .27 -.22 nationality x mcsis -.50 .35 -.13 -.14 .33 -.04 adding personal distress .05 .01 depression x mcsis .06 .03 .35 -.02 .03 -.12 anxiety x mcsis -.05 .03 -.29 .02 .03 .12 stress x mcsis -.04 .03 -.24 -.01 .03 -.07 note. * p < 0.05, ** p < 0.001 social identity and psychological well-being 43 issues that are often marginalized, our findings suggest that multiple forms of social identity factor into life satisfaction and self-esteem. this is unsurprising, given that the psychological and neurological mechanisms underlying group affiliation and social identity are likely consistent across multiple forms of identity (brewer, 1991). given these results, perhaps it is time to integrate the divergent lenses through which various aspects of human social identity have been considered and begin integrating these perspectives into a common conceptualization of social and group identity. limitations this research was limited by use of a self-selected, internet sample, which was necessary to obtain a broad and diverse assortment of social identities, but may limit the generalizability of the study findings. another limitation is that the dass instrument appeared to be only moderately internally consistent; future research using a more reliable measure is needed. additionally, due to the correlational nature of this research, any causal interpretation of the link between social identity and psychological wellbeing should be cautiously viewed. further longitudinal or experimental research examining the process of social identity formation and disruption is necessary. finally, the broad measure of identity used did not elicit the content – or diverse meanings, roles, and attitudes – implicit in a specific social identity. these aspects of identity can be expected to differ, and thereby influence the relationship between social identity and psychological variables. for example, an identity of ―criminal‖ or ―mentally ill‖ would likely have very different consequences than the identity of ―student‖ or ―accountant.‖ future research can also explore the extent to which socio-economic status influences the choice and importance of social identities. nevertheless, the current research sheds light on the link between social identity, satisfaction with life, and self-esteem demonstrating the utility to future research. in conclusion, although previous research consistently relates a variety of social identities with psychological outcomes, our results integrate these findings and suggest that possessing a strong social identity of any type is an important correlate of satisfaction with life and self-esteem. references ahren, c., & ryff, c. 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(2004). acculturation and subjective well-being of chinese students in australia. journal of happiness studies, 5, 57-72. doi:10.1023/b:johs.0000021836.43694.02 graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 57 expanding the biopsychosocial model: the active reinforcement model of addiction annie hunt teachers college, columbia university the contemporary understanding of addiction is expanding rapidly as emerging research across multidisciplinary fields informs treatment and intervention techniques. current prevention efforts work from the well-accepted biopsychosocial model and are aimed at identifying the underlying causes of addiction and attempting to block them from manifesting, primarily through educational methods. however, once an addiction has already emerged, intervention and treatment efforts should operate from a more comprehensive conceptualization of addiction that takes into account more than just underlying factors – these efforts must address how these factors are currently operating and reinforcing one another. the active reinforcement model proposed in this paper addresses the mechanisms of action that govern the relationships among three primary elements of addiction: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this model serves as a more comprehensive conceptualization of addiction as it accounts for each of the present factors and places them in an interdependent context. thus, while the biopsychosocial model effectively addresses the underlying causes of addiction, the proposed active reinforcement model addresses the mechanisms of existing addictions in a more comprehensive manner. a better description of the relationship between each element provides a deeper understanding of the full phenomenon of addiction, and may therefore be more effective in generating successful treatment outcomes than previous models. introduction to addiction medical, psychological, and social understandings of addiction have evolved rapidly over the past century, and contemporary addiction research and treatment is becoming increasingly interdisciplinary. addiction studies, initially based in the field of pharmacology, now incorporate psychological, neurobiological, genetic, environmental, social, and spiritual considerations. furthermore, addiction is being studied in schools of social work, public health, medicine, and psychology. addiction has thus become a multi-disciplinary construct that necessitates a wide range of understanding from contemporary practitioners, and as this understanding expands, the professional obligation to maintain a consistent and regulated standard of practice becomes significantly more challenging. standardized clinical practices in the field of addiction are developed, tested, and disseminated through clinical research, and the myriad factors influencing this field present an interesting challenge for researchers who must take them into consideration when designing and implementing studies. these studies are the mechanism for generating empirically based findings, which are the necessary prerequisite in allowing new considerations to be incorporated into standardized treatment options. in order to increase evidence-based treatment options in response to the expanding conceptualization of addiction, one must first begin with a clear understanding of the current state of the field, and then propose areas for further academic consideration and research. the starting point for this process is the diagnostic and statistical manual of mental disorders (dsm), originally published in 1952, which significantly influences treatment options, research, insurance policies, public opinion, and social stigma. while the dsm acknowledges that the diagnostic classification process is a challenging one, and that there are no strict boundaries dividing one disorder from the others or from no mental disorder at all, it does offer a professional consensus about the categorization and identification of mental disorders at the time of its publication (dsm-5; american psychiatric association, 2013). thus, it provides a reliable tool for establishing standards of diagnoses, terminology, and criteria for classification while at the same time emphasizing the importance of flexibility, appropriate training, and cultural sensitivity during clinical application. addiction terminology. chemical and behavioral addictions have long been recognized as serious and prevalent psychological problems throughout history, so it is interesting that the most recent version of the dsm—the fifth edition, annie hunt is now a clinical case manager at the mental health center of denver. correspondence concerning this article should be addressed to annie hunt, 1850 bassett street, apt. 307, denver, co 80202. email address: anniehunt1@gmail.com. 58 published in may 2013—does not actually include the term “addiction” (apa, 2013). the category used in the dsm-5 to describe the phenomenon colloquially referred to as chemical or substance addiction is titled “substance use disorder,” and it combines the former categories of substance abuse and substance dependence (from the dsm-iv) into a single disorder that is to be measured on a scale from mild to severe (apa, 2013). neither did the previous edition, the fourth edition, text revision, published in 2000 by the american psychological association, include the term “addiction,” as the term ‘dependence’ won out over ‘addiction’ by one vote during the last revision process (dsmiv-tr, apa, 2000; o’brien, volkow, & li, 2006). specific and accurate terminology plays an important role in the conceptualization of this phenomenon. according to the national institute on drug abuse (nida), the term “dependence” indicates a physiological need or dependency on a substance. this is evidenced by a biological adaptation to the substance in which the body requires more of it to achieve an effect (the phenomenon of tolerance) and also manifests physical indicators if use is suddenly stopped (the phenomenon of withdrawal; nida, 2012). physical dependence, however, can occur with continued use of many different substances, including those taken as prescribed, and does not necessarily include the psychological or behavioral consequences that characterize an “addiction” or “disorder.” the term “disorder,” according to the apa (2012), includes the following: 1. a behavioral or psychological syndrome or pattern that occurs in an individual 2. that reflects an underlying psychobiological dysfunction 3. the consequences of which are clinically significant distress or disability 4. must not be merely an expectable response to common stressors and losses or a culturally sanctioned response to a particular event 5. that is not primarily a result of social deviance or conflicts with society. thus, “disorder” indicates the presence of behavioral and psychological symptoms, but fails to clearly articulate the aspect of compulsory repetition that the terms “dependence” or “addiction” include in their definitions. finally, the term “addiction,” according to the national institute on drug abuse, indicates compulsive use of a substance despite harmful consequences, such as failure to fulfill social, work, or family responsibilities, and an inability to stop using the substance of one’s own accord (2013). additionally, according to the apa website, addiction falls under the category of “mental health disorders/ issues,” and is defined as “a chronic brain disease that causes compulsive substance use despite harmful consequences” (apa, 2012). arguably, the most comprehensive and specific definition of addiction comes from the american society of addiction medicine (asam; 2010), who define an addiction as: a primary, chronic disease of brain reward, motivation, memory and related circuitry . . . [which] is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. (asam, 2010) it is interesting to compare the terms to identify differences as well as overlaps. according to the above definitions, dependence on a substance does not necessarily constitute an addiction, and an addiction does not necessarily involve physiological dependence (nida, 2012). furthermore, a disorder does not necessarily constitute an addiction. these terms therefore cannot be used interchangeably, as they each indicate the presence of different symptoms it should be noted, however, that the dsm-5 does use the category of “addictive disorders” to describe pathological gambling as a behavioral addiction (apa, 2013). this is the only condition listed in this category, despite general clinical recognition of other non-chemical, behavioral addictions such as sex addiction, internet addiction, compulsive tanning, hunt 59 and compulsive shoplifting (e.g., grant, potenza, weinstein, & gorelick, 2010). neither the nida definition of disorder nor the apa definition of addiction include non-chemical addictions, despite the widespread social, medical, and cultural call for recognition and treatment of these particular problems (griffiths, 2000; wang et al., 2013). this paper argues that one of the most critical aspects of active addiction treatment is addressing the phenomenon of being unable to stop certain substance use or behaviors solely of one’s own volition – namely, the compulsive aspect of the condition regardless of known negative consequences. as of the most current edition, the dsm still does not comprehensively articulate the presence and significance of this symptom. the continued exclusion of this component indicates that at this point in time, contemporary research has still not sufficiently pinpointed what exactly this phenomenon is, what it involves, how it operates, and how to address it. it is this phenomenon that the proposed active reinforcement model attempts to describe, validate, and address by drawing together parts of prior conceptualizations and constructing a more comprehensive model. this paper argues that once an addiction is manifest, it is actively reinforced by the relationships between three essential factors: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior, the combination of which results in the compulsive aspect of the phenomenon. understanding the relationship between these factors and how they actively reinforce addiction would offer a starting point for developing interventions aimed at disrupting these relationships. previous conceptualizations of addiction. addiction has previously been conceptualized using different models, with the most historically prominent being the “adaptive” and the “disease” models. the adaptive model preceded the disease model, and suggested that addictions develop when specific psychological needs – such as acceptance, autonomy, competence, or confidence – are not met; this was also termed “integration failure” (alexander, 1990). the adaptive model argues that addictions develop to meet these specific psychological needs, and that the addictive behavior provides a sense of support, reassurance, or meaning that individuals feel is missing in their lives. the disease model, also sometimes called the medical model, posited that addiction is neither an issue of failed willpower nor the result of conscious repeated habitual behavior, but is rather a chronic, progressive medical illness characterized by abnormalities or defects in brain functioning (sheehan & owen, 1999). silkworth (1939) was one of the pioneers of this model, originally applying it to alcohol dependence. in the primary text of the alcoholics anonymous program, he described alcoholism as an unusual or distorted behavioral response to alcohol consumption, and described problematic chronic drinking as a manifestation of a “physical allergy” to alcohol (alcoholics anonymous, 2001). sheehan and owen (1999) argue that the disease model represents a more comprehensive explanation of addiction through its depiction of neurological deficits and abnormal behavioral responses. these models offered initial foundations for the development of addiction studies and treatment, and they remained prominent until the emergence of george engel’s “biopsychosocial model” (engel, 1978). current conceptualization of addiction. the biopsychosocial model, which is used to describe many different mental disorders, is arguably the most prominent construct used to conceptualize addiction today (alonso, 2004). this model built upon the disease model by accepting that addiction involves abnormalities in brain functioning, but then expanded that model by integrating the subjective psychological experiences of individuals into the conceptualization of illness. it suggests that an understanding of the patient’s subjective experience is critical in developing accurate diagnoses and successful treatment options (borrel-carrio, suchman, & epstein, 2004). the biopsychosocial model thus seeks to explain suffering, disease, and illness as generated by multiple causes, including social, biological, and psychological factors. this inclusion of subjective psychological components into the disease model expands the concept of addiction to include individual experiences, perceptions, stressors, and perspectives as mediating the active reinforcement model of addiction 60 factors in the expression of clinical illnesses and medical problems. thus, this model helps to bridge the gap between the medical and psychological fields, and is extensively accepted in the field of addiction studies and psychology today (alonso, 2004). drawing from the above-mentioned previous and contemporary definitions of addiction, three core elements of addiction can be identified – unmet psychological needs, impaired neurological mechanisms, and problematic behaviors. however, the adaptive and disease models do not sufficiently describe the relationships involved in the phenomenon of addiction because they suggest simple linear causality between either coping and problematic behaviors or disease and problematic behaviors. this paper argues that the previous conceptualizations of addiction, including the biopsychosocial model, do identify the core elements of addiction, but fail to sufficiently demonstrate the reciprocal relationships among them. emerging research reveals evidence that unmet psychological needs, impaired neurological mechanisms, and problematic behaviors can act as both causes and effects in the construct of addiction (castellani, wedgeworth, wootton, & rugle, 1997; grant, brewer, & potenza, 2006; hyman & malenka, 2001). while the biopsychosocial model offers a more substantive argument for acknowledging the presence of combined psychological and biological/ pharmacological factors in the development of addiction, and partially identifies some of the relationships involved among these factors, it does not offer a comprehensive conceptualization of all of the relationships between these factors that contribute to active addiction and compulsive behaviors. it states that these different factors play a role in impacting outcomes, and that there is a relationship between biological/psychological elements and external functioning, but it makes use of an eclectic approach that does not specifically or explicitly describe how that relationship functions and impacts addiction (ghaemi, 2009). furthermore, it fails to establish the impact that psychological factors have on neurobiological factors, the impact that neurobiological factors have on psychological factors, and the reverse impact that dysfunctional behaviors may have upon psychological and biological functioning—an important new relationship that has been demonstrated in emerging research (hyman & malenka, 2001). this paper will propose a new model that includes the critical elements of addiction and places them in an interdependent context that offers a more comprehensive understanding of how addictions function. it will also defend each of these relationships with recent research findings. proposed “active reinforcement model of addiction.” current research consistently indicates the presence of neurological, psychological, and external/behavioral components in the overall conceptualization of addiction, though each element may have varying degrees of intensity and causality (i.e., one element may be more powerful or have more influence than others, depending on the individual; grant, brewer, & potenza, 2006). this paper argues that there is a cause-effect relationship between all three elements, meaning that each element both influences and is reinforced by the other two elements. in light of this knowledge, a new model, entitled the “active reinforcement model of addiction” (figure 1), is proposed. from this conceptualization, the critical principle that emerges is not the importance of determining which element came first, or finding an underlying reason for why the addiction emerged. rather, the focus is shifted to the importance of acknowledging how all three coexist and reinforce one another in an interdependent context once an addiction has become active. from there, an altered focus for treatment and interventions can be proposed, again shifting the focus of treatment techniques from why to how addictions function. prevention efforts generally focus on the question of why addictions develop and use education, risk protection techniques, and resilience training based on the proposed answers to this question, though there still is no consensus on exactly what causes addiction (samhsa, 2013). the field is full of varying hypotheses and theories that attempt to explain addiction’s underlying causes in order to create successful prevention efforts and education programs aimed at stopping addiction before it starts. hunt 61 this paper, however, is not focused on prevention efforts, but rather proposes use of a different model to guide treatment of active addictions. prevention efforts are distinctive from treatment efforts, according to the american society of addiction medicine, though they may both be used concurrently in certain circumstances (asam, 2005). treatment, according to asam, is aimed at helping individuals currently suffering from an addiction. once addiction symptoms (according to either the dsm or apa criteria) are manifest, prevention models should be substituted for a working understanding of how the addiction is actively functioning. while research on preventive measures is valuable and will continue to hold its place in the field, this paper argues that addiction treatment and intervention should be based on a more comprehensive conceptual model of how addictions are actively sustained. as demonstrated by the figure above, the phenomenon of addiction is sustained by the presence of and relationship among three elements: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this model serves as a comprehensive conceptualization of addiction that incorporates the main elements of addiction and places them in an interdependent context. it helps to organize the concept of active addiction into a structured mechanism defined by reinforcing relationships, which may allow studies and interventions to specifically focus on particular sections or relationships in the model. at the same time, it also offers a full depiction of the phenomenon, which may help to remind practitioners that each element and relationship must be attended to in treatment. this paper will describe how many existing theories and interventions fit directly into the active reinforcement model, and will explain how each encompasses one or some of the six relationships described: a → (causing) b, a → c, b → a, b → c, c → b, and c → a. any element, standing alone or impacting only one of the other elements, does not necessarily lead to the emergence of an addiction. this model theorizes that all relationships must be present to some degree in order to constitute an active addiction. this paper will begin to justify this theory by examining the current working definition of what the term “addiction” means. definition of addiction (a, b & c) all people engage in self-regulatory behaviors in response to their biological, psychological, social, and spiritual wants and needs (bandura, adams, & beyer, 1977). many people use substances or engage in risky behaviors to meet these needs, and these do not always develop into disruptive or chronic patterns of use. the crossover from substance use or occasional dysfunctional behavior to the full manifestation of addiction is ambiguous and difficult to define. one must consider the motivations for, frequency and intensity of, and consequences of the substance use or dysfunctional behavior in order to determine whether it can be considered problematic (c). as noted previously, the dsm acknowledges that there are no absolute boundaries in diagnoses, and the same flexibility must be utilized when attempting to define addiction (apa, 2013). despite the challenge the phenomenon of addiction poses, it is still critical to develop a generally accepted working definition so that researchers and clinicians can work toward standardizing the field, developing best practices, and regulating the associated treatment options for addiction. the american society of addiction medicine’s definition of addiction, previously quoted in this paper, clearly supports the concept of a biological the active reinforcement model of addiction figure 1: active reinforcement model of addiction. this figure illustrates the critical relationships that reinforce active addiction. 62 element in the reinforcement model of addiction, suggesting that neurological dysfunction (a) directly causes problematic psychological (b) and behavioral (c) manifestations (a → b, a → c). it also indicates that the behavior (c) in turn can affect psychological and emotional components (b) of the individual’s life (c → b). in the longer definition, asam goes on to explain that brain “morphology, connectivity, and functioning are still in the process of maturation during development and young adulthood, and early exposure to substance use is another significant factor in the development of addiction” (asam, 2011). this suggests that dysfunctional behaviors such as chemical abuse (c) also impact brain development (a) in a phenomenon known as “neuroadaptation” (c →a; asam, 2011). it is worthwhile to note that this definition includes both “substance use and other behaviors” in its definition, and that the inclusion of both chemical and non-chemical addictions is a critical element to the reinforcement model, as will be discussed later. thus, asam’s definition of addiction fits into the proposed model, and supports some of the relationships it describes (a →b, a → c, c → − a, c → b). another widely-recognized definition of addiction came from the former president of the american society of addiction medicine, dr. michael miller, who stated: at its core, addiction isn’t just a social problem or a moral problem or a criminal problem. it’s a brain problem whose behaviors manifest in all these other areas . . . [the] disease is about brains, not drugs. it is about underlying neurology, not outward actions. (smith, 2011, p. 901) this statement also directly supports the reinforcement model, and demonstrates the significance of neurophysiology in affecting the full conceptualization of addiction (a → b, a → c). goodman (1990) proposed a similarly well-accepted definition of addiction: addiction may be defined as a process whereby a behavior that can function to produce pleasure and provide relief from internal discomfort, [and] is employed as a pattern characterized by (1) recurrent failure to control the behavior (powerlessness) and (2) continuation of the behavior despite severe negative consequences (unmanageability). this definition highlights the behavioral element included in the reinforcement model, and defines what is meant by “dysfunctional” behavior (c) and psychological causes and consequences (b). while it does not specifically mention non-chemical behaviors, it does not explicitly exclude them, and as such they too can be incorporated into this conceptualization. furthermore, this definition addresses the impact that these behaviors have on psychological functioning, and supports and fits into the reinforcement model (b → c, c → b). smith and seymour (2004) included the additional element of “compulsive use or engagement in the behavior” to this definition, which suggests an underlying biological urge (a → c). moreover, they suggested that addictive behaviors (c) are used to gain either psychic (mood-related), recreational (social or activity-related), or instrumental achievement (performance-related) rewards (b). this also directly ties into the reinforcement model in that it explains the relationship that dysfunctional behaviors can have on psychological functioning and the attainment of needs (c→ b). application of the term “addiction” to both chemical and behavioral disorders. one critical theoretical consideration that supports the reinforcement model is the inclusion of non-chemical or behavioral dependencies (c) in the broader conceptualization of addiction. chemical dependencies alone are not necessarily considered dysfunctional, as many medical patients develop dependencies even when they take their medications as prescribed. these dependencies do not necessarily result in a compulsive or disruptive pursuit of chronic use. dependencies become dysfunctional only once they develop causal relationships with psychological and biological processes (c → b, c → a). additionally, certain behaviors, such as gambling, hand-washing, or exercising, are not considered dysfunctional on their own—these behaviors only become dysfunctional when they disrupt psychological and biological processes (c →b, hunt 63 c → a), resulting in a non-chemical addiction. for example, hand-washing is a normal human behavior, but if it becomes a psychological obsession and an individual feels compelled to do it repetitively, then it has developed into an addiction (c → a, c → b). traditionally, the clinical terms “addiction” and “addictive behavior” have been applied exclusively to substance abuse and dependency, but there is growing empirical evidence of a related category of “nonchemical” addictive behaviors, “including gambling, eating disorders, and sexual behavior,” that have recently been included in the conceptualization of addiction (donovan & marlatt, 2005, p. 4). there are easily recognizable external patterns that are similar between chemical and behavioral addictions, including tolerance, withdrawal, repeated unsuccessful attempts to stop, and significant impairment in areas of life functioning. however, the emerging recognition of biology’s influence on addiction has encouraged researchers to explore whether behavioral addictions and substance addictions recruit similar biological processes (a → c, c → a; grant, brewer, & potenza, 2006). brain science and neural imaging have begun to validate food and sex addictions, compulsive shopping and gambling, and eating disorders, among others, as “process,” “non-chemical,” or “behavioral” addictions that can be included in the new, broader category of addiction disorders. emerging research indicates that dysfunctional behaviors can be powerful determinants of psychological functioning (c → b) and can also cause neuroadaptation (c → a; lubman, yucel, & pantelis, 2004; hyman & malenka, 2001). it has also been demonstrated that dysfunctional behavior can be the direct result of brain deficits or maladaptive psychological states (a → c, b → c) (grant et al., 2006). these findings support the incorporation of non-chemical addictions into the reinforcement model, as they follow the same relationship patterns of chemical addictions. this recognition greatly enhances the argument for the reinforcement model of addiction, as it helps to illuminate the interconnectedness of both internal and external factors involved in this phenomenon, regardless of the involvement of substances and chemicals. the 2013 dsm revisions reflect this increasing awareness of the role of non-chemical dysfunctional behaviors in the construct of addictions through their inclusion of “gambling disorder” (apa, 2012). this movement to include a non-chemical addictive disorder demonstrates that researchers and practitioners are migrating toward the general understanding that both chemicals as well as behaviors can impact neuroadaptation within the brain’s reward system (c → a). smith (2012) reinforced this by stating that addiction disrupts the areas of the brain responsible for regulating cognitive, emotional, and social behaviors, and marks suggested that “syndromes of behavioral addiction share [similar neurological] features with those of substance abuse . . . [including] obsessive-compulsive disorder, compulsive spending (including gambling), overeating, hypersexuality, kleptomania, and perhaps trichotillomania, tics, and the tourette syndrome” (c → a, c → b; marks, 1990, p. 1389). as supported by these findings, both chemical and behavioral dependencies can be included in the reinforcement conceptualization of addiction. the emerging understanding of the ability of external behaviors to influence brain chemistry, as well as the recognition that brain chemistry affects external behaviors, demonstrates that these two factors are mutually influential (a → c, c → a). thus, including problematic and dysfunctional behaviors that do not include chemicals greatly supports the active reinforcement model, and further illuminates the extent to which external factors influence internal processes and vice versa. three core components and six core relationships the psychological and behavioral components of addiction have been well established in contemporary research, so an extensive discussion of these elements is not necessary in this paper and they will be only briefly mentioned below. research on the neurobiological components, however, is the more recent and emerging area that will be discussed in more detail. psychological components of addiction (b → a, b → c) the active reinforcement model indicates a distinct relationship between psychological components the active reinforcement model of addiction 64 (b), such as stressors, the effects of environmental influences, thoughts, and emotions, upon both the brain as well as behavior (b → a, b → c). there are numerous studies that support the causal relationship between unmet psychological needs and dysfunctional behaviors, as well as the impact of psychological stress on brain chemistry and neurological functioning (b → c, b → a) (castellani et al., 1997; whang, lee, & chang, 2003; young, boyd, & hubbel, 2000; sinha, 2001). these two relationships in the reinforcement model of addiction are well established, and a detailed discussion of these two mechanisms can be easily found in contemporary literature and is thus beyond the scope of this paper. one particularly good explanation of these relationships can be found in franken (2003), who explains the relationship between psychological urges and their impact upon neurological functioning and addictive behaviors. behavioral components of addiction (c→ a, c→ b) as previously mentioned, dysfunctional or risky behaviors alone do not comprise addiction. dysfunctional behavioral or chemical dependencies only become addictions when they develop relationships with the psychological and neurobiological elements of the active reinforcement model. this means that when a behavior or chemical use becomes a method of psychological coping to deal with stress, or when the individual feels compelled to engage in this behavior due to pressing internal impulses, the full relationship of these factors manifests as an active addiction (c → a, c → b). there are numerous studies that demonstrate the wide range of addictive behaviors, including both non-chemical and chemical dependencies, and a discussion of all of the behavioral elements associated with addiction is beyond the scope of this paper. for a more detailed discussion of these relationships, see smith (2012), smith and seymour (2004), marks (1990), or hyman and malenka (2001). neurobiological components of addiction (a → b, a → c) while the current definitions of addiction explain some of the neurological and psychological influences on behavior (a → c, b → c), it is critical to also incorporate recent research that indicates that behaviors influence neurological and psychological functioning (c → a, c → b). this research indicates that behaviors can contribute to neuroadaptation and psychological problems (lubman, yucel & pantelis, 2004). an individual may not necessarily have an underlying neurological deficit to begin with, but could develop one as a result of engaging in dysfunctional behavior or encountering psychological stressors (lubman et al. 2004). thus, neurobiology is not necessarily the primary causative factor of this phenomenon. the active reinforcement model effectively demonstrates both the significance as well as the relationship of neurobiology to the overall conceptualization of addiction, instead of placing it as the primary causal factor. the active reinforcement model indicates that neurobiology both influences and mediates the relationship between dysfunctional behaviors and psychological issues, and in combination with these factors it can generate chemical or behavioral addictions. neuroimaging and neuropsychological studies have revealed clear differences in brain function between chronically addicted and non-addicted individuals, suggesting that addiction is indeed associated with alterations in brain functioning and neuropsychological changes (lubman, yucel, & patelis, 2004; a → c, c → a). the research they describe has been primarily focused on the brain’s reward pathways, which involve dopamine and serotonin receptors. dopamine and serotonin are neurotransmitters released by the brain as a result of certain actions and behaviors, and they are associated with the experience of pleasure and reinforcement and can function as ‘rewards’ in the brain. hyman and malenka (2001) report that the chemicals released as a direct result of engagement in addictive behaviors are both rewarding, or interpreted as intrinsically positive by the brain, as well as reinforcing, meaning that the behaviors involved with these rewards tend to be repeated (c → a, a → c). thus, substances and behaviors that produce these neurotransmitters can become very powerful reinforcers that influence future behavior and can result in inhibitory dysregulation (hyman & malenka, 2001). this means that individuals either develop lowered inhibitions against risky behavior or experience urges so strong that they overwhelm typical inhibitions (c → a; lubman et al., 2004). hunt 65 tolerance. neurochemical changes in response to addiction often manifest in the development of tolerance, defined as a decrease in the effect of an addictive substance that often results in more frequent or intense engagement in addictive behavior (a → c). individuals who develop these altered brain states may demonstrate tolerance as “reward deficiency syndrome, a hypothesized hypo-dopaminergenic state involving multiple genes and environmental stimuli that puts an individual at high risk for multiple addictive, impulsive, and compulsive behaviors” (a→ c; grant et al., 2006, p. 925). this hypo-dopaminergenic state is one of the proposed mechanisms of brain chemistry in addiction. lower levels of dopamine (or decreased activation of dopamine circuits and receptors) may result in an individual’s increased attempts to compensate for these deficits through particular chemicals or behaviors (a → c). higher levels of tolerance can promote increased and frequent use, which may then result in dependence (c → a). sensitization. another result of chronic addiction is sensitization. this occurs through enhanced reward responses in the brain resulting from repeated administration of a substance or engagement in an addictive behavior (c → a; hyman & malenka, 2001). individuals who develop more sensitive brain states may experience a higher level of euphoria after engaging in behaviors that release dopamine or serotonin. due to the experience of more substantial “rewards,” they may have greater difficulty in controlling impulses to engage in and continue addictive behavior (c → a, a → c). with chronic use of or engagement in these behaviors, adaptations at genetic, molecular, and cellular levels occur within distinct brain regions that counter acute drug effects in an attempt to maintain internal homeostasis (c → a). when intake of the substance ceases, these neuroadaptations initially persist and act unopposed, resulting in a characteristic rebound syndrome, or “withdrawal” (lubman et al., 2004). hyman and malenka (2001) note that this response can develop beyond just a physical or psychological liking of one’s addictive behavior into the experience of intense urges or “wanting.” it is at that point that physical dependence can cross over to compulsive desire and pursuit as neurological systems become hypersensitive, which significantly increases the incentive to seek out these stimuli (a → c, c→ a; hyman & malenka, 2001). disrupting the relationships between the active elements of addiction as discussed, the active reinforcement model of addiction demonstrates six relationships between three primary elements of addiction: biological deficits (a), unmet psychological needs (b), and dysfunctional behaviors (c); these relationships are described as a → b, a → c, b → a, b → c, c → a, and c → b. any of these elements in isolation do not necessarily indicate an addiction, and as such cannot be considered primary causal factors of this phenomenon. for example, an individual can engage in dysfunctional or risky behavior without it affecting their psychological or biological functioning. similarly, one may experience stress from unmet psychological needs but never turn to dysfunctional behavior as a coping mechanism, or may suffer from neurological deficits without the additional experience of unmet psychological needs or attempting to compensate for these deficits behaviorally. rather, it is the relationships among these factors – not the factors themselves – that indicate an active addiction. therefore, this model suggests that addiction treatment research should be devoted to disrupting these mechanisms and developing interventions to block the relationships between the factors that combine to sustain addiction (indicated by the sign x). a comprehensive treatment plan must therefore involve interventions to disrupt these relationships (a x b, a x c, b x a, b x c, c x a, c x b). addressing and resolving one element can reduce the severity of the addictive behavior, but this paper argues that attention to all three factors and their respective relationships with one another is vital to successful, comprehensive addiction treatment. treatment of biological factors (a x b, a x c) emergency care. the very first step in addiction treatment is to focus on the most urgent needs of the client (wallace, 2005). this typically involves meeting essential physiological requirements and ensuring that basic physical functioning is supported and maintained, as many clients cannot take action in addressing problem behaviors if they are not first the active reinforcement model of addiction 66 stabilized (wallace, 2005). regardless of whether clients enter addiction treatment voluntarily or not, they can initially present in a state of shock, trauma, severe emotional disturbance, despair, depression, and other varying states of instability, and at that stage they may not be capable of identifying or attending to their basic needs. thus, prior to any psychological interventions, the client must be placed in a safe, calm environment without easy access to their addictive drug or behavior, and they must be thoroughly screened for any pressing physiological problems that can be immediately addressed (a x b, a x c). this includes any kind of treatment of overdose symptoms, medicine for management of withdrawal symptoms during detoxification, administration of essential nutrients or electrolytes for severe cases of eating disorders, and other related medical treatment. pharmacological treatment. the use of prescription drugs to treat neurobiological deficits is a critical component of addiction treatment. this has become the subject of extensive research as the conceptualization of addiction as a brain disease becomes more prevalent. while a full discussion of the pharmacological component of addiction treatment is beyond the scope of this paper, it is worth noting that the emerging trends of successful prescription drug use in the treatment of addiction often involve drugs associated with supporting or enhancing the serotonin or dopamine pathways of the brain (grant et al., 2006). alleviating these neurological deficits can directly promote psychological health and reduce engagement in dysfunctional behaviors as coping mechanisms (a x b, a x c; grant et al., 2006). treatment of psychological factors (b x a, b x c) interdisciplinary approaches to addiction studies have allowed for more comprehensive incorporation of the psychological aspects of addiction. there have been several widely recognized movements that have defined and influenced the field as it relates to addiction treatment, and while there are many different orientations to psychological counseling, one of the primary approaches – cognitive behavioral therapy – will be discussed here as an example of a psychological treatment that can be directly incorporated into the active reinforcement model. the cognitive-behavioral orientation is one of the main approaches used in addiction treatment today, and it purports that that human thoughts and behavior are driven by the conditioning and reinforcement that people experience throughout their lives (b → c). dysfunctional thoughts and behavior, such as behavioral and chemical addictions, are considered to be the result of the development of inaccurate and unhealthy life schemas, which are the mental framework used to organize information about the self and the external world (b → c) (alford & beck, 1997). the goals of cognitive-behavioral therapy are therefore to focus on individual problematic behaviors and thoughts, identify their origins and influences, and challenge and change them as needed to promote healthier psychological functioning and recovery (b x c). cognitive-behavioral therapy, or cbt, developed out of this psychological orientation and is prominent in addiction treatment programs today. it is a highly standardized therapeutic process that utilizes such techniques as identifying individual goals, focusing on present problems, exposure therapy, cognitive restructuring, behavior change, and psychoeducation (b x c). thus, while there are many approaches to the treatment of the psychological factors of addiction, cbt is one example of a well-established practice that is compatible with and supports the active reinforcement model. treatment of behavioral factors (c x a, c x b) a final critical component of the active reinforcement model is the existence and relationship of dysfunctional behaviors and their impact on both psychological functioning and neurology. the most prominent treatment approach is the promotion and facilitation of abstinence or sobriety from dysfunctional behaviors or chemical dependencies as a way to disrupt the final relationships in this model (c x a, c x b). other approaches, such as the harm-reduction model, emphasize the importance of moderation, self-regulation, honest and open self-reporting of engagement in problematic behaviors, and other measures to significantly reduce engagement in disordered behavior (marlatt & tapert, 1993). one critical aspect of intervention efforts aimed at treatment of behavioral factors is the consideration hunt 67 of replacement behaviors that may be utilized in the absence of the typical addictive behavior, and the importance of providing the client with adaptive rather than harmful substitutes for these behaviors (shaffer et al., 2004). treatment of behavioral factors also involves a combination of the techniques used to treat the neurological and psychological aspects of addiction, and each of the interventions described above also work to disrupt the relationships between dysfunctional behaviors and psychological or neurological mechanisms (c x a, c x b). conclusion the working conceptualization of addiction continues to develop as emerging research across multidisciplinary fields informs treatment and intervention techniques. while prevention efforts are often aimed at identifying the underlying causes of addiction, intervention and treatment should operate from a more comprehensive conceptualization of addiction that is focused on the mechanisms of action among three primary elements: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this paper argues that all three must be present and involved in an active relationship with one another for an active addiction to be manifest. thus, the proposed active reinforcement model serves as a more comprehensive conceptualization of addiction that accounts for and incorporates all of the elements of addiction and places them in an interdependent context that may be more effective in generating successful addiction treatment outcomes than previous models. the next steps in validating the proposed model are to evaluate it using research studies and psychometric evaluations. one of the most critical aspects of this model is its comprehensive incorporation of multiple concepts of addiction, and demonstrating its effectiveness empirically could start with an evaluation of each of these elements and the six relationships described by the active reinforcement model. demonstrating the validity of these individual relationships empirically and introducing intervention efforts intended to disrupt them would support the relevance of this model and demonstrate the need for continued exploration of this conceptualization of addiction. once the individual relationships have been empirically validated, a treatment approach that addresses all components should be implemented, evaluated, and compared to models that operate from a less comprehensive conceptualization of addiction. in conclusion, the active reinforcement model serves as a more comprehensive conceptualization of addiction as it accounts for multiple interrelated factors. while the currently accepted biopsychosocial model effectively addresses the underlying causes of addiction, the proposed active reinforcement model addresses the mechanisms of existing addictions in a more comprehensive manner. a better description of the relationship between each element provides a deeper understanding of the full phenomenon of addiction, and may therefore be more effective in generating successful treatment outcomes. references alcoholics anonymous. 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post-hoc analysis demonstrated that binge eaters had significantly higher levels of attentional and nonplanning impulsivity than non-binge eaters. when we used participants’ scores from the extreme ends of the distribution, comparing binge eaters with non-binge eaters reporting no symptoms, the analysis demonstrated significantly higher levels of motoric impulsivity in addition to attentional and nonplanning impulsivity among binge eaters. the implications of these results are discussed, as are areas for future research. many individuals binge eat at some point in their lives but will never develop disordered eating problems that interrupt their daily functioning. the difference between the normal incidence of binge eating and a binge eating disorder (bed) is based on food consumption patterns (i.e., intake frequency, duration of binge eating, and amount of food consumed at a time) (keel, 2005; fairburn, 1995). women are 1.5 times more likely to be diagnosed with bed than men (keel, 2005). several researchers claim that binge eating results from restricting food intake and is used as a way to avoid feeling intense emotions (polivy & herman, 1985; heatherton & baumeister, 1991).  others have correlated binge eating with impulsivity, which is also associated with obesity among women (davis, levitan, smith, tweed, & curtis, 2006; nederkoorn, braet, van eijs, tanghe, & jansen, 2005), substance abuse (kane, loxton, staiger, & dawe, 2004), spontaneity and sensation seeking (wonderlich, connolly, & stice, 2004), and dietary overcontrol and dietary restraint (steiger, lehoux, & gauvin, 1999). impulsivity is commonly associated with an inability to inhibit specific actions, irresponsibility, and a failure to consider the consequences of one’s actions (logan, schachar, & tannock, 1997; moeller, barratt, dougherty, schmitz, & swann, 2001; patton, stanford, & barratt, 1995). studies examining comorbidity between attention deficit hyperactivity disorder (adhd) and overeating have found connections between adhd and childhood obesity (agranatmeged et al. 2005; rojo, ruiz, dominguez, calaf, & this study was supported by california school of professional psychology-alliant international university. the authors would like to thank remuda ranch treatment center, summit eating disorders, sean mcfarland, and ellyn herb for their assistance in data collection. correspondence concerning this article should be addressed to keiko y. miller, california school of professional psychology, alliant international university, 2030 w. el camino avenue, ste. 200, sacramento, ca 95833. email: impulsivityresearch@gmail.com. livianos, 2006) and eating disorders (biederman et al., 2007; altfas, 2002). three aspects of adhd (hyperactivity, inattention, and poor executive functioning) are similar to three aspects in barratt’s impulsivity model (motoric, attentional, and nonplanning impulsivity; barratt, 1993). barratt’s impulsivity model considers biological, cognitive, environmental, and behavioral factors impacting an individual (patton et al., 1995). motoric impulsivity, engaging in a behavior with no prior thinking/reasoning, has been associated with difficulty in maintaining treatment gains following successful obesity treatment (nederkoorn, jansen, mulkens, & jansen, 2006). attentional impulsivity, making quick decisions without paying attention to stimuli, has been shown to result in less positive parenting and parental involvement (zinchuk, noe, & gerdes, 2007). finally, nonplanning impulsivity, orienting oneself in the present with no regard for future consequences or events, has been shown to affect one’s sensitivity to positive rewards, such as praise and money (de wit, flory, acheson, mccloskey, & manuck, 2007). when examining the association between binge eating and motoric, attentional, and nonplanning impulsivity, binge eaters have been shown to have higher levels of all three types of impulsivity during meals (following an 8-hour fast) and during cortisol suppression (after receiving dexamethasone, which reduces stress levels), but lower levels of nonplanning impulsivity on several behavioral measures of response planning compared to non-binge eaters (galanti, gluck, & geliebter, 2007; diaz-marsá et al., 2008; rosval et al., 2006). given the current literature that suggests an association between binge eating behaviors and impulsivity (lledo & waller, 2001; rosval et al., 2006; díaz-marsá et al., 2008; galanti et al., 2007), this study analyzes the relationship between three specific types of impulsivity (i.e., motoric, attentional and nonplanning) and how it affects eating behaviors using a sample of binge eaters and non-binge eaters. this study attempts to clarify any misinterpretations miller & limberg 46 about how impulsivity affects eating behaviors and highlights the importance of how the term “impulsivity” is defined in the current literature. based on the research reviewed above, we hypothesized that binge eaters would have higher levels of attentional and motoric impulsivity and lower levels of nonplanning impulsivity compared to non-binge eaters. method measures barratt impulsiveness scale-version 11 (bis-11). the bis-11 measures motoric, attentional, and nonplanning impulsivity (barratt, 1993). the participants were asked to respond to items examining how frequently they engage in impulsive behaviors on a four-point likert scale ranging from 1 (rarely/never) to 4 (almost always). the measure produces a score for each type of impulsivity as well as a total impulsivity score. the coefficient alphas (internal reliability) from previous research were .72 with substance abusers, .82 with undergraduate students, and .83 with psychiatric patients (rosval et al., 2006). eating disorder diagnostic scale (edds). the edds is a diagnostic measure that is intended to diagnose anorexia nervosa (an), bulimia nervosa (bn) and bed using the dsm-iv-tr criteria (stice, telch, & rizvi, 2000). however, a binge eating subscale, which is based on the edds, was organized by the first author for the purpose of examining binge eating behaviors among those who endorse a range of symptoms, including those who endorse none. the binge eating subscale is comprised of the ten bed diagnostic items (based on the dsm-iv-tr) listed in the original edds measure for the purpose of determining presence of binge eating behaviors. at the time this study was conducted, no such scale had been published. on both the original edds and the binge eating subscale, symptoms are rated by participants using a likert-type scale ranging from yes/no responses to numbered responses (stice, telch, & rizvi, 2000). there is good internal consistency indicated by a cronbach’s alpha of .89 for the original edds measure (stice, fisher, & martinez, 2004). the binge eating subscale is comprised of eight yes/no and two likert scale answer choices. one point per item was counted for participants endorsing yes on any of the eight yes/no items and for circling any number besides zero on each of the two likert scale items. the overall maximum score was 10. the coefficient alpha (internal reliability) for the subscale was .94, but the external validity for the subscale has not been determined since the subscale has not yet been validated. it may have been more useful and more powerful to use a scale that assesses only binge eating behaviors, however the one binge eating scale published (binge eating scale) only assesses the severity of binge eating in obese binge eaters (gormally, black, daston, & rardin, 2002). therefore, it was not feasible to use the binge eating scale in this study because the sample population was not intended to exclude non-obese individuals. participants a total of 76 adult women participated in this study. they were divided into a binge eating group and a non-binge eating group in order to examine the associations and differences between the two groups. a median split was conducted because the population sample was non-normal and it provided a way to equally divide the number of participants into each group. the binge-eating group comprised of participants who endorsed a total of 9+ points on the binge eating subscale, and the non-binge eating group comprised of those that endorsed 0 to 8.89 points on the binge eating subscale. the binge-eating group comprised of 40 women and the non-binge eating group comprised of 36 women. since a large number of non-binge eating participants fell on the extreme ends of the distribution, an additional median split was conducted. after the median split, the non-binge eating group (n=10) comprised of participants that endorsed 0 points on the subscale, and the binge eating group (n=40) comprised of participants that endorsed a total of 9+ points on the subscale. the sample size remained unchanged for the binge eating group after the median split. all of the participants ranged in age from 17 to 56 years old (m = 28.85 years). their ethnicity composition was 66% european american, 16% asian american, 8% hispanic american, 7% african american, and 3% pacific islander. the participants income ranged from $0-$100,000+ (m = $14,294). the participants were originally recruited from eating disorder treatment centers, private therapists, and a community college class via mail. each participant received a sealed research packet consisting of a letter of introduction, informed consent form, bis-11 and edds questionnaires. a second attempt was made to increase the sample size of this study by recruiting participants online through the national eating disorder association (neda) and through a survey website called psychdata. initially, we mailed 50 packets over a 4-month period and 30 participants returned the packets. the response rate jumped to a total of 86 research packets after using psychdata for three weeks. it was the first author’s original intention to use the whole population sample to correlate the binge eating subscale with the edds; however, this could not be done because there was an unforeseen psychdata website restriction in transferring a hardcopy of the edds to a softcopy on psychdata; therefore, the online data could not be utilized for examining the validity of the binge eating subscale. procedure all participants were treated ethically and in accordance with the american psychological association’s guidelines regarding treatment of human subjects, obtaining consent from participants, conducting data collection, and handling confidential materials. this study was submitted to the institutional review board of a major university in california and was approved. participants who were recruited through the eating disorder treatment centers gave prior consent to participate in the study and were given the binge eating behaviors and impulsivity 47 sealed research packets individually by a proctor at the research site. participants who were recruited through a community college class gave prior consent and the classroom professor administered the sealed packets to consenting students. all participants were offered an opportunity to enroll in a raffle to win either a $10 starbucks or amazon.com gift card as an incentive for their participation. results binge eating subscale and edds the correlation between the edds scale and the binge eating subscale was calculated to test whether the binge eating subscale could be externally validated in the future. a significant positive correlation was found between the edds scale and the binge eating subscale: participants who had higher scores on the binge eating subscale also had higher scores on the edds (r = .36, p < .01). however, the strength of that relationship was relatively weak (r 2 = .13), suggesting that, while the binge eating subscale and the edds are statistically related, they are measuring different constructs. participants who had higher scores on the binge eating subscale also had higher scores on the attentional, motoric, and nonplanning subscales of the bis-11, and higher combined scores across all three subscales. participants who had higher attentional impulsivity had higher motoric and nonplanning impulsivity. in addition, participants who had higher motoric impulsivity also had higher nonplanning impulsivity. a zero-order correlation matrix of the edds, bis-11, binge eating subscale, and attentional, motoric, and nonplanning subscales is presented in table 1. the means and standard deviations of the whole sample and extreme sample by type of impulsivity and group are presented in table 2. binge eating and type of impulsivity first, we conducted two-sample t-tests to examine differences in the mean score of impulsivity between the bingeand the non-binge eating groups. results indicated that the binge eating group demonstrated significantly higher levels of total impulsivity on the bis-11 (t(74) = -2.61, p < .05). in addition, the binge-eating group reported significantly higher levels of attentional (t(74) = -2.86, p < .05) and nonplanning (t(74) = -2.06, p < .05) impulsivity than the non-binge eating group. there was no significant difference in motoric impulsivity between the binge eating and non-binge eating group (t(74) = -1.43, p > .05). the differences in means are presented in figure 1. similarly, we conducted two-sample t-tests to examine differences in the mean score of impulsivity between the binge-eating and asymptomatic groups. the binge eating group included those that reported more than 9 binge eating symptoms (as in the previous analysis), whereas the asymptomatic group included those that reported having no binge eating symptoms. the binge eating group was found to have significantly higher levels of total impulsivity on the bis-11 than the asymptomatic binge eating group (t(48) = 4.06, p < .05). moreover, the binge eating group had significantly higher levels of motoric (t(48) = -3.75, p < .05), attentional (t(48) = -3.83, p < .05), and nonplanning (t(48) = 2.58, p < .05) impulsivity than the non binge-eating group. notably, in contrast to analyses using the whole sample, when comparing binge eaters with asymptomatic non-binge eaters, binge eaters had significantly higher levels of motoric impulsivity in addition to attentional and nonplanning impulsivity. the differences in means are presented in figure 2. table 1 correlation matrix of edds, bis-11, binge eating subscale, attentional, motoric, and nonplanning impulsivity edds bis-11 binge eating subscale attentional motoric nonplanning edds -- bis-11 .22 -- binge eating subscale .36** .42* -- attentional .05 .71** .40* -- motoric .17 .78** .30* .34* -- nonplanning .27 .84** .30* .41* .50* -- *p < .05. **p < .01. mean z-score for binge eating scale by type of impulsivity and presence of binge eating type of impulsivity attentional motoric nonplanning m ean z -s core -0.4 -0.3 -0.2 -0.1 0.0 0.1 0.2 0.3 0.4 binge eaters non-binge eaters whole sample bis-11 figure 1. mean z-score for binge eating scale by type of impulsivity and presence of binge eating – whole sample miller & limberg 48 discussion we hypothesized that binge eaters would have higher levels of motoric and attentional impulsivity and lower levels of nonplanning impulsivity compared to non-binge eaters. the binge-eating group was found to have significantly higher impulsivity scores compared to both the non-binge eating and the asymptomatic groups (whole and extreme samples analysis). more specifically, binge eaters had significantly higher levels of attentional and nonplanning impulsivity than non-binge eaters. additionally, binge eaters had significantly higher levels of motoric impulsivity only when compared with asymptomatic non-binge eaters. these results must be interpreted with caution because the binge eating subscale has not yet been validated by other studies. attentional impulsivity was linked to binge eating behaviors. our results suggest that this type of impulsivity is higher in binge eaters compared to non-binge eaters, regardless of how our population sample is split. rosval and colleagues (2006) also found that attentional impulsivity was higher in the eating disordered groups compared to a nonclinical control group, although the way in which attentional impulsivity and disordered eating are related is unclear. this study highlights the importance of how binge eaters may be driven by impulsive actions, especially inattention. one possible explanation is that binge eaters may be attentive to internal or external processes (e.g., cravings to binge, environmental stressors) instead of being attentive to the behavior and process of eating. non-binge eaters typically are cognizant of what they are eating, how it tastes, how fast they are eating, whereas binge eaters are not aware of how fast they are eating or whether they are full. interventions should aim to help binge eaters be mindful and attentive to the behavior and sensations of eating. the current study found that nonplanning impulsivity was also higher in binge eaters, regardless of which sample was compared. this finding is consistent with other studies that have used the bis-11 to study motoric, attentional and nonplanning impulsivity (díaz-marsá et al., 2008; rosval et al., 2006; galanti et al., 2007). the identification of nonplanning impulsivity as characteristic of binge eating has implications for treatment. it may be that non-binge eaters are aware of their dietary plans during the course of the day (planned meal times, thoughts on what will be eaten at meals) or as they become hungry, while binge eaters may react without planning. treatment interventions could target creating a structure around eating (e.g., regulated times to eat, duration of eating, frequency of eating, amount of food). however, rosval and colleagues (2006) found that nonplanning impulsivity was not elevated in those diagnosed with bn, and that nonplanning impulsivity was deflated in those diagnosed with both an, restricting type and an, binge-eating/purging type. additionally, several table 2 means of z-scores and standard deviations of whole sample and extreme sample by type of impulsivity and group whole sample presence of binge eating binge eaters non-binge eaters type of impulsivity n m (z-score) sd n m (z-score) sd attentional 40 .31 .91 36 -.33* 1.01 motoric 40 .14 .96 36 -.19 1.02 nonplanning 40 .22 1.02 36 -.25* .95 extreme sample presence of binge eating binge eaters non-binge eaters type of impulsivity n m (z-score) sd n m (z-score) sd attentional 40 .31 .91 10 -.94* .95 motoric 40 .14 .96 10 -1.07* .69 nonplanning 40 .22 1.02 10 -.76* 1.30 note. *p < .05 between the binge eating and non-binge eating groups. mean z-score for binge eating scale by type of impulsivity and presence of binge eating type of impulsivity attentional motoric nonplanning m ea n z -s co re -1.2 -1.0 -0.8 -0.6 -0.4 -0.2 0.0 0.2 0.4 binge eaters non-binge eaters extreme sample bis-11 figure 2. mean z-score for binge eating scale by type of impulsivity and presence of binge eating – extreme sample binge eating behaviors and impulsivity 49 community studies have found lower levels or no correlation between nonplanning impulsivity and binge eaters (rosval et al., 2006; lyke & spinella, 2004). these contradictory results suggest that the relationship between binge-eating and nonplanning impulsivity is not fully understood, and warrants further investigation. the relationship between binge eating and motoric impulsivity differed depending on which sample was compared. in the whole sample analysis, binge-eaters did not show higher rates of motoric impulsivity than non-binge eaters. however, when compared to asymptomatic nonbinge eaters (those who reported no symptoms), binge eaters (those reporting more than 9 symptoms) did have significantly higher rates of motoric impulsivity (extreme sample analysis). a previous study found that individuals diagnosed with bn and an, binge-eating/purging type had higher levels of motoric impulsivity compared to the control group and compared to individuals diagnosed with an, restricting type (rosval et al., 2006). our finding that the symptomatic non-binge eating group is more similar to the binge eating group in terms of motoric impulsivity, compared to the asymptomatic group suggests that motoric impulsivity may present as a risk factor in the development of bed. future research comparing the three groups (no binge eating symptoms, some binge eating symptoms, and bed) may enable further understanding of the relationship between motoric impulsivity and levels of disordered binge eating behavior. in addition, future research might examine the time it takes for a binge eater to start binging after the thought enters the person’s mind or the duration of binge episodes. these findings may also have clinical implications. high motoric impulsivity may enable a person to binge without thinking about what is causing or motivating her to binge eat. if this is the case, then it would be important to address the time it takes for a binge eater to start binging after the urge enters the person’s mind. additionally, treatment could help a binge eater develop cognitive interventions, such as writing down thoughts and motivations associated with binge eating, to thereby enable mindfulness and decrease motoric impulsivity and the urge to binge. limitations although the findings in this study are of importance, there are several limitations to be considered. for example, the number of participants in this study may be too small to accurately evaluate the relationship between motoric, attentional, and nonplanning impulsivity in binge eaters and non-binge eaters. the use of a new measure without established clinical cut-offs to identify the binge eating group is also a limitation of this study. another limitation is the exclusion of men from this study. although, data from men may have yielded important information about their binge eating behaviors (e.g., prevalence, frequency, duration, presence of impulsivity), it would have been difficult to obtain a strong sample size with an equal number of experimental and control participants because of the low number of self-reported male binge eaters (costin, 2007). the lack of ethnic diversity in this sample is also a limitation, as few people from minority backgrounds are represented. due to the high number of european americans in this study, it is difficult to generalize to other ethnicities. however, existing literature suggests that european american women are more likely to be referred for eating disorders than other ethnicities (cachelin & striegel-moore, 2006). this may simply indicate that women of noneuropean descent present less frequently for treatment than european american women. another limitation is associated with data collection. one of the initial difficulties with data collection was the low response rate from mailed research packets. initially, we mailed 50 packets over a 4-month period and only 30 participants returned the packets. the response rate jumped to a total of 86 research packets after using psychdata for three weeks. finally, the use of self-report measures (one of which is not yet validated) adds limitation to this study. furthermore, since the research-revised subscale of the edds and the bis11 are self-report questionnaires, the objectivity of the participants’ responses may be limited. implications for future research given the limitations of this study and the importance of this topic, further research on binge eating and attentional, motoric, and nonplanning impulsivity should be conducted. replicating this study using a larger sample size may provide a clearer association between impulsivity (i.e., motoric, attentional, and nonplanning) and binge eating behaviors, which could illuminate additional factors that contribute to the relationship between impulsivity and binge eating. additionally, although it is apparent that motoric, attentional, and nonplanning impulsivity are correlated with binge eating behaviors, it remains unclear how they are related to one another. adding a binge eating subscale to the edds, such as the one developed for this study, may prove helpful in assessing those who do not meet the full diagnosis of bed, but who display features of bed. also, adding a binge eating subscale to the edds, such as the one developed for this study, would likely prove helpful in assessing those who do not meet the full diagnosis of bed, but who display features of bed. establishing a validated binge eating scale would give future researchers and treating professionals an accurate and effective way to separate out those who binge eat and those who do not. not having a validated binge eating scale has created a limitation and the results of this study may have been different if one existed. additionally, future studies with large samples should clarify the relationship(s) between motoric, attentional, and nonplanning impulsivity and binge eating. it is important that impulsivity is measured as a multidimensional construct in future research, as evidenced by previous research and our results. the current study suggests that multiple constructs and variables may impact the relationship between miller & limberg 50 impulsivity and eating behaviors. it is important for future research to identify the underlying variables that impact this relationship, such as, how impulsivity is defined, how eating behaviors are categorized, and the demographic variables (i.e., age, gender, presence of disordered eating). at present, there is limited literature that examines the relationship between impulsivity and binge eating. further research in this area would benefit patients with disordered eating and impulse problems. for example, it would inform treatment protocols to know if there is a directional relationship between binge eating and impulsivity 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http://dx.doi.org/10.1037/1040-3590.16.1.60 http://dx.doi.org/10.1037/1040-3590.12.2.123 http://dx.doi.org/10.1037/1040-3590.12.2.123 http://dx.doi.org/10.1002/eat.20033 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 93 school psychology students, faculty, and practitioners: an evaluation of training experiences, knowledge, and comfort with glbtq students lindsey rutledge university of kentucky sara flynn university of kentucky alicia fedewa university of kentucky laura jackson university of kentucky violence among sexual minority students is widespread in schools and can be found as early as elementary school. although several studies have investigated issues related to gay, lesbian, bisexual, transgender, and questioning youth (glbtq), there remains a gap in the literature with respect to the training school psychologists receive and their knowledge and comfort level in working with glbtq youth. to address this gap, school psychology graduate students, faculty, and school psychology practitioners were invited to participate in a survey assessing their training experiences, knowledge, and comfort levels in working with glbtq youth. participants were recruited through nasp-approved statewide organizations and graduate training programs. results indicate that while participants rate their training as inadequate, they nonetheless feel comfortable working with this population. demographic variables did not correlate with training, knowledge, and comfort as hypothesized. implications for graduate training and future research are discussed in light of the present study’s findings.  various forms of violence have been present in schools for decades. attempts have been made through policy changes and targeted training modules to address problems related to violent behavior; however, the prevalence of violence toward sexual minorities in schools remains high and can be found as early as elementary school (center for mental health in schools at ucla [cmhs], 2007; fontaine, 1998). violence against gay, lesbian, bisexual, transgender, and questioning (glbtq) youth is often seen as socially sanctioned, leaving victims unprotected from harassment and abuse and instances of violence unreported by school administrators and staff (cmhs, 2007; fontaine, 1998). some have argued that schools tend to treat sexual minorities as nonexistent and disregard this sensitive topic (black & underwood, 1998; marinoble, 1998). nonetheless, sexual minority students do exist within schools and an increase in harassment toward lgbtq youth has been reported since the mid-1990's (cmhs, 2007; fontaine, 1998). specifically, research from cmhs (2007) has reported that 34% of glbtq students have suffered anti-gay harassment in the school setting and more than 90% of glbtq youths have lindsey rutledge, university of kentucky, department of educational, school, and counseling psychology; alicia l. fedewa, department of educational, school, and counseling psychology, university of kentucky. sara flynn, department of educational, school, and counseling psychology, university of kentucky; laura jackson, department of educational, school, and counseling psychology, university of kentucky. correspondence regarding this article should be addressed to alicia l. fedewa, department of educational, school, and counseling psychology, university of kentucky, lexington, ky 40506. email: alicia.fedewa@uky.edu experienced some other form of victimization (e.g., physical violence such as being punched, kicked, or beaten) on account of their actual or perceived sexual orientation. in addition, cmhs (2007) reports that one-third of all students and three-quarters of glbtq students consider school to be an unsafe place for sexual minority youth. harassment among sexual minority youth has been linked to a number of psychosocial stressors and health problems. due to the physical and verbal harassment and abuse impacting glbtq youth (herek, 2008), such individuals are at increased risk for emotional isolation, low self-esteem, poor academic performance, substance abuse, exposure to hiv and other sexually transmitted diseases, school dropout, and suicide. in fact, suicide is the number one cause of death among sexual minority students (black & underwood, 1998; cmhs, 2007; fontaine, 1998; marinoble, 1998; national association for school psychologists [nasp], 2006). additionally, these students often lack familial support and are ostracized, isolated, and rejected by family members and friends, and many become depressed and even homeless upon disclosure of their sexuality (cmhs, 2007; fontaine, 1998; marinoble, 1998; nasp, 2006). given these risk factors, school staff and mental health providers need to be trained adequately on issues affecting sexual minority youth. schools should be safe havens for all students, where they can develop their personal identities freely and are given the opportunity to learn in an atmosphere of dignity that is free of discrimination, harassment, violence, and abuse (cmhs, 2007; nasp, 2006). furthermore, with 3% to 10% of the general population identifying as sexual minorities and many high school students classifying themselves as questioning their sexual identities, it is certain rutledge, fedewa, flynn, & jackson 94 that professionals will encounter glbtq youth in their daily practices (cmhs, 2007). there are clear legal and ethical guidelines for school psychologists in working with glbtq youth (american psychological association [apa], 2002; nasp, 2010). however, it is unclear whether the existing guidelines are routinely applied in practice. thus, ample training opportunities need to be provided to school staff, administrators, and health care providers, and changes in policy are required to address the current inequities and needs of this particular student population (cmhs, 2007; nasp, 2006). training sexual minority issues are part and parcel of school counseling and other psychology professions but seem largely absent in school psychology training. in fact, the majority of research in this area has focused on training of school counselors and other psychology professionals that engage in counseling services, rather than school psychologists per se. a study by pilkington and cantor (1996) examined syllabi of graduate courses in social psychology, developmental psychology, personality, learning theory, abnormal psychology, family therapy, and ethics to determine how frequently sexual minority issues were focused upon and discussed. the researchers found that sexual minority issues were included in the course curricula of less than 25% of these graduate courses (pilkington & cantor, 1996). similar results were found in a study by erwin (2006) that examined training of school counselors in sexual minority issues. erwin found that although sexual minority students reported a need for counseling services, counselors often did not feel adequately trained to work with these students. these studies suggest that training in sexual minority issues is not common in graduate education in school psychology. bahr, brish, and croteau (2000) examined school psychologists’ training in sexual minority issues as related to professional ethics. they suggest that three ethical principles should be considered in the inclusion of these issues in training programs. first, the principle of professional relationships and responsibilities requires that school psychologists be familiar with the individual differences of the students with whom they work. second, school psychologists must be competent to work with a variety of individuals. third, according to the professional practices principle, school psychologists must respect the rights of every individual. these three ethical guidelines necessitate adequate training and competency when working with diverse populations, including sexual minority youth. when considering these ethical principles that guide the practice of school psychology, it is important that training programs include current issues related to glbtq youth. although there is current literature suggesting ways in which these issues can be included in training (e.g., bahr et al., 2000), there is little research that examines the amount of training school psychologists actually receive in this area. knowledge knowledge of glbtq issues and concerns, as well as the dissemination of pertinent information about glbtq individuals, is a common area of interest to researchers seeking to evaluate this broad area (e.g., butler, 1995; evans, 1994; hirsch, 2007; mudrey & medina-adams, 2006; savage, prout, & chard, 2004). within this area, little research has been performed to evaluate the knowledge of school-based personnel, including current teachers, school psychologists, school counselors, and other school professionals. it appears that school-based professionals, including preservice teachers (i.e., those who have not completed educational and certification requirements) and school psychologists, have relatively low levels of knowledge regarding glbtq issues and concerns (hirsch, 2007; mudrey & medina-adams, 2006; savage et al., 2004). in a sample of pre-service teachers, who were undergraduate students taking education courses, mudrey and medinaadams (2006) found that female pre-service teachers had greater knowledge than males and that non-minority preservice teachers had greater knowledge than racial/ethnic minority pre-service teachers. a study by hirsch (2007) determined that future teachers, on average, correctly answered only 10.88 questions out of 18 questions pertaining to knowledge of glbtq issues. only 13.3% of the sample accurately answered 80% or more of the questions. with regard to school psychologists’ knowledge, a study by savage and colleagues (2004) revealed that school psychologists had low to moderate levels of knowledge about dropout rates, academic challenges, and violence experienced by lesbian and gay male students. to our knowledge, no other research has been conducted examining the knowledge of school psychology graduate students, school psychology graduate faculty, or school psychology practitioners. the knowledge of school psychologists with respect to glbtq issues is important given that school psychologists are perhaps the individuals most ideally situated in the school setting to handle the issues and concerns of students who identify as glbtq. attitudes and comfort discrimination against sexual minorities is common in schools (kahn, 2006). negative attitudes and discrimination in schools on the basis of sexual orientation and gender expression are not only displayed by students but may be expressed by teachers, counselors, administrators, school psychologists, and other school staff. sears (1991), for example, surveyed prospective teachers’ attitudes and feelings toward sexual minorities, encounters with high school-aged sexual minorities, and knowledge about sexual minority issues. results indicated that eight out of ten prospective teachers reported negative feelings toward sexual minority individuals and one-third were classified as “highgrade homophobic.” hirsch (2007) expanded sears’ (1991) study to include prospective teachers’ behaviors. hirsch (2007) surveyed 203 future educators who completed glbtq youth and school psychology training 95 measures assessing their attitudes toward, feelings about, and knowledge of sexual minorities and their anticipated behaviors toward sexual minority students. example questions included, “i would feel nervous being in a group of homosexuals” and, “i would feel comfortable working with a female homosexual.” results indicated that prospective teachers expressed relatively positive attitudes and feelings toward sexual minorities. however, the prospective teachers also displayed somewhat contradictory behaviors; for example, teachers indicated that they would behave differently toward a sexual minority student than toward a heterosexual student because they would be unwilling to discuss age-appropriate topics related to sexual orientation in the classroom. ninety-four percent of prospective teachers said they would refer a student who wanted to talk about sexual orientation to the school counselor or school psychologist. similar findings were reported in a study by ruebensaal (2006), in which school counselors were more likely to refer the client to the school psychologist if he or she identified as lesbian or gay. given that teachers often refer sexual minority students to school psychologists, it is particularly important to examine school psychologists’ attitudes and feelings in working with students who identify as glbtq. it is important to note that in the study by ruebensaal (2006) as well as in most studies in this body of literature, findings related to attitudes toward individuals who identify as gay or lesbian cannot necessarily be generalized to attitudes toward those who identify as bisexual, transgender, or queer. thus, while collapsing the various categories of sexual minorities is commonplace in the literature, it is important to note that individual differences between groups may be masked by this approach (herek, 2002). there is currently a gap in the literature on school psychologists’ comfort level in working with students who identify as sexual minorities. previously, comfort level has been measured by single questions embedded within a comprehensive study. no study to date has utilized a widerange examination of school psychologists’ comfort in working with students who identify as sexual minorities. while a relationship between attitudes and comfort has been found (ruebensaal, 2006), attitude measures may not be fully representative of an individual’s beliefs. therefore, it is important when examining training and knowledge to obtain an accurate gauge of comfort within various situations. the purpose of this study was to address the gaps related to school psychologists’ training experiences, knowledge, and comfort level in working with glbtq youth. specifically, the current study examined: (a) the overall training experiences among participants with respect to glbtq issues; (b) participants’ knowledge regarding glbtq issues and differences across groups pertaining to their knowledge; and (c) the comfort levels across groups when working with the glbtq population. based on prior research in this area (pilkington & cantor, 1996), there were several hypotheses made regarding the questions in the current study. first, the researchers hypothesized that the amount of training received would be positively correlated with knowledge of glbtq issues and comfort level, corroborating previous research findings (e.g., hirsch, 2007; mudrey & medina-adams, 2006; ruebensaal, 2006; savage et al., 2004). second, it was hypothesized that certain demographic characteristics (conservative political orientation, religious orientation, and geographic region) would be negatively correlated with knowledge and comfort level, as has been found in prior studies (kahn, 2006; ruebensaal, 2006; savage, 2004; sears, 1991; smith, 2007). method participants three groups were invited to participate in this nationwide survey: school psychology graduate students, school psychology graduate faculty, and school psychology practitioners. any individuals who did not fit into one of these three categories were excluded from this study. school psychology graduate students and faculty were recruited through personal contact with the program directors of all nasp-approved graduate programs (nasp, 2008). to better ensure generalizability of findings, a random sample of program directors were asked to distribute the questionnaire to full-time school psychology faculty, as well as school psychology graduate students within their programs, by means of the programs’ email listservs. microsoft excel was used to select a random sample of programs and organizations. out of 177 graduate programs, 120 were randomly chosen to participate in the study. out of 120 programs, 96 (80%) responded to the email inquiry and agreed to distribute the survey to their programs’ faculty and graduate student body. the rest of the programs either did not respond (n = 22) or refused to send out the survey due to conflicts of interest with the survey content and overall university policies (n = 2). school psychology practitioners were recruited through random sampling of each state’s school psychology association. out of 50 statewide organizations, 40 were randomly selected to be contacted. out of these 40 organizations, 24 responded (60%) and indicated that they were willing to distribute the survey to their organization members. after obtaining permission from each association’s governing board, the survey was sent via email to their listserv by the president or another board member. of the 834 respondents, 64% (n = 534) were students, 10.5% (n = 87) were faculty, and 25.5% (n = 213) were practitioners. the participants were 83% women (n = 691) and 17% men (n = 141). two participants did not indicate their sex. practitioners reflected a breadth of experience in the schools, ranging from one year of practice to 38 years, with a mean of 10 years of experience as a school psychologist (sd = 6.5). students also varied in their stage of graduate training, with approximately 48% of students in their first two years of training and 52% in their final two years of training (m = 5.5 years of graduate schooling, sd = 3.2). types of training were roughly evenly distributed, with approximately 38% of students in specialist (i.e., eds) rutledge, fedewa, flynn, & jackson 96 programs, 40% of students in doctoral programs, and 22% in specialist doctoral (i.e., psyd or edd) programs. work/school settings for respondents were equally dispersed across urban (35%) and suburban (36%) areas, with the remaining 19% of respondents working or attending school in a rural area. ten percent of respondents did not answer this question. remaining demographic information for participants’ ethnicity, sexual orientation, political affiliation, and religiosity is presented in table 1. measures the survey was a six-page questionnaire based on the school climate literature on glbtq youth developed by the authors. three versions of the questionnaire (i.e., student, professor, and practitioner forms), containing between 50 and 55 questions each, were divided into four separate sections that addressed demographics, training experiences, knowledge, and comfort level for each respondent. the first section of the survey (section a) included demographic questions. typical demographic information (e.g., date of birth, ethnicity, highest degree earned/working toward) as well as additional information more closely related to the topic of this study (e.g., personal relationships with individuals who identify as glbtq, sexual orientation, school policy related to glbtq issues and concerns) were addressed. section b measured participants’ training experiences in glbtq issues. school psychology graduate students and school psychology practitioners were asked to answer nine questions pertaining to whether or not they received training in various areas related to glbtq students and issues, how effective their training was in preparing them to serve glbtq students (measured on a four point likerttype scale), and through what means they received their training (e.g., peer presentations, graduate course, assigned readings, professional development). these questions were developed by the authors as a means of measuring student training and revealed strong internal consistency for the present sample (cronbach’s α = .89). example questions included, “did you receive training related to the counseling needs of glbtq students?” and, “how well do you think table 1 participant demographic characteristics variable students faculty practitioners n % n % n % gender female 458 85.8 54 62.1 179 84 male 76 14.2 33 37.9 32 15 missing 0 0 0 0 2 1 mean age in years 26.7 (5.5) 44.3 (11.3) 40.0 (11.9) ethnicity african-american 27 5.1 4 4.6 4 1.9 asian-american 20 3.7 3 3.4 1 0.5 hispanic-american 30 5.6 4 4.6 2 0.9 caucasian 442 82.8 76 87.4 200 93.9 missing/other 14 2.6 0 0 6 2.8 sexual orientation gay/lesbian 14 2.6 3 3.4 9 4.2 bisexual 13 2.4 4 4.6 3 1.4 heterosexual 497 93.2 76 87.4 199 93.4 questioning/other 20 1.8 4 4.6 2 1.0 census region northeast 205 38.0 16 19.3 48 22.9 midwest 188 35.2 22 26.5 65 31.0 south 87 16.3 27 32.5 84 40.0 west 53 10.5 18 21.7 13 6.2 work or university setting urban 247 46.3 65 75 49 23.0 suburban 183 34.3 13 15 113 53.1 rural 104 19.4 9 10 51 23.9 political affiliation democrat 286 53.7 59 67.8 116 54.5 republican 80 15 5 5.7 33 15.5 independent 111 20.8 14 16.2 30 14.1 missing/other 56 10.5 9 10.3 34 15.9 religiosity identify religious/spiritual 183 34.5 33 40 47 22.1 not at all religious/spiritual 350 65.5 54 60 166 77.9 glbtq youth and school psychology training 97 your training related to the risk factors associated with glbtq students prepared you to work with this population?” a different set of questions was given to school psychology graduate faculty pertaining to the content of their courses and whether they felt it prepared their students to work with glbtq youth. the third section of the survey (section c) used a 14-item scale to measure participants’ knowledge about glbtq issues. to assess respondents’ knowledge of glbtq-related issues, 14 true/false questions were included in the survey. questions were adapted from the knowledge about homosexuality questionnaire (harris, nightengale, & owen, 1995) and included questions such as, “homosexuality is a phase which children outgrow” and, “according to the american psychological association, homosexuality is an illness.” this measure has shown high internal consistency across studies, with a cronbach’s alpha of .86 (bliss & harris, 1999; koch, 2000). lastly, section d measured participants’ comfort in taking action in various scenarios related to glbtq youth. respondents were given 13 scenarios assessing their comfort level in addressing glbtq-related issues or working directly with glbtq youth. these items were adapted from the index of homophobia (bouton, gallaher, garlinghouse, leal, rosentein, & young, 1987) which has demonstrated consistently high reliability coefficients ranging from .90 to .95 (hudson & ricketts, 1980; patgolum-an & clair, 1986). the scenarios outlined a variety of situations commonly encountered with glbtq youth, including counseling a student who identifies as glbtq or overhearing homophobic statements from teachers or administrators. on a scale of 1 to 4, with 1 being the “least comfortable” and 4 being “very comfortable”, a total comfort score was calculated for respondents. procedures the survey was approved by the university of kentucky institutional review board and email invitations were sent using state-level school psychologist association listservs to access practicing school psychologists and the naspapproved graduate program list to access program directors. an accompanying letter was attached to each email explaining the purpose of the study. one reminder prompt was sent to each university institution or professional organization if a reply had not been obtained. as an additional incentive for completing the survey, participants were informed that two respondents’ emails would be chosen at random to win a monetary gift card. all responses were given a numerical code and transferred from the online survey database to a statistical program (statistical package for the social sciences version 18.0; spss 18.0) for analyses. results demographic relationships to assess the relationship between respondents’ training experiences, knowledge, and comfort levels, pearson bivariate correlations were examined. demographic variables, including respondents’ religiosity, gender and relationship with a glbtq individual, were included in the correlational matrix using spearman’s rank order correlation to examine relationships with the three dependent variables. as shown in table 2, amount of training, knowledge of glbtq issues, and comfort levels with glbtq topics were all correlated, though to a small degree. not surprisingly, having a close relationship with a person who identified as a sexual minority was correlated with having a higher comfort level with glbtq individuals, although the correlation was relatively small. further, gender was also negatively correlated with comfort. on a scale of 1 to 4, with 1 being the “least comfortable” and 4 being “very comfortable”, a total comfort score of 52 was calculated for respondents. females (m = 38.9, sd = 8.3) reported higher comfort levels in working with glbtq youth than did males (m = 36.8, sd = 8.7), although the results were not significant at the .05 level, t(830) = 0.008, p = .93, 95% ci [3.64, 3.68]. given the low intercorrelations among training, knowledge, and comfort levels, separate one-way analysis of variance (anova) tests were used to ascertain differences among the dependent variables based on geographic location (northeast, midwest, south, and west), political affiliation (democratic, republican, independent, or other), ethnicity/race (african american, asian american, hispanic american, and caucasian), and sexual orientation (gay/lesbian/bisexual or heterosexual). all anova results were analyzed using bonferroni’s adjustment to control for type i error (tabachnick & fidell, 1996). as presented in table 3, training, knowledge, and comfort levels did not significantly vary depending on one’s geographic region, political affiliation, or ethnicity/race. however, respondents who identified as gay or lesbian had significantly higher comfort and knowledge scores than those who identified as heterosexual. using eta squared to calculate effect sizes, however, the magnitude of these differences was small for both comfort (η2 = .02) and knowledge (η2 = .01). table 2 intercorrelations among demographic and dependent variables 1 2 3 4 5 6 7 1. training 2. knowledge .09** 3. comfort .11** .23** 4. religiosity .02 .05 .06 5. gender -.06 .04 -.09** 6. sexual orientation -.02 .06 .08 7. relationship w/glbtq .02 .01 .12** note.* p < .05, **p <.01. religiosity, gender, sexual orientation, and personal relationship with glbtq individual all reflect dichotomous variables. rutledge, fedewa, flynn, & jackson 98 training survey questions provided information on respondents’ level of training in glbtq issues across a number of forums (e.g., entire course content dedicated to glbtq issues versus readings or lectures addressing the topic). students and practitioners were asked to rate the prevalence of glbtq training, while faculty were asked to indicate how much and through what means their program delivered this training. one-way anova was used to assess group differences. results showed some incongruence between student and practitioner reports versus faculty reports of training experiences. overall, students and practitioners rated their training lower than the level of training indicated by faculty, although the results were not statistically significant, f(2, 831) = 1.30, p = .27. in other words, faculty reported providing higher levels of glbtq training than students and practitioners reported they received. on a scale of 1 to 4, with 1 being the least competent and 4 being very competent, students (mdn= 1.45, ir = 1.60) and practitioners (mdn = 1.68, ir = 1.85) also rated themselves in the range of “incompetent” with respect to their perceived ability to work effectively with glbtq youth). table 4 displays the separate areas in which each respondent rated both their training and perceived effectiveness of training with glbtq youth. students and practitioners indicated that very little graduate training was devoted to glbtq issues. however, those that did receive training in the various domains rated this training as very helpful in preparing them to work with the glbtq population (mdn = 3.65, ir = 3.69). knowledge across all three groups, respondents answered an average of 64% of questions correctly. on the 14-question test of knowledge about glbtq issues, faculty appeared to be the most knowledgeable (m = 9.76, sd = 2.98), followed by students (m = 9.40, sd = 2.65) and practitioners (m = 9.12, sd = 2.30). anova results reflected significant differences for knowledge between groups, f(2,826) = 4.26, p =.01. however, the differences in mean score were quite small, as reflected in the effect size which was calculated using eta squared (η2 = .01). out of the 14 true/false questions, respondents were most likely to incorrectly rate as “true” the statement that “homosexuality describes a person’s sexual preference.” consistent with the literature, females were significantly table 3 anova omnibus results for glbtq training, knowledge, and comfort: group differences according to demographic status outcome training knowledge comfort demographic measure n f p n f p n f p political affiliation 823 2.3 .057 818 2.26 .061 826 1.54 .061 geographic location 826 .855 .464 821 .360 .782 826 .360 .782 race/ethnicity 830 .421 .656 825 .477 .752 830 1.23 .296 sexual orientation 830 2.45 .38 830 1.06 .03** 825 3.04 .01** note.* p < .05, **p <.01. table 4 student and practitioner training experiences with glbtq youth students practitioners counseling received training 2.04 (.90) 1.93 (.76) training effective? 2.09 (.77) 2.38 (.75) interventions received training 1.67 (.86) 1.70 (.71) training effective? 1.83 (.87) 2.15 (.79) risk factors received training 1.90 (.85) 1.90 (.71) training effective? 2.02 (.78) 2.31 (.73) ethics received training 1.78 (.82) 1.66 (.73) training effective? 2.00 (.85) 2.13 (.88) advocacy received training 1.67 (.83) 1.58 (.70) training effective? 1.89 (.83) 1.99 (.82) identity development received training 1.59 (.80) 1.51 (.69) training effective? 1.73 (.78) 1.88 (.85) mental health received training 1.83 (.84) 1.88 (.69) training effective? 1.96 (.74) 2.23 (.78) physical health received training 1.26 (.60) 1.34 (.62) training effective? 1.43 (.71) 1.69 (.86) overall training 1.84 (.76) 1.98 (1.13) note. all figures are average scores based on a scale of 1 (not at all helpful or no training) to 4 (very helpful and three or more modes of training). faculty members were asked if their overall training was effective, and were therefore not asked about individual training domains. standard deviations are provided in parentheses. glbtq youth and school psychology training 99 more likely to answer the 14 questions correctly than males, t(830) = 2.11, p = 0.001; d = 0.80, 95% ci [.56, 3.7]. comfort with the highest possible score being 52, respondents rated themselves at a mean of 37.3 (sd = 9.8), suggesting a moderate level of comfort in working with glbtq youth. faculty rated themselves as most comfortable (m = 39.8, sd = 13.6), followed by students (m = 37.0, sd = 7.0) and practitioners (m = 36.2, sd = 9.5). these differences were statistically significant at the .05 level, f(2, 831) = 5.47, p = .01. however, using eta squared to calculate an effect size, the difference (d = .01) was minimal (cohen, 1988). across respondents, being alone with a same-gender sexual minority student was rated as the most comfortable scenario (m = 3.82, sd = 0.93). two scenarios were equally rated as the most uncomfortable for respondents. one of the scenarios perceived as uncomfortable involved a student seeking help because of transgender feelings (m = 2.12, sd = 0.97) while the other scenario described a school psychologist working in a school that discriminated against sexual minorities (m = 2.13, sd = 0.87). discussion the purpose of the current study was to expand the literature base examining school psychologists’ training, knowledge, and comfort levels in working with glbtq youth. in order to understand the various background characteristics of the survey respondents and their association with these variables, a number of demographic questions were also included in the survey related to political affiliation, sexual orientation, geographic region, and religious orientation. with regard to training, the results of the study suggested that student and practitioner reports were somewhat inconsistent with faculty reports when indicating how much training was conducted at the university level. school psychology faculty reported more training in glbt areas, while overall, students and practitioners judged their training less favorably and reported feeling incompetent to work with sexual minorities. there are several possible explanations for these findings. first, at best, training offered in graduate programs may not be relevant or helpful to the work being done in school settings and, at worst, may actually be harmful. for example, studies done by erwin (2006) and pilkington and cantor (1996) found elements of heterosexual bias and discrimination in graduate training programs. heterosexual bias may have been present in the training being assessed by the present study and may have been perceived by respondents. given that the questionnaires did not explicitly tap into heterosexism or discrimination present in graduate training, this hypothesis remains speculative. second, it is possible that the amount of training offered at the university level may not be adequate in making students feel prepared to work with sexual minority youth upon completion of their graduate training. for instance, erwin (2006) found that students in counseling programs did not feel prepared to work with lesbian and gay clients upon completion of their training, even though some training had been provided. thus, our results appear consistent with prior research in suggesting that many students feel “incompetent” to work with glbtq populations. although faculty in our sample reported having provided training in glbtq issues, it is clear that students require additional training or exposure to glbtq clients to feel more competent in working with this particular population. results related to faculty, students, and practitioners’ knowledge levels of glbtq issues fit our expectations based on previous research studies among school counselors. overall, school psychologists rated their training as inadequate and answered just over half of the questions concerning glbtq issues correctly, suggesting the need for factual-based training that addresses common glbtq concerns. the fact that there was no significant difference in knowledge level between the groups indicates that training in this area is consistently low, and seems to remain so over time. that is, current graduate students are no more knowledgeable on glbtq issues than school psychologists who were trained years ago, despite the fact that the extent and severity of sexual minority victimization has increased over the past two decades (cmhs, 2007; gay, lesbian and straight education network, 2007). with increased victimization and visibility of glbtq youth, the training offered by universities should increase as well. unfortunately, the results of this study do not indicate that this is the case for current school psychology graduate students. despite the lack of training reported by students and practitioners, respondents feel surprisingly comfortable working with glbtq students in the school setting. these results supported our hypothesis that more training would result in an increased comfort level with glbtq youth. given that having a close relationship with an individual who identified as glbtq was significantly and positively correlated with comfort, it is possible that students merely had more exposure to glbtq individuals and therefore were more comfortable with them. it could be that respondents reported greater levels of comfort due to this exposure of having more personal experiences with glbtq individuals. as has been shown in prior research, increasing comfort with issues of diversity can result from personal experiences or relationships with others from diverse backgrounds. smith (2007) found that respondents who had had positive interactions with lesbian women or gay men reported lower levels of homophobia. training programs may therefore help to improve knowledge of glbtq issues as well as changing individuals’ comfort levels with this population. more research is needed to explore the relationships among these variables. in particular, it remains unclear whether having a sexual minority family member may reduce homophobia in school psychologists. it is also unclear how best to define a “close” relationship with a person who identifies as glbtq, nor is it known how close one needs to be with a glbtq rutledge, fedewa, flynn, & jackson 100 individual in order for this relationship to reduce homophobia and increase comfort levels in working with sexual minorities. given that this survey included only one question to assess whether the respondent was “close” to someone who identified as a sexual minority, much more information is needed to explore these questions as they pertain to school psychologists. the results from the demographic questions did not support the authors’ hypotheses. religious orientation, geographic region, political affiliation, and ethnicity/race were not significantly correlated to knowledge and comfort level, as we had predicted. this may indicate that school psychologists are able to separate their personal from their professional lives, such that they do not allow their belief systems to interfere with their work in schools. this study had a number of limitations. random sampling is a vital part of ensuring the generalizability of survey results (langston, 2005; ray, 2003); thus, surveys were sent out to a random sample of nasp-approved programs. however, programs nonetheless participated through self-selection. although every attempt was made to ensure that most faculty, students, and practitioners completed the survey, there were a number of potential respondents who did not. it is unclear if willing participants differed in terms of knowledge, training, and comfort level from those who did not participate in the survey or who were not members of statewide nasp organizations, creating a potential selection bias. moreover, because faculty and students were not from the same training programs, direct correlations between the training offered and training received could not be assessed. future research should include students from non-nasp-approved programs and should contact practitioners through their respective counties or consortiums to ensure all school psychologists are reached regardless of their nasp membership status and affiliation. in addition, the survey did not address years of work experience or personal experiences participants had had with glbtq individuals. research shows that those with more exposure to others from diverse backgrounds (including glbtq populations) have more tolerance and higher comfort levels with individuals from diverse backgrounds (green, murphy, blumer, & palmanteer, 2009). again, additional research is needed to explore in more depth the relationship between personal experiences with glbtq populations and individuals’ levels of knowledge and comfort. finally, as with any survey, participants can affect the outcome by answering in a fashion they deem socially appropriate or pleasing to the researcher (langston, 2005). although the current study attempted to curtail possible social desirability effects by piloting the study and using questions from other scales already tested and used in the field, this phenomenon could affect results, particularly with a socially and politically controversial topic (kimberlin & winterstein, 2008; nauta & kluwer, 2004; sjöström & holst, 2002). as the results of the present study showed, there is a critical need to address the lack of training related to glbtq individuals within graduate school programs and to provide professional development opportunities for practitioners. results indicate that more training is necessary for school psychologists to provide appropriate services, to meet educational needs, and to create a school environment that is a safe place for all children to learn. further research is therefore needed to determine which training options might be the most helpful in increasing knowledge and comfort levels in working with glbtq youth. in addition, studies that examine training which will translate effectively into school practices that support and encourage glbtq mental and physical well-being are warranted. these higher levels of knowledge and comfort should be a goal not only for school 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(1996). using multivariate statistics (3rd ed.). new york, ny: harper collins.     37   graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university onset or exacerbation of ocd during pregnancy: clinical characteristics and etiological considerations eleni vousoura teachers college, columbia university although there are a large number of studies on postpartum illnesses, such as depression and psychosis, only recently have perinatal anxiety disorders received attention. a number of studies indicate that there can be a rapid onset or exacerbation of obsessive-compulsive disorder (ocd) during pregnancy. this article reviews the extant research on pregnancy-related ocd. due to their small samples and the retrospective nature of most of the studies, the prevalence and course of pregnancy-related ocd remains unclear. however, research in this area has demonstrated that in contrast to the heterogeneous symptomatology generally observed in ocd, the clinical characteristics of obsessions and compulsions in pregnancy are relatively homogeneous, with fear of contamination and compulsive cleaning the predominant features. the article discusses biological and psychosocial factors as possible causes of ocd, as well as potential directions for historically, pregnancy has been regarded as a period of emotional well-being, which protects the mother from psychological distress. however, it is now acknowledged that the perinatal period can be a time of increased vulnerability for the onset of mental disorders. in addition, pregnancy and the postpartum are considered to be highrisk periods for women with preexisting psychiatric illnesses. although there are a large number of studies on postpartum depression and puerperal psychosis, the literature on perinatal anxiety disorders has only developed recently. within this literature, research on obsessivecompulsive disorder (ocd) has focused mainly on the postpartum period (for a review, see abramowitz, schwartz, moore & luenzmann, 2003), with pregnancyrelated ocd remaining largely understudied, despite preliminary findings indicating development or exacerbation of ocd symptoms during that period. obsessive compulsive disorder is an anxiety disorder characterized by (a) recurrent, excessive, and intrusive thoughts that cause significant distress, and/or (b) compulsive behaviors or mental acts that are performed to neutralize or suppress these thoughts (american psychiatric association [dsm-iv-tr], 2000). patients with ocd are also characterized as having some insight into their symptoms, recognizing that these thoughts are excessive, unreasonable, and maladaptive. a common element of the disorder is avoidance of situations related to the obsessional concerns (dsm-iv-tr, 2000).                                                                                                   the author would like to thank charlie baily, m.a., and sarah bellowin-weiss, m.a., for their numerous helpful suggestions. correspondence concerning this article should be addressed to eleni vousoura, teachers college, columbia university, 525 w 120th street, new york, new york 10027-6696, email: ev2225@columbia.edu. obsessive compulsive disorder is one of the most common psychiatric disorders with a lifetime prevalence of 2-3% in the general adult population (karno, golding, sorenson, & burnam, 1988; ruscio, stein, chiu, & kessler, 2008). data from the epidemiologic catchment area program (eca) show a 12-month prevalence of 1.2-2.4% (fullana et al., 2009; karno et al., 1988). the male to female ratio is approximately equal, but men have an earlier age of ocd onset (nestadt, bienvenu, cai, samuels, & eaton, 1998). in women, the age of onset has a bimodal distribution (the first peak between 13-16 years of age, and the second between 22-32 years of age); though some evidence has found ocd onset in later life (nestadt et al., 1998; neziroglu, anemone, & yaryura-tobias, 1992). the clinical picture of ocd is strikingly heterogeneous: obsessional thoughts may be fear of contamination, excessive doubting, symmetry, aggression, as well as sexual and religious obsessions, whereas compulsive behaviors may include cleaning, checking, counting, praying, and repeating words silently. these symptoms have been metaanalytically clustered into four symptom dimensions: 1) symmetry obsessions and ordering compulsions, 2) aggressive obsessions and checking compulsions, 3) contamination obsessions and cleaning compulsions, and 4) hoarding obsessions and compulsions (bloch, landerosweisenberger, rosario, pittenger, & leckman, 2008). the prognosis of ocd is mixed, but if it is not effectively treated, it usually has a deteriorating and chronic course (abramowitz et al., 2003). prevalence of pregnancy-onset o c d the exact prevalence of ocd during pregnancy is unknown, but there is evidence that pregnant women have a vousoura     38 greater likelihood of manifesting ocd symptoms compared to the general population. several early studies report an association between ocd symptoms and significant life events, including pregnancy and childbirth. in a study of 150 ocd patients, pollitt (1957) found that 62% (n = 93) reportedly linked the onset of their symptoms with a specific life event with three patients reporting the development of ocd symptoms during pregnancy, and seven after childbirth. ingram (1961) found that out of 89 ocd patients, 69% (n = 61) developed ocd within a year of a significant life event. moreover, of those 61 patients, 15 (25%) associated the onset of symptoms with pregnancy, the strongest precipitating correlate of obsessive symptoms. in contrast, lo (1967) found that of 56 patients only 5% reported that pregnancy triggered ocd. this conflicting evidence is likely due in part to the several limitations of the above cited studies: they were retrospective, did not differentiate based on gender, and used vague diagnostic (pollitt, 1957, p. 194). in a more recent study of 60 patients (39 females and 21 males) diagnosed with ocd as defined by the diagnostic and statistical manual of mental disorders, third edition revised (dsm-iii-r), six women first manifested ocd during their pregnancy (buttolph & holland, 1990). neziroglu and colleagues (1992) similarly found that of 59 mothers who met criteria for ocd according to dsm-iii, 23 (39%) linked pregnancy with the onset of ocd. based on these findings, the authors hypothesized that pregnancy is indeed an important life event that may precipitate ocd. additional evidence supports the association between ocd onset and pregnancy. for example, williams & koran (1997) document that the onset of ocd was associated with pregnancy in 5 (13%) of the 38 study participants, while a controlled study of nigerian women, adewuya, ola, aloba, and mapayi (2006) found that pregnant women were three times more likely to have ocd. in contrast, a study of 136 italian participants conducted by maina, albert, bogetto, vaschetto, and ravizza (1999) did not find a significant association between pregnancy and ocd onset, with only two out of 35 women (0.05%) reporting first-onset ocd during pregnancy. the authors however suggested that these findings deserve critical consideration as the low rates of first-onset ocd in this sample compared to other studies might be attributable to the exclusion of co-morbid depression, suggesting that pregnancy may be a risk factor for the development of ocd particularly for those with concomitant depression. in one recent prospective study assessing women before and after childbirth, uguz and colleagues (2007a) found that three of 16 participants (18.8%) experienced ocd symptoms for the first time during pregnancy. while the sample size is small, the strength of this study lies in its prospective methodology. in a larger subsequent study with 434 women, the same authors reported that 3.5% (n = 15) of participants developed ocd as defined by the structured clinical interview for dsm-iv axis i disorders [scid-i] in the third trimester of pregnancy (uguz et al., 2007b). exacerbation of o c d during pregnancy besides ocd with perinatal onset, there is evidence supporting the exacerbation of ocd symptoms during pregnancy. buttolph and holland (1990) reported exacerbation of ocd symptoms in 8% of the 39 female patients. in a case study, chelmow and halfin (1997) reported exacerbated ocd symptoms in a 28-year-old pregnant woman with previously diagnosed ocd following her first pregnancy. other studies show a bidirectional change in symptom severity during pregnancy. williams and koran (1997) found that of 29 pregnant patients with preexisting ocd, five (17%) reported worsening, four (14%) described improvement, and 20 (69%) described no change in symptoms during pregnancy. vulink, denys, bus, and westenberg (2006) assessed symptom severity using the yale-brown obsessive compulsive scale (ybocs) symptom checklist in 52 women meeting criteria for ocd according to the diagnostic and statistical manual of mental disorders, fourth edition (dsm-iv). pregnancy was associated with a worsening of ocd symptoms in 33% of patients (severe worsening for 23% of them), and a moderate improvement in 21% of patients. uguz and colleagues (2007b) reported worsening of preexisting ocd in six patients (46.1%), compared with amelioration of symptoms in three patients (23.1%); four patients (30.8%) reported no change in ocd symptoms during pregnancy. overall, these findings suggest that pregnancy may be associated with the onset of ocd, or exacerbation of the ongoing disorder in pregnant women. however, due to the retrospective design of the majority of the studies, no causal relationships can be inferred. also, discrepancies in the data reported above could be due to small sample sizes, methodological variability, and the lack of standardized diagnostic criteria for ocd. clinical character istics of pregnancy-related o c d contrary to the varied symptom pattern in typical ocd, pregnancy-related ocd tends to be remarkably homogeneous. findings from case studies with pregnant ocd patients reveal a relatively consistent content of obsessions and compulsions. buttolph and holland (1990) described two women with onset of ocd during compulsive washing rituals and obsessions involving fear of the fetus becoming contaminated by toxic agents. in another case study of pregnancy-induced ocd, kalra, tandon, trivedi, and janca (2005) described a patient who had fears of contamination; while she recognized her thoughts as irrational, she continued to engage in compulsive washing rituals. similarly, in a case of pregnancy-complicated ocd, chelmow and halfin (1997) ocd during pregnancy   39 presented a patient who experienced a fear of blood-borne disease and engaged in compulsive cleaning and organizing of household items. more recent studies have used the y-bocs symptom checklist to assess the severity and type of ocd symptoms. in the study by uguz and colleagues (2007b), the most common obsessions among pregnant women with ocd were fear of contamination (80%) and preoccupation with symmetry/exactness (60%), while the most common compulsions were cleaning/washing (86.7%) and checking (60%). the authors found similar results in their prospective study of 16 women (uguz et al., 2007a), noting that the most common obsessions reported by women in the 38th gestational week were fear of contamination (81.3%), preoccupation with symmetry/exactness (50%), aggressive (43.3%), and religious obsessions (37.5%), whereas the most common compulsions were cleaning/washing (81.3%), checking (56.3%), and ordering/arranging (43.8%). in a more recent study, labad and colleagues (2010) interviewed 90 female outpatients with ocd. the authors found that patients who predominantly had obsessions about contamination and compulsions about cleaning had greater chance of developing these symptoms during the perinatal period. conversely, patients in the hoarding dimension mostly reported onset of ocd at menarche. course and comorbidity of pregnancy-related o c d though the course of pregnancy-related ocd has received little empirical attention, there is some evidence that ocd symptoms improve during the postpartum period. in their prospective study of 16 ocd patients, uguz and colleagues (2007a) found that 11 patients (69%) reported a decrease in ocd symptoms at six weeks after birth. kalra and colleagues (2005) presented a case of a 30-year-old primigravid woman with onset of ocd in the fourth month of gestation who fully recovered two weeks after delivery without psychiatric intervention. in contrast, there is ample evidence that women with anxiety disorders during pregnancy are at higher risk of presenting depressive symptoms at early postpartum, even after controlling for antenatal depression (heron, o'connor, evans, golding, & glover, 2004; milgrom et al., 2008; moss, skouteris, wertheim, paxton, & milgrom, 2009; sutter-dallay, giaconne-marcesche, glatigny-dallay, & verdoux, 2004). therefore, while pure ocd symptoms might improve postpartum, it is possible that pregnancy-related ocd is a precipitating factor for postnatal depression. however, no definitive conclusions can be drawn since, to date, there has been no prospective study exploring the relationship between postpartum depression and ocd specifically. results from epidemiological studies demonstrate that, in general, ocd patients manifest a number of additional psychiatric conditions, predominantly major depressive disorder (hollander et al., 1997). in addition, research on the postpartum period shows a strong association between ocd symptoms and postpartum depression (abramowitz, schwartz, & moore, 2003b; wisner, peindl, gigliotti, & hanusa, 1999; zambaldi, cantilino, montenegro, paes, de albuquerque & sougey, 2009). however, there are few studies exploring the comorbidity of ocd with depression during pregnancy; in the majority of studies on pregnancyrelated ocd, concomitant depression has been regarded as an exclusion criterion rather than a focus for investigation. etiological considerations the etiology of ocd remains largely unknown. several biological (genetic, neurochemical and anatomical) and psychosocial factors may contribute to the development of ocd in pregnancy. biological factors the well-established efficacy of serotonin reuptake inhibitors (sris), particularly clomipramine, in the treatment of ocd symptoms (ackerman & greenland, (barr et al., 1993). according to this neurochemical model, obsessive-compulsive symptoms are generated due to deficits in the serotonin neurotransmitter system. however, not all ocd patients respond positively to sri monotherapy. findings regarding the role of serotonin on ocd have been equivocal (rauch & jenike, 1993). during pregnancy there is a significant increase in sex hormones, mainly estrogen and progesterone, which is followed by an abrupt drop after parturition. there is evidence that fluctuations in gonadal steroid levels may alter serotonergic transmission, reuptake, and binding (rubinow, schmidt & roca, 1998). research has also shown that ocd symptoms begin or worsen during the premenstruum (labad et al., 2005; williams & koran, 1997). thus, it has been proposed that ocd during pregnancy or following on serotonergic functioning (sichel et al., 1993). investigation beyond the serotonergic system shows that neuropeptides may be involved in the pathogenesis of ocd. of particular interest is oxytocin, a nonapaptide synthesized in the hypothalamus and released into the blood from the pituitary gland (leckman et al., 1994a). oxytocin has been implicated in the promotion of grooming behavior. it has been suggested that contamination obsessions and excessive cleaning rituals are analogous to oxytocinbody or appearance (allogrooming) commonly observed in social animals. in addition, oxytocin attenuates memory retrieval, which offers a plausible explanation to pathological doubting and checking compulsions in ocd (mcdougal et al., 1999). several findings suggest an association of ocd with oxytocin. in one well-known study (leckman et al., 1994b), patients with ocd had significantly increased oxytocin levels in their cerebrospinal fluid (csf). during late pregnancy and the postpartum vousoura     40 period, oxytocin concentration in the bloodstream increases, stimulating uterine contractions and milk ejection for lactation. therefore, it is possible that ocd during pregnancy is oxytocin-induced. however, other studies have not reported the same correlation between ocd symptoms and oxytocin levels (altemus et al., 1999). while biological theory has proved intriguing, findings from genetic and family investigations have provided some support for a genetic basis for ocd. the concordance rate of ocd is higher for monozygotic twins than for dizygotic twins and genetic influence ranges from 27% to 47% (for a review, see van grootheest et al., 2005). in addition, the prevalence of ocd is higher among first-degree relatives of affected probands than those of control probands, 12% and 3%, respectively (nestadt et al., 2000). there is also evidence that a family history of ocd is associated with early onset of the disorder (hanna, himle, curtis, & gillespie, 2005). genetic studies in ocd during pregnancy knowledge, only one study has addressed this issue. uguz and colleagues (2007b) found that pregnant women with ocd were significantly more likely to have a positive family history of ocd compared to pregnant women without ocd. however, family history of ocd was based on self-reports rather than structured, standardized diagnostic interviews. psychosocial factors while biological theories are largely successful at explaining the unique etiological factors of pregnancyrelated ocd, a growing body of research suggests that there may also be psychosocial determinants of the disorder. one such finding is that the male partners of pregnant women appear to be susceptible to the development of ocd symptoms. abramowitz and colleagues (2001) reported four cases of male spouses who or after delivery. all four fathers reported intrusive egodystonic thoughts of harming the child (e.g., intrusive ideas of stabbing the baby with sharp objects, shaking the baby to death, etc.), a finding that points out the inadequacy of purely biological theories to explain the onset of symptoms during this period. the high prevalence of obsessions among new fathers was further corroborated in a survey of 600 childbearing women and their partners (2003). twentythree (57.7%) out of 40 male respondents endorsed some intrusive obsessive thoughts, a rate similar to this of mothers (abramowitz, schwartz, & moore, 2003). furthermore, it may be valuable to consider the interaction between biological vulnerability and environmental stressors in the development of ocd during pregnancy. not all women associate their pregnancy with positive emotions, an oft-held notion. some women experience pregnancy as a stressful life event (geller, 2004). among a growing body of literature investigating the role of stressful life events (sle) in the onset of depressive and anxiety disorders (paykel & dowlatshahi, 1988), evidence suggests that sles are associated with the onset of ocd (cromer, schmidt, & murphy, 2007). research has identified other risk factors for pregnancypregnancy, comorbid premenstrual dysphoric disorder (pmdd), prior history of abortion and miscarriage, obstetric complications and medical conditions, unplanned mother (adewuya et al., 2006; fontenelle & haler, 2006; labad et al., 2005; neziroglu et al., 1992). moreover, lack of social support with household responsibilities and childcare is associated with a poorer prognosis of the disorder (uguz et al., 2007a) and greater likelihood of developing depression postnatally (webster et al., 2000). drawing on d. w. researchers hypothesize that mothers may be genetically predisposed to demonstrate increased protectiveness and safe environment that ensures the survival of the infant (e.g., leckman et al., 2004). obsessive-compulsive behavior could thus be conceptualized as an extension of an adaptive maternal behavior. findings by jennings and colleagues (1999) lend support to this, showing that as high as 6.5% of asymptomatic postpartum women experienced aggressive thoughts towards their infants. the cognitive appraisal model (salkovskis, 1999) supports the evolutionary perspective by theorizing that the majority of adults experience intrusive, upsetting, ego-dystonic thoughts, which are indistinguishable from clinical obsession in terms of content. vulnerable individuals tend threatening. for example, they falsely believe that thinking about a violent act is equivalent to committing such an act (morality bias), or that thinking about something increases the probability that it will actually occur (probability bias). it is when individuals misappraise these thoughts as threatening that clinical obsessions occur, further leading to attempts to prevent or neutralize the thoughts by engaging in ritualistic behaviors (salkovskis & harrison, 1984). clinical implications and recommendations obsessive compulsive disorder during pregnancy causes significant disturbance and has a negative impact on physical and psychological well-being, as well as social relationships (gezginc et al., 2008). in addition, a significant body of research supports a link between prenatal anxiety and neonatal outcomes, such as preterm labor, heart defects, and growth retardation (see talge, neal, & glover, 2007 for a review). moreover, prenatal anxiety can have longcognitive, behavioral, and emotional functioning (huizink, mulder, & buitelaar, 2004). furthermore, in the absence of treatment, anxiety disorders are a strong precipitating factor in postpartum depression (skouteris, wertheim, rallis, milgrom, & paxton, 2009), and thus, ocd may have ocd during pregnancy   41 negative implications for the mother-infant relationship (chelmow & halfin, 1997). research in the postpartum ability to care for the infant and engage the infant in social interactions (murray, cooper, & hipwell, 2003). depressed mothers may talk less to their infants, manifest fewer facial expressions, show less physical affection, have impaired bonding, and negatively influence the affective regulation of their child (moehler, brunner, parzer, wiebel, reck, & resch, 2006; tronick, & reck, 2009). maternal depression may also have adverse effects on infan cognitive and emotional development (murray & cooper, 1996; murray, hipwell, hooper, stein, & cooper, 1996). however, there is evidence indicating that the association between prenatal anxiety and child adjustment is not fully explained by the mediation of postnatal depression. for significant effect of antenatal anxiety on child behavioral and emotional problems after accounting for postnatal depression. together these findings point to the importance of detection and treatment of ocd in pregnancy. clinical surveillance for ocd during pregnancy should be part of the screening process in obstetrical and primary care. screening should first include simple questions regarding intrusive, unwanted thoughts (i.e., contamination) and compulsive behaviors (i.e., excessive washing and checking behaviors). should the patient endorse such symptoms, the frequency and severity of the symptoms should be assessed using measures of ocd with wellestablished psychometric properties (e.g., ybocs). in the event of clinically significant ocd symptoms, a referral for psychiatric consultation and/or treatment should be considered (brandes, soares, & cohen, 2003). several selective serotonin reuptake inhibitors have demonstrated efficacy and tolerability in the treatment of ocd, among them fluoxetine, sertraline, fluvoxamine, and paroxetine (see pigott & seay, 1999 for a review). however, antidepressant medication may not be a viable treatment option during pregnancy; despite their low side-effect rates, ssris have not been approved by the food and drug administration (fda) for use during pregnancy (weisberg & paquette, 2002). among non-pharmacologic treatments, cognitivebehavioral therapy (cbt) is the most widely tested psychosocial approach for ocd. within the cbt paradigm, numerous different treatment models for ocd exist, such as exposure (imaginal or in-vivo), response prevention, cognitive therapy (ct), and rational-emotive therapy (ret). a number of randomized controlled trials (rcts) attest to the efficacy of exposure in combination with response prevention (erp) for treating ocd either in an individual or group format (deacon & abramowitz, 2004). however, there has been no research on the efficacy of cbt or other psychosocial intervention in the treatment of ocd in pregnancy. conclusion existing findings indicate that a sizeable proportion of women experience a sudden onset or exacerbation of ocd during pregnancy suggesting that pregnancy is a vulnerable period for the development or exacerbation of ocd. several biological and psychosocial factors are implicated in the etiology of ocd in pregnancy, yet the exact mechanism of pathogenesis is unknown. due to limited research and methodological shortcomings, future research is needed to further explore the prevalence, course, and etiology of the disorder. prospective studies are needed to further elucidate the prevalence and course of ocd during pregnancy and to identify at-risk subgroups. longitudinal studies should commence prior to conception, if possible, and follow-up should be performed postpartum. future studies need larger samples and assessment of ocd symptoms should be carried out at multiple points during gestation, ideally during each trimester. in addition, pregnant women with ocd should be compared with control groups of nonpregnant women matched for demographic and clinical variables such as age, marital status, socioeconomic status, family history of the disorder, and co-morbid mental disorders. future studies should incorporate a number of additional parameters. inclusion of patients with concurrent depression is needed in order to clarify the nature of the relationship between ocd and major depression. studies would also benefit from the inclusion of subclinical obsessive-compulsive symptoms (abramowitz et al., 2003a) because cut-off scores tend to simplify the clinical picture of the disorder. finally, given the possible association between ocd symptoms and complications in pregnancy, future studies should record a detailed medical and gynecological history, including obstetric complications (e.g., pre-eclampsia), premenstrual symptoms, and number of previous pregnancies, miscarriages, and abortions. a better understanding of the prevalence and pathogenesis of the 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(2009). postpartum obsessive-compulsive disorder: prevalence and clinical characteristics. comprehensive psychiatry, 50, 503-509.   interpreter-mediated therapy for refugees: graduate student journal of psychology copyright 2011 by the department of counseling and clinical psychology 2011, vol. 13 teachers college, columbia university 4 the psychosocial context and mental health needs of unaccompanied children in united states immigration proceedings charles d. r. baily teachers college, columbia university amber s. ricks teachers college, columbia university schuyler w. henderson columbia university amanda r. taub fordham university helen verdeli teachers college, columbia university little is known about the psychosocial context and mental health needs of children who migrate to the united states without a parent. under federal law, this group is classified as unaccompanied alien children. they are a particularly vulnerable population, who are at high risk for exposure to traumatic experiences in their countries of origin, during their journeys to america, and following their arrival and apprehension by u.s. immigration. this paper focuses on the needs of unaccompanied children who have been detained in government custody and are seeking immigration relief to prevent them from being deported. we first outline recent developments in legislation and legal service provision designed to protect unaccompanied children. next, we describe psychosocial stressors associated with the various stages of their migration and explore the potential psychological impact of these stressors. in light of this literature, we discuss different reasons lawyers may seek mental health services for their unaccompanied child clients. finally, we suggest areas for future research to improve understanding of the mental health needs of these children. over the last 15 years, there has been an exponential growth in the literature on the mental health of immigrant children and families (e.g., berry, phinney, sam, & vedder, 2006; lustig et al., 2004; pumariega & rothe, 2010). however, one subgroup of immigrants that has received little attention is that of children who migrate without a parent or other adult family member. these children have been described, among other categorizations, as “children asylum seekers,” “juvenile aliens,” “juvenile asylum seekers,” “refugee children,” “separated aliens,” “unaccompanied immigrant children,” “unaccompanied juvenile aliens,” and “unaccompanied minors.” these terms reflect the varying political attitudes and immigration policies of the different countries through which the children are traveling or to which they are attempting to migrate, and have important implications for their legal and social status (chavez & menjívar, 2010).  charles d. r. baily, m.a., amber s. ricks, m.a., helen verdeli, ph.d., department of counseling and clinical psychology, teachers college, columbia university; schuyler w. henderson, m.d., m.p.h., columbia university; amanda r. taub, j.d., fordham university. correspondence concerning this article should be addressed to charles d. r. baily, teachers college, columbia university, department of counseling and clinical psychology, box 102, 525 west 120th street, new york, ny 10027. email: cdb2123@tc.columbia.edu. under the terms set out in 6 u.s.c. § 279(g)(2), u.s. immigration law defines an unaccompanied alien child as any child or adolescent who is without lawful immigration status in the united states, is under the age of 18, and does not have a parent or legal guardian to provide care and physical custody (haddal, 2007). this umbrella legal term encompasses children with a variety of circumstances, to include asylum seekers, recognized refugees, and other externally displaced people (shah, 2005). throughout this paper, the abbreviated term unaccompanied children will be used to refer to children who meet the § 279(g)(2) definition. a growing number of unaccompanied children attempt to enter the united states each year (chavez & menjívar, 2010). in 2005, the department of homeland security (dhs) apprehended over 114,000 unaccompanied children, compared with approximately 98,000 in 2001 (haddal, 2007). most of the children captured by u.s. immigration are mexican, choose voluntary repatriation, and are deported within 72 hours. a second group, largely comprised of children from other central american countries, is transferred to the division of unaccompanied children’s services (ducs) and enters a more formal custodial process. in addition to those deported and those detained, a third group of unaccompanied children is not detected, and does not come into contact with the authorities at all. very little is known about this population (byrne, 2008). baily, henderson, ricks, taub, & verdeli 5 this paper will focus primarily on the second group of children referred to above, unaccompanied children who have been detained in u.s. immigration custody and are awaiting immigration proceedings. in 2010, 8,302 such children were detained in ducs custody (m. dunn, personal communication, april 1, 2011). though demographic information fluctuates slightly from year to year, approximately 85% of the children detained are from guatemala, honduras, or el salvador, three-quarters are males, and their median age is 16 (dunn, 2011; haddal, 2007). advocacy organizations (e.g., amnesty international, 2003; byrne, 2008; human rights first, 2004; human rights watch, 1998; women’s refugee commission, 2009) and government agencies (e.g., united states department of health and human services: office of the inspector general [dhhs], 2008) alike have expressed their concern about the well-being of unaccompanied children awaiting immigration proceedings. these unaccompanied children are likely to be exposed to psychosocial stressors at each stage of the migration process (sourander, 1998). they may be fleeing violence in their countries of origin, suffer abuses on the long journey to the united states, have traumatic detention experiences, and go through the adversarial legal process without the support of close family and friends (women’s refugee commission, 2009). such experiences put them at elevated risk for posttraumatic stress disorder (ptsd) and other forms of psychopathology, including depression, anxiety, and conduct problems (piwowarczyk, 2006). this paper explores the link between the legal and mental health needs of unaccompanied children, and situates the work of lawyers representing them in immigration proceedings in the wider psychosocial context of their migration process. as a backdrop to this discussion, we first outline recent developments in legislation and the provision of legal services to support unaccompanied children. legal provisions for unaccompanied children there is an inherent tension in the functions assigned to the u.s. immigration service vis-à-vis unaccompanied children. on the one hand, like any immigration service, the dhs has an adversarial role in prosecuting children’s presence in the country and arguing for deportation. on the other hand, it has a duty of care towards children in its custody (women’s refugee commission, 2002, 2009). at the international level, guidelines from the united nations high commissioner for refugees (unhcr) assert that any children apprehended by immigration authorities should not be detained, and stress the importance of providing children with access to schools and other developmentally important activities such as recreation and play (unhcr, 1999). at the domestic level, the u.s. federal class action settlement of 1985 known as the flores settlement established minimum standards for placement, treatment, and release to sponsors of unaccompanied children in federal custody (dhhs, 2008). over the last 10 years, considerable efforts have been made to improve the treatment of unaccompanied children in immigration custody, expand the forms of immigration relief available to them, and increase their access to legal services. in order to separate its conflicting roles as prosecutor and caretaker, the government created the ducs in 2003 to administer to this population’s needs (women’s refugee commission, 2009). the flores settlement mandates that unaccompanied children be placed “in the least restrictive setting appropriate” and released to such settings “without unnecessary delay” (women’s refugee commission, 2009, p. 69; p. 70). the ducs has greatly improved adherence to these guidelines, and the majority of children detained are now released within a few days (dhhs, 2008). when possible, they are sent to relatives residing in the u.s. if they have no suitable relatives available, they are placed in ducs-funded foster care or other child-appropriate residential facilities (haddal, 2007). the ducs has created guidelines for the provision of psychological and psychosocial services within its facilities while children are going through the often long and stressful legal process to determine their eligibility to stay in the united states (women’s refugee commission, 2009). however, it is unclear how consistently these services are provided. a 2008 survey of 22 ducs-funded facilities found that the majority of children’s files were missing assessments or lacked required documentation of mental health services or engagement in psychosocial activities (dhhs). improvements have been made in the immigration relief available to unaccompanied children. special immigrant juvenile status (sijs) is a form of immigration relief through which eligible unaccompanied children may obtain lawful immigration status (byrne, 2008). it provides a relatively fast route to permanent residence, with a high rate of successful adjustments of status (shah, 2005). other forms of immigration relief that may be available to unaccompanied children include asylum and petitions based on the victims of trafficking and violence protection act (vtvpa) (byrne, 2008). access to legal services for children petitioning to remain in the united states is also improving. unlike criminal defendants, immigration petitioners do not have a right to appointed counsel (kerwin, 2005). organizations such as legal aid, catholic charities, and pro bono programs in law firms provide free legal representation to unaccompanied children in many parts of the country, but have never been capable of serving the entire population. in a government survey of unaccompanied children in custody in 1999, only 43% were represented by attorneys (united states department of justice: office of the inspector general, 2001). to supplement existing legal resources and coordinate the provision of counsel to unaccompanied children, angelina jolie and microsoft co-founded kids in need of defense (kind) in 2008. the organization now has offices in major cities across the united states. improving representation is an important component of access to justice. multiple studies have shown that immigrants with legal mental health of unaccompanied children 6 representation are more likely to be successful in their petitions for immigration relief (e.g., ramji-nogales, schoenholtz, & schrag, 2007; transactional records access clearinghouse, 2006). unaccompanied children, in particular, are unlikely to be able to represent themselves effectively without the aid of counsel (byrne, 2008). legal advocacy is situated within the wider psychosocial context of unaccompanied children’s ongoing migration process. lawyers may spend many months working with their unaccompanied child clients, the children's u.s. sponsors, and their families abroad to prepare their immigration cases and lead them through the multiple court hearings and other administrative steps involved in securing immigration relief. their advocacy efforts can also include helping these children connect to other professional services to address their academic, social, and psychological needs. anecdotal reports from lawyers working with unaccompanied children suggest that many of their clients are struggling with psychological difficulties. to better serve these children, their mental health needs should be contextualized in terms of the different psychosocial stressors to which they may be exposed during their migration process. psychosocial stressors associated with migration of unaccompanied children an extensive literature on the psychosocial stressors associated with migration has characterized this process as a series of phases: (1) premigration, (2) transit, (3) temporary resettlement, and (4) permanent settlement (berry, phinney, sam, & vedder, 2006; lustig et al., 2004; pumariega & rothe, 2010). although only a small proportion of this work has been conducted with a focus on unaccompanied children, the available research suggests that their experience can be conceptualized in terms of these four phases. premigration during the premigration phase, unaccompanied children are often caught up in social and political conflict as a result of civil war or other forms of institutional violence, such as the gang problems afflicting much of central america (dalrymple, 2006). they are likely to have experienced threats or persecution, either directly or against loved ones (sourander, 1998), and to have witnessed and/or engaged in violence (lustig et al., 2004). whereas younger children tend to migrate to the united states to reunify with family members, older children often migrate for economic purposes (lópez castro, 2007). apprehended children have also described migrating to the united states to flee gangs, evade forcible recruitment by military or paramilitary organizations, escape coercion into child labor or prostitution, and avoid the aftermath of natural disasters (chavez & menjívar, 2010). transit in the transit phase, unaccompanied children can spend months traveling alone to the united states in dangerous conditions. they may be attacked by bandits or gangs or abused by local police who are ostensibly there to protect them (casillas, 2006; seugling, 2004). due to the tightening of immigration controls, children are increasingly being entrusted to coyotes (people smugglers), exposing them to potential abuse and sexual exploitation (bhaba & schmidt, 2008; fazel & stein, 2002). many of the most impoverished central american children travel north towards the united states on the roofs of trains or under the boxcars. there are often accidents in which people lose limbs or even die (chavez & menjívar, 2010). temporary resettlement in the temporary resettlement phase, unaccompanied children who have been apprehended and detained may have stressful detention experiences. subsequently, upon their release, they face a period of legal uncertainty in unfamiliar surroundings and without their usual sources of support (perez foster, 2001; sourander, 1998). since the creation of ducs, there have been improvements in the detainment conditions of unaccompanied children (byrne, 2008). however, there is also evidence that some of the policies designed to protect children are inconsistently followed. for example, ducs facility staff have reported that procedures for identifying victims of rape, abuse, and trafficking as well as for assessing mental health issues are insufficient (women’s refugee commission, 2009). a minority of unaccompanied children are not transferred to ducs custody and remain in prisonlike conditions in secure immigration and customs enforcement (ice) facilities (women’s refugee commission, 2009). reports by advocacy organizations about conditions in such facilities have revealed practices such as not informing unaccompanied children of their rights, detaining them among adult or juvenile criminal offenders, forcing them to wear prison-like uniforms, hand-cuffing or shackling them, and denying them access to legal counsel or contact with family members (bhaba & schmidt, 2008; byrne, 2008; women’s refugee commission, 2009). under the terms of the flores settlement, many unaccompanied children are released quickly from detention to family members residing in the united states (byrne, 2008). however, these relatives may not know the children well nor be anticipating their arrival, and they may not be financially or emotionally equipped to accommodate them. for those children released to ducs-funded foster care or residential facilities, accommodation varies from houses in residential neighborhoods to secured buildings with barred windows and locked doors (dhhs, 2008; women’s refugee committee, 2009). whether unaccompanied children are housed with family members or in ducs-sponsored facilities, evidence from the wider immigration literature suggests that the temporary resettlement phase may present a variety of psychosocial stressors (ehntholt & yule, 2006). fear of deportation, delays in processing applications for immigration relief, and worries about relatives left at home are common during this baily, henderson, ricks, taub, & verdeli 7 period of uncertainty (silove, mcintosh, & becker, 1993; sinnerbrink, silove, field, steel, & manicavasagar, 1997). permanent settlement for unaccompanied children who are successful in their immigration petitions, permanent settlement in the united states brings its own set of potential stressors, such as acculturation issues and prejudice within the local culture (perez foster, 2001). most unaccompanied children do not speak english when they arrive, and as a result they may struggle academically and socially (portes, 1999). furthermore, they may not seek mental health support or treatment due to cultural stigma or other barriers to accessing care such as limited financial resources or a lack of local psychosocial services appropriate to their needs (sinnerbrink et al., 1997). psychological impact of migration of unaccompanied children to date, no empirical study has assessed the psychological impact of migration on unaccompanied children in the united states (chavez & menjívar, 2010). most of the available information on the mental health of these children comes from qualitative reports by advocacy groups and focuses specifically on the adverse impact of prolonged detention in immigration facilities (e.g., women’s refugee commission, 2002, 2009). these reports have documented high rates of ptsd, anxiety, depression, aggression, psychosomatic complaints, and suicidal ideation among unaccompanied children in detention (bhaba & schmidt, 2008; chavez & menjívar, 2010; women’s refugee commission, 2009). these qualitative findings from the united states mirror the types of psychopathology found in empirical studies of unaccompanied children detained in finland (sourander, 1998) and the netherlands (reijneveld, de boer, bean, & korfker, 2005). however, with the exception of this work on the impact of detention, there is a paucity of information regarding the effects of psychosocial stressors associated with unaccompanied children’s migration. the wider literature on immigration and trauma suggests that unaccompanied children in the united states are at high risk for the development of psychopathology. the majority are from central america, a region whose recent history of civil wars and institutionalized violence make children especially likely to have been exposed to potentially traumatic events. thus, they are vulnerable to developing ptsd symptoms and other mental health problems (locke, southwick, mccloskey, & fernández-esquer, 1996). repeated traumatic exposure during the various phases of the migration process can exert a compounding effect on the impact of premigration trauma (robjant, hassan, & kasona, 2009; sinnerbrink et al., 1997), and may lead to complex trauma reactions (national child traumatic stress network, 2003). children’s responses to complex trauma can include attachment problems, emotional and behavioral regulation difficulties, dissociative episodes, poor self-image, and physical and cognitive deficits (courtois, 2004; herman, 1992; national child traumatic stress network, 2003). lack of parental support, which can provide an important regulating influence following traumatic exposure, may place unaccompanied children at particular risk for developing psychopathology (lustig et al., 2004). in addition to mental health problems, unaccompanied children may be at risk for other psychosocial problems. separation from parents has been shown to predict poor academic achievement in recently arrived immigrant children (suárez-orozco, bang, & onaga, 2010), and unaccompanied children’s academic and social development may have been disrupted by lack of access to schools in their countries of origin or during the migration process (fazel & stein, 2002). however, there is a lack of research focusing specifically on psychosocial difficulties among unaccompanied children. despite the multiple stressors associated with migration, many unaccompanied children show resilient outcomes. both individual variables (e.g., a child’s sense of selfefficacy) and contextual factors (e.g., transit or detention experiences) may contribute to whether or not children develop psychopathology (luthar & zelazo, 2003). different children may experience psychosocial stressors in a variety of ways. for example, the presence of family members is not necessarily protective against the stress of immigration custody: a study of children in immigration detention in australia (mares & jureidini, 2004) found that the experience of parental distress, traumatization, and mental illness during detention increased children’s vulnerability to psychopathology. in some circumstances, the fact that a child has successfully navigated multiple stressors to make it to the united states can be evidence of psychological resourcefulness. based on low rates of mental health problems observed among adult mexican immigrants, escobar and colleagues developed the migration of the fittest hypothesis (escobar, 1998). this construct holds that, due to the harsh realities of the immigration process, only the strongest and most resilient attempt and succeed in coming to the united states. this idea may also apply to unaccompanied children, who are likely to endure a host of psychosocial stressors alone. alternatively, in some cases a child’s highly developed survival skills may mask other social and emotional deficits (piwowarczyk, 2006). taken as a whole, the literature on the psychosocial stressors associated with migration suggests that unaccompanied children in immigration proceedings are at high risk for psychopathology. however, there are likely considerable differences between children based on individual characteristics (e.g., children’s age and gender) and their varied migration stories (e.g., why they left their country of origin, how they traveled to the u.s border, and how long they were detained in immigration custody). the impact of these different factors warrants further study, and a better understanding of the mental health needs of unaccompanied children will assist lawyers who work with this population in making appropriate referrals. mental health of unaccompanied children 8 mental health referral practices of lawyers working with unaccompanied children lawyers may request psychological services for their clients for a variety of reasons: to provide assessment and expert testimony to bolster a client’s case; to give advice or clarification about a client’s presentation and history; to deliver treatment to a client who is exhibiting distress or symptoms of a mental illness (galowitz, 1999; price & mccreary, 1976). given their elevated risk for psychological distress, unaccompanied child clients may be particularly in need of such services. mental health professionals can be called upon to support unaccompanied children’s immigration cases by conducting a psychological assessment and providing expert testimony. the three primary forms of humanitarian relief for which unaccompanied children may be eligible each require evidence of psychosocial stress. in the case of sijs petitions, evidence must be provided that children are eligible for long-term foster care due to neglect, abuse, or abandonment, and that it is not in their best interests to return to their home country (shah, 2005). to make an asylum claim, a well-founded fear of persecution on the basis of race, religion, national origin, political opinion, or social group must be established. petitions based on vtvpa require evidence of transportation of unaccompanied children for subsequent exploitation, usually in the form of forced labor or prostitution (byrne, 2008). expert mental health testimony can bolster each of these types of claims by documenting exposure to relevant psychosocial stressors and their impact on the unaccompanied child. lawyers may call upon mental health professionals to help unaccompanied children recount traumatic events from their history that provide grounds for one of the above forms of relief. anecdotal evidence from lawyers suggests that without such assistance, unaccompanied children with trauma histories often avoid telling the truth about what has happened to them, which can undermine legitimate claims for immigration relief. this is consistent with findings from the psychological literature that children with ptsd may avoid talking about traumatic experiences (schaal & elbert, 2006). aside from case-specific considerations, lawyers may also seek mental health services for unaccompanied children out of a more general concern for their well-being. however, mental health treatment may also, indirectly, assist in children’s immigration relief claims. for example, improvements in symptoms of disorders such as ptsd and depression can increase children’s ability to recount or verify difficult migration experiences. additionally, immigration judges commonly inquire about children’s school attendance and other behaviors over the course of the immigration process. a child who has received mental health services may be better able to respond to such questions. although lawyers frequently call on mental health professionals to assist unaccompanied children in immigration proceedings, there has been little systematic study of how, when, and why they decide to make referrals. research in this area is urgently required to ensure that the mental health needs of unaccompanied children are being appropriately met. for example, efforts should be made to help children provide testimony with the least discomfort possible. child advocacy centers routinely use multidisciplinary teams (including lawyers and mental health professionals) to interview victims of abuse and their families about sensitive material. not only does this protect children by reducing the number of times they have to recount abuses, it has also been shown to lead to more reliable and consistent information, and higher rates of successful cases (smith, witte, & fricker-elhai, 2006). whether such an approach would be feasible and applicable to the case of unaccompanied children bears exploration. directions for future research unaccompanied children are a challenging population to study. typically, they are only officially identified when apprehended and placed in immigration proceedings. conducting research with children is always ethically complicated, but when there are sensitive legal considerations and parents are not available to provide informed consent, the task is rendered even more difficult. furthermore, while legal categories like unaccompanied alien child are created to protect the rights of children, they also create a propensity to assume high degrees of similarity among individuals within a given category (lópez castro, 2007). however, beyond their uncertain immigration status, there is no other single factor that consistently unites unaccompanied children as a homogenous group (henderson, baily, & weine, 2010). nevertheless, as a whole, the existing evidence suggests that unaccompanied children in immigration proceedings are a highly vulnerable population and at risk for exposure to multiple psychosocial stressors and their psychological sequelae. at this time, several domains of study warrant further attention: the familial context of these children; their psychosocial and psychiatric needs; their experience of the u.s. immigration process; and their lawyers’ perceptions of their mental health needs. with regard to the familial context of unaccompanied children, there are many questions one might ask: where are their families and what compelled the children to separate from them? do they intend to reunite with parents or other family members and, if so, when and where? how do they understand this separation is it something normal, unusual, temporary, or permanent? these children’s thoughts about their family situation are likely be varied and complex, and possibly quite different from other culture-bound expectations for children of their age. one of the concerns some unaccompanied children raise with their lawyers is whether they will be able to get into the workplace promptly in order to start sending money to family members back home. even if they have a promising case for acquiring permanent legal status, the pressure to start earning causes some children to choose voluntary repatriation and attempt to baily, henderson, ricks, taub, & verdeli 9 reenter the country again illegally, rather than pursue the time-consuming immigration process. information on the psychosocial and psychiatric needs of unaccompanied children is also limited. both studies (e.g., bhaba & schmidt, 2008; chavez & menjívar, 2010) and anecdotal accounts from their lawyers suggest that some of these children are very distressed and have identifiable clinical disorders, but many questions remain: how do the children themselves tell their own stories? and what place is there in their narratives for psychological, psychiatric, and psychosocial explanations (e.g., “i’m not crazy”, “this is normal”, or “i feel very sad”)? how do they conceptualize loss, trauma, and resilience? what coping resources are available to them, and how do they access this support? how do factors such as age, gender, reason for migration, and country of origin moderate the experience of migration stress? finally, how can psychological and psychiatric expertise, which is subject to criticism of its own cultural specificity (summerfield, 2008), help understand and assist this varied population? further research is also required to understand how the immigration process impacts unaccompanied children’s mental health and psychosocial functioning. anecdotally, lawyers report that some of their clients express relief at being apprehended by u.s. immigration, freed from abusive coyotes, and given regular meals and a warm place to sleep. some children are intimidated by coyotes into lying to immigration officials about their age and, as a result, get sent to adult detention facilities entirely inappropriate to their needs. out of fear for themselves and family members, some opt to take voluntary departure to mexico so that they can attempt to reenter the country immediately and start paying off the coyotes to whom they are in financial bondage. more generally, how do children feel about being apprehended and “criminalized”? how are laws explained to them? how do they understand the legal options that may be available to them, and what informs their decisions about how to proceed? more systematic research on how lawyers understand the psychosocial context and mental health needs of their unaccompanied child clients is also needed. what are lawyers’ experiences of working with these children? how do they identify mental health problems in their clients, and how does it impact their work with them? how might having a clinical diagnosis affect immigration proceedings? often unaccompanied children live in immigrant communities in which many people are undocumented and understandably wary of contact with official institutions and public services. given this context, lawyers may offer a rare point of access and source of information about these children. they also provide one conduit into the mental health system for those children in need. however, currently this process is poorly understood. when, how, and why do lawyers access assessment or treatment services for their unaccompanied child clients? do they have any process for screening for mental health problems, either formally or informally? these, and other questions like them, offer not only an avenue for better understanding the mental health needs of unaccompanied children, but also the possibility of improving their access to feasible and effective mental health services. conclusion the research reviewed in this paper suggests that unaccompanied children in immigration proceedings are likely to have experienced multiple psychosocial stressors during the process of their migration to the united states, and are at high risk for psychological problems. the literature also indicates that over the last 10 years considerable progress has been made in improving their situation. at the legislative level, the forms of immigration relief available to unaccompanied children have expanded; at the advocacy level, legal and non-governmental organizations have successfully lobbied for improved conditions for children apprehended and detained by immigration services; at the services level, access to expert legal representation has been improved. there seems to be growing consensus that it is in society’s best interests to normalize unaccompanied children’s immigration status and, for those permitted to stay, support them in their aspirations. in order to facilitate this process, it is crucial that their psychosocial circumstances and mental health needs be understood and addressed. references amnesty international. 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(2002). prison guard or parent?: ins treatment of unaccompanied refugee children (research report). retrieved from http://www.womenscommission.org/reports/cat_view/68reports/71-detention-a-asylum?start=10 women’s refugee commission. (2009). halfway home: unaccompanied children in immigration custody (research report). retrieved from http://www.womens commission.org/reports/cat_view/68-reports/71-detention -a-asylum?start=10 http://www.acslaw.org/files/refugeeroulette http://law.vanderbilt.edu/%0bpublications/journal-oftransnational-law/index.aspx http://law.vanderbilt.edu/%0bpublications/journal-oftransnational-law/index.aspx gsjp volume 16 final graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 5 measuring purpose in life: a review danielle schultz teachers college, columbia university human beings are said to be unique in that we are the only meaning-making species. while purpose in life has long ehhq�d�vrxufh�ri �lqtxlu\�e\�uholjlrxv�àjxuhv��sklorvrskhuv��dqg�vfkroduv�dolnh��lw�kdv�ehfrph�dq�lqfuhdvlqjo\�vljqlàfdqw� focus of psychological research, which has suggested that an individual’s sense of purpose in life affects their mental health in a variety of ways. with the recent emergence of the positive psychology movement, a renewed interest in the subject of purpose in life has resulted in a rapidly growing body of literature on the topic. however, purpose lq�olih�kdv�ehhq�ghàqhg�dqg�frqfhswxdol]hg�lq�pdq\�gliihuhqw�zd\v³�jlylqj�ulvh�wr�d�odujh�euhdgwk�ri �lqvwuxphqwv� seeking to measure the concept. this article is intended to provide a comprehensive guide to a wide and diverse array of measures to assist beginning researchers seeking to assess purpose in life and related constructs. although wkhvh�vfdohv�fdq�eh�hdvlo\�orfdwhg�lq�wkh�olwhudwxuh��gxh�wr�gliihuhqfhv�lq�phwkrgrorj\��frqvwuxfw��dqg�ghàqlqj�ri � purpose in life, this review is the only article that attempts to review all these measurements in one place for the ease of accessibility. furthermore, few resources exist outlining the science and measurement underlying the concept. an extensive review of 26 measures of purpose in life and related constructs was completed. careful exploration uhyhdohg�wkdw�dowkrxjk�fxuuhqw�phdvxuhv�kdyh�pdgh�vljqlàfdqw�frqwulexwlrqv�wr�wkh�h[wdqw�olwhudwxuh��pdq\�ri �wkhvh� lqvwuxphqwv�vxiihu�iurp�glvfuhsdqflhv�lq�krz�sxusrvh�lq�olih�lv�ehlqj�ghàqhg��pdnlqj�lw�gliàfxow�wr�fdswxuh�wkh�ixoo� breadth and nuances of the purpose in life construct and potentially hampering research on mental health outcomes. suggestions for further research and different methodological approaches to measurement construction are made. � 7kh�sxuvxlw�ri �sxusrvh�lq�olih�lv�d�ghàqlqj�dqg� universal feature of the human experience, regardless of age, gender, social-cultural background, economic status, or geographic location. it has long been a vrxufh�ri � lqtxlu\�e\�uholjlrxv�àjxuhv��sklorvrskhuv�� and scholars alike and has gained increasing clinical uhohydqfh� lq� wkh�àhog�ri �sv\fkrorj\��zklfk�kdv� lpplicated the concept in the etiology of various psychological disorders such as depression, anxiety, and addiction(s) (bronk, 2014; crumbaugh & maholick, 1964; edwards & holden, 2001; harlow, newcomb, & bentler, 1986; kleftaras & psarra, 2012; padelford, 1974; phillips, 1980; schulenberg, schnetzer, & buchanan, 2011; shek, 1992). psychological revhdufk� kdv� dovr� lghqwlàhg� sxusrvh� lq� olih� dv� dq� hvsential component of well-being and optimal human functioning, linking the concept to higher life satisfaction, improved physical health, and overall greater happiness (bronk, 2014; keyes, 2002; king, hicks, krull, & gaiso, 2006; ryff, 1995; ryff & singer, 2008; schulenberg, hutzell, nassif, & rogina, 2008; zika & chamberlain, 1992). more recently, purpose in life has begun to emerge in popular culture such as nationally recognized books (warren, 2002), seminars, and topics of discussion on talk shows and news broadcasts, resulting in a rapidly growing purpose-seeking industry (bronk, 2014). while the concept has been attracting more attention, very few resources exist that outline the science behind the concept, particularly in terms of measurement. this article is an attempt to provide researchers with a comprehensive and nuanced understanding of purpose in life and how it is being measured. it is in large part a review of instruments measuring purpose, beginning with a brief exploration of the history of the concept, followed by a thorough examination of instruments that measure purpose in life and related constructs. suggestions for future directions in research are made. (yroxwlrq�ri �wkh�3xusrvh�&rqvwuxfw��'hàqlqj� purpose in life and theoretical foundations western concepts of purpose in life draw much from early greek philosophers like socrates, plato, and aristotle (bronk, 2014; macdonald, wong, & gringas, 2012; reker, peacock, & wong, 1987). other early conceptualizations are mostly rooted in reoljlrq��zlwk�sxusrvh� ixqfwlrqlqj� dv� d� ixoàoophqw�ri � god’s will, supernatural forces providing a sense of meaning to one’s life, or that god is serving as the provider of sources through which one can derive meaning and purpose, such as relationships, work, or other activities (bronk, 2014; nozick, 1981). keywords: purpose in life, meaning in life, measurement, review, scale development, existential psychology, logotherapy, goals, commitment, self-transcendence 6 � ,q� wkh� àhog� ri � sv\fkrorj\�� wkh� ehjlqqlqjv� ri � the purpose in life concept can be credited to existentialists such as viktor frankl, salvatore maddi, and irvin yalom, all of whom who believed that àqglqj�d�vhqvh�ri �sxusrvh� lq� olih�zdv�pdq·v�sulpdry motivational force (frankl, 1959) and an “ultimate concern” of existence (yalom, 1980) that, if ohiw� xqixoàoohg�� frxog� uhvxow� lq� vljqlàfdqw�� qhjdwlyh� psychological consequences such as suicide (yalom, 1970), or syndromes characterized by anxiety, depression, hopelessness, and boredom (auhagen, 2000; bronk, 2014; frankl, 1959; maddi, 1957; reker et al., 1987; steger, frazier, oishi, & kaler, 2006). � 'lyhuvh�shuvshfwlyhv� dqg� wkhrulhv�pdnh� lw�gliàcult to operationalize purpose in life, giving rise to qxphurxv� dqg� hyroylqj� ghàqlwlrqv� ri � wkh� frqfhsw� dprqj� uhvhdufkhuv�� 7kh� eurdghvw� ghàqlwlrqv� lpply that purpose in life is the recognition of goals or reasons for the process of living (auhagen, 2000; baumeister, 1991; steger et al., 2006). one complication lies in distinguishing between purpose in life and the close-related concept, meaning in life. while some theorists have simply equated purpose with meaning (crumbaugh & maholick, 1964; frankl, 1959), others have delineated purpose as one component of a larger meaning construct (baumeister & vohs, 2002; bronk, 2014; emmons, 2003; makola & berg, 2008; reker & wong, 1988). other scholars give primacy to purpose as the larger concept subvxplqj�phdqlqj�� ghàqlqj� sxusrvh� dv� d� fhqwudo� olih� dlp� wkdw� ixhov� jrdov�� lqáxhqfhv� ehkdylruv�� dqg�survides a sense of meaning (mcknight and kashdan; 2009). for the purposes of this review, we discuss purpose as a separate construct. as bronk (2014) and makola and berg (2008) point out, the two constructs are inextricably related, if not synonymous. perhaps the clearest description of purpose comes from bronk (2014), who notes three core elements present in both historical and modern ghàqlwlrqv�� jrdo�gluhfwhgqhvv�� frpplwphqw�� dqg� personal meaningfulness. each of these core elements is marked by a fourth element, self-transcendence. each concept will be discussed in turn. the presence of personal goals is seen as an important source of purpose in life, acting as incentives that govern behavior and daily functioning (emmons, 2003; klinger, 1977; pinquart, silbereisen, & fröhlich, 2009). emmons (2003) emphasizes goal-directedness as an essential component of purpose in life, arguing that “goals are signals that orient a person to what is valuable, meaningful, and purposeful” (p.107). purpose serves as a motivational iudphzrun�� lqáxhqflqj� erwk� orqj�whup� dqg� vkruw� term goals. bronk (2014) uses the following example to illustrate this point: “studying hard to get into medical school may represent a worthwhile shortterm goal for an individual pursuing a long-term purpose of providing high quality healthcare” (p. 5). $�vhqvh�ri �phdqlqjixoqhvv�dqg�sxusrvh�lv�uháhfwhg� lq� wkh� dfwlyh� sxuvxlw� dqg� ixoàoophqw� ri � wkhvh� jrdov������ commitment is another common element found lq�ghàqlwlrqv�ri �wkh�sxusrvh�lq�olih�frqvwuxfw��%dwwlvwd� & almond, 1973). it has been noted that individuals often feel compelled or inspired by their life purpose, changing their behavior and directing their energy and resources to pursuing their own purpose. this is often accentuated by a strong sense of motivation and active engagement in pursuing one’s goals (bronk, 2014). in many cases, this high level of commitment manifests as one’s career. in this context, one’s career is referred to as a “calling,” or the sense of purpose that their work is what they are meant to do (hall & chandler, 2005). this calling need not be religious, but implies a commitment to a value that one believes in. while an individual may have goals they are complwwhg�wr�ixoàoolqj��wkh\�pd\�qrw�kdyh�dq\�orqj�whup� vljqlàfdqfh�iru�phdqlqj�iru�wkh�lqglylgxdo��(pprqv�� 2003). in the context of purpose in life, a third component of the purpose construct – and perhaps most salient – is personal meaningfulness. in terms of life purpose, meaning takes a central role to the individxdo�� lqáxhqflqj�wkrxjkwv��dfwlrqv��dfwlrqv��dqg�hprtions in one’s life (bronk, 2014; mcknight & kashdan, 2009). although what contributes to a personal sense of meaning varies and isn’t necessarily straightiruzdug�� vwxglhv� kdyh� lghqwlàhg� vhyhudo� grpdlqv� lq� which people strive for: work/achievements, relationships/intimacy, religion/spirituality, and self-transcendence/generativity (emmons, 2003). while personal meaning is not limited to these domains, and sources of meaning can change throughout the lifetime, many authors agree that personal meaning schultz 7 can be derived from anything that imbues life with shuvrqdo�vljqlàfdqfh���2wkhu�uhvhdufkhuv�h[sdqg�wklv� idea of personal meaning to be an individually-constructing cognitive system consisting of affective, motivational, cognitive, relational, and personal components (macdonald, wong, & gingras, 2012; wong, 1998). regardless, personal meaning appears to be a uhjxodu�frpsrqhqw�lq�ghàqlwlrqv�ri �sxusrvh�lq�olih���������� finally, self-transcendence is a feature of all three core elements. while goals, commitments, and sources of meaning vary between individuals, all of these components are rooted in the idea of self-transcenghqfh�²�ruljlqdoo\�ghàqhg�e\�9lfwru�)udqno�dv�d�kxpdq� characteristic of being directed or oriented something other than itself (1966). self-transcendence has been referred to as an expansion of one’s personal boundaries beyond the self. although the topic of self-transcendence is beyond the scope of this paper, concepts of self-transcendence have emerged as a common theme in individual’s subjective sense of purpose in life. this encompasses goals such as leaving a legacy, contributing to society, caring for others, etc. in many cases, self-transcendence in the context of purpose in life involves a life goal of contributing something of value to others (bronk, 2014). purpose in life and mental health outcomes numerous studies have suggested that purpose dqg�phdqlqj�lq�olih�fdq�ixqfwlrq�wr�lqáxhqfh�phqwdo� health (bronk, 2014; reker et al., 1987; zika & chamberlain, 1992) and offer empirical support for earlier theories put forth by frankl, maddi, and yalom. purposelessness has been associated with negative mood states and psychopathology such as boredom, depression, anxiety, suicidal ideation, and drug/alcohol use (bronk, 2014; crumbaugh & maholick, 1964; edwards & holden, 2001; harlow, newcomb, & bentler, 1986; kleftaras & psarra, 2012; padelford, 1974; phillips, 1980; schulenberg et al., 2011; shek, 1992). conversely, a sense of purpose in life can help individuals cope with life challenges, fend off negative states, and serve as a moderator of stress effects (krause, 2007), as well as protect against suicidal ideation (edwards & holden, 2001; heisel & flett, 2004), help prevent illness (shek, 1992), and contribute to the promotion of health behavior (garcini, short, & norwood, 2013). a more recent line of research, growing out of the positive psychology movement (seligman & csikszentmihalyi, 2000), has found many positive associations to purpose and meaning in life beyond protective and mitigating factors. a growing body of olwhudwxuh�kdv�lghqwlàhg�phdqlqj�dqg�sxusrvh�dv�ylwdo� elements of optimal human functioning and well-being (bronk, 2014; keyes, 2002; king, hicks, krull, & gaiso, 2006; ryff, 1995; ryff & singer, 2008; schulenberg et al., 2008; zika & chamberlain, 1992). ryff and singer (2008) included purpose in life as a leading component in their eudaimonic model of sv\fkrorjlfdo�zhoo�ehlqj��0duwlq�6holjpdq� lghqwlàhg� meaning and purpose in life as a core component of what constitutes a “balanced psychology and full life” and necessary for “authentic happiness” (duckworth, steen, & seligman, 2005; seligman, 2002). seligman sees meaning and purpose as not just an indicator of an individual’s well-being, but of their árxulvklqj� �6holjpdq�� �������2wkhu� vfkroduv� lq� wklv� tradition have linked life purpose to life satisfaction, quality of life, and subjective well-being, positive affect and happiness (hughes, 2006; keyes, shmotkin, & ryff, 2002; peterson, park, & seligman, 2005). purpose in life has also been associated with nuphurxv�sk\vlfdo�khdowk�ehqhàwv��vxfk�dv� orzhu�udwhv� of alzheimer’s disease and mild cognitive impairment (boyle, barnes, buchman, & bennett, 2010), better cardiovascular health, reduced risk of mortality (boyle et al., 2009), and less chronic pain (kass, 1991). the present study the premise of this review stems from the lack of literature synthesizing psychological theory and empirical research on the topic of purpose in life, particularly in terms of measurement. given the abstract, yet complex nature of life purpose, measuring the construct presents a challenge. while attempts to study purpose in life are abundant, conceptualizations of the subject are as numerous and varied, giving rise to over 25 different measures, ranging from self-report surveys and rankings, to interviews that seek to illicit one’s sense of life purpose or lack thereof. despite the existence of many diverse methodical approaches measuring purpose in life, most research measuring purpose in life 8 on the topic has relied heavily on the purpose in life test (pil; crumbaugh & maholick, 1964), followed by ryff ’s scales of psychological well-being (rpwb) purpose in life subscale (ryff, 1989). although the pil has been found to be a reliable and valid measure of life purpose (bronk, 2014; zika & chamberlain, 1988, 1992), it has been subject to numerous criticisms related to its dimensionality, factor structure, and construct validity (shek, 1988; yalom 1980; zika & chamberlain, 1992). it has also been argued that the pil has confounding and value-laden variables (chamberlain & zika, 1988), and thus does not accurately or adequately measure the purpose in life construct. dyck (1987) suggested that the pil is an indirect measure of depression. the rpwb has also been criticized in terms of its dimensionality, with conceptual overlap being cited as a primary limitation of the scale. the purpose in life subscale was also found to be not as closely tied to pre-existing measures of well-being (dierendonck, 2004; springer & hauser, 2006) and estimates of internal consistency were lowest in this subscale, suggesting that the full conceptual breadth of the purpose construct is less developed or full represented in by the scale (ryff & singer, 2006). � 1hjohfw�lq�wkh�wdvn�ri �h[solflwo\�ghàqlqj�sxusrvh� in life has resulted in discrepancies that are potentially hampering research on mental health outcomes. withrxw�d�fohdu�ghàqlwlrq�ri �wkh�frqvwuxfw��phdvxuhv�zloo� not identify accurate relationships between its components or other constructs. in order to conduct further research on life purpose, it is imperative that we look at the instruments that are being used to measure the concept. the following study is part of a larger aim to highlight the need for better tools and methrgv�wr�dvvhvv�sxusrvh�lq�olih��6shflàfdoo\��lw�lv�d�uhylhz� of current measures of purpose in life and related constructs in an effort to provide researchers with an overview how the construct is being measured, suggestions for future research, and to serve as a guide. methods search methods a literature search spanning 55 years (1959-2014) was conducted using google scholar and clio because of their function as large aggregates of other major databases. the following search terms were used: purpose in life, meaning in life, measuring purpose in life, measuring meaning in life, meaning instruments, purpose in life instruments. additional sources were obtained form reference lists of retrieved articles. inclusion criteria papers were included if they were a) published in english, b) discussed instruments to measure either purpose in life, meaning in life, or other constructs related to purpose in life and c) included at least some psychometrics of the instrument discussed. search outcome one hundred and forty eight sources were found that contained information about instruments measuring purpose in life, meaning in life, and related constructs. articles were primarily suryh\� vwxglhv� vsdqqlqj� wkh�àhog� ri � sv\fkrorjlfdo� vflence and validation studies of purpose and meaning in life measurements, along with a small number of books serving as literature reviews on meaning in life. only one book was centered strictly on purpose in life. this resulted in in the retrieval of 26 measures: nine instruments measuring purpose in life, three instruments measuring concepts similar to sxusrvh� lq� olih�� dqg�àiwhhq� vfdohv�phdvxulqj�phdqing in life and constructs related to purpose in life. review the instruments were reviewed by the author for operational congruence with the intended purpose of the instrument (how well the instrument measured the intended concept), factor structure, reliability and validity. if a scale was cited in multiple articles, those articles were reviewed to gather additional information regarding the instrument, including background information such as development of the measure, psychometric properties, and other population samples to which it was administered. data abstraction a summary overview is provided to orient the reader to the measures reviewed and to describe overdoo�àqglqjv��revhuydwlrqv��wkhphv��krz�sxusrvh�lq�olih� zdv�ghàqhg��hwf�����)roorzlqj�wkh�vxppdu\�ryhuylhz�� a brief description is provided for each measure, along with relevant background information. each instrument is placed in a table according to the type ri �phdvxuhphqw�� dv� fodvvlàhg� e\� wkh� dxwkru� �gluhfw� schultz 9 measures of purpose in life, measures of meaning in life and other life purpose-related constructs, and indirect measures of purpose in life). data includes name of instrument, a brief description, a sample item, the theoretical framework or conception of purpose or meaning of life on which the scale is based, and common factor or dimensions that emerged. results summary overall, as observed by the author, the measures reviewed appear to fall into three broad categories: direct measures of purpose in life, measures of meaning in life and other life purpose-related constructs, and measures that indirectly measure purpose in life via subscales that designate the concept as a component of the construct being measured. although purpose in life has been the subject of lqtxlu\� iru� fhqwxulhv�� lw� frqwlqxhv� wr� eh� ghàqhg� lq� different ways and assessed through different means dqg�prgdolwlhv��pdnlqj� lw�gliàfxow�wr�dfklhyh�d�fohdu� grasp on the concept. consequently, these various frqfhswxdol]dwlrqv�ri �sxusrvh�lq�olih�duh�uháhfwhg�lq� the instruments developed, potentially biasing results. for example, ten of the instruments were composed ri �grpdlqv�wkdw�wkh�dxwkruv�eholhyh�uháhfw�wkh�wkhrrized phenomenology of purpose and meaning in life constructs. some measures, such as personal meanlqj�3uràoh��303��:rqj���������wkh�0hdqlqj�lq�/lih� measurement (mlm; morgan & farsides, 2009), and the meaning in life measurement tool (mlmt; lee et al., 2002) appear to be more successful in identifying domains in their scales that assess for concepts present in the extant literature. even so, while multidimensional scales offer the advantage of evaluating different components of purpose in life at the same time, they are limiting insofar as they only measure the dimensions designated in the instrument; the confhswv�ehfrphv�ghàqhg�e\�krz�lw�lv�phdvxuhg��2wkhu� measures with a more open-ended format, such as the schedule for meaning in life evaluation (smile; fegg, kramer, l’hoste, & borasio, 2008), revised youth purpose suvey (ryps; bundick et al., 2006), the meaning essay document (med; ebersole & devogler, 1981), and the meaning in life depth instrument (mild; devogler & ebersole, 1981), doorz� iru� pruh� áh[lelolw\� lq� vxemhfw� uhvsrqvhv� dqg� thus can give a more nuanced picture of life purpose. although the scope of existing instruments is large and varied, many contain similar and sometimes overlapping dimensions, which identify different components of the purpose in life construct. most widely cited and intimately related to purpose in life is meaning. virtually all purpose in life measures include meaning in life in some way, and all meaning in life instruments designate purpose as a factor, highlighting the centrality of meaning in the purpose in life. however, the relationship between the two components is not straightforward. much like the proverbial chicken or the egg question (“which frphv�àuvw"µ���lw�lv�qrw�fohdu�zkhwkhu�sxusrvh�fuhdwhv� meaning, meaning contributes to purpose, or if both conditions must be met. also consistent with the pre-existing literature is the pursuit of goals. eleven instruments implicate or directly refer to goal-directness as a measurement domain or identify the pursuit of goals as a factor that promotes purpose in life. another observation that supports previous theoretical conceptualizations of purpose in life is the frequent reference to self-transcendence. nine scales hlwkhu� lghqwlàhg� vhoi�wudqvfhqghqfh� dv� d� grpdlq� ri � purpose or meaning in life or incorporated transcendent values such as religiosity, spirituality, altruism, service to others or dedication to a larger societal or political cause. other overlapping, but less cited concepts, include coherence, relationships, knowledge, and existential vacuum/meaninglessness. none of the survey measures contain all dimensions of the purpose construct as delineated by bronk (2014): goals, commitment, meaning, and self-transcendence. the most promising measures related to purpose in life represent good methodological approaches to the development of scales that assess the purpose construct. these include the personal meaning proàoh��303��:rqj���������wkh�6fkhgxoh�iru�0hdqlqj�lq� life evaluation (smile; fegg et al., 2008), and the meaning in life measurement tool (mlmt; lee et al., 2002). the pmp was constructed beginning with a bottom-up approach, in which lay-people’s conceptions of the meaning in life construct was studied, allowing researchers to understand common beliefs derxw�phdqlqj� lq� olih�zlwkrxw� lqáxhqfhv� iurp� wkhmeasuring purpose in life 10 oretical biases. similarly, the smile probes for implicit theories of meaning by allow respondents to identify areas of their life that gives them meaning. alternatively, the mlmt was created after an extensive review of meaning in life literature and interviews with professionals in psychology, philosophy, theology, and nursing. given that purpose in life is a construct that spans many domains, this type of approach allows researchers to create measures that represent and capture and potentially measure a wider breadth of the concept. other instruments, such as the meaning essay document (med; ebersole & devogler, 1981), utilize a qualitative approach in the measurement of meaning and purpose in life by asking participants to describe and rank their three most important sources from which they derive meaning. for each source of meaning, they were then asked to describe a concrete experience associated with hdfk� rqh�� doorzlqj� iru� pruh� wkhruhwlfdo� áh[lelolw\��� review of the measures also revealed that different scales are suited to examining different conceptual elements of purpose and meaning in life. surveys such as the frankl questionnaire (fq; frankl, 1959), the purpose in life test (pil; crumbaugh & maholick, 1964), the life purpose questionnaire (lpq; hablas & hutzell, 1982), the life engagement test (let; scheier et al., 2006), the existence of purpose in life scale (epil; law, 2012), and ryff ’s scales of psychological well-being purpose subscale (rpwb; ryff, 1989; ryff & keyes, 1995) all assess the degree to which a sense of purpose in life is present in an individual. measures such as the personal meaning index (pmi; reker, 1992), the personal meaning proàoh� �303��:rqj�� ������� wkh�0hdqlqj� lq� /lih� 6fdoh� (ml; warner & williams, 1987), the meaning in life measurement tool (mlmt; lee et al., 2002), and the meaningful life measure (mlm; morgan & farsides, 2009) assess the degree to which meaning is present in one’s life. these measures are appropriate for those looking to simply evaluate the level of perceived purpose or meaning in one’s life. it should be noted that that although the mlm was designed to measure different components of meaning, it appears to assess a construct that more closely resembles purpose than meaning, given that the instrument was derived from scales meant to measure purpose in life (pil, lap-r, rpwb-purpose subscale). +huh��lw�lv�hylghqw�krz�d�odfn�lq�fodulw\�lq�wkh�ghàqlwlrq�ri �sxusrvh� lq� olih� fdq� lqáxhqfh�phdvxuhphqw��� the seeking of noetic goals scale (song; crumbaugh, 1997), takes a different approach in measurement by assessing the degree to which individuals are actively searching for purpose in their lives. however, according to dyck (1987), the song is conceptually inconsistent with frankl’s conceptualization of purpose in life and contains confounding variable that assess the cognitive components of depression. a recent factor analysis by schulenberg et do���������vkhgv�pruh�oljkw�rq�'\fn·v�fulwltxh��àqglqj� that those items of the song assessing search for meaning were psychometrically unrelated to either the center for epidemiologic studies’ depression scale (ces-d; radloff, 1977), or the meaning in life questionnaire (mlq; steger, frazier, oishi, & kaler, 2006). if the search for meaning does not correlate with depression or perceived meaning in life, then evidence does not support frankl’s assumption that people who achieve meaning will stop searching for it. the relationship between will to meaning and the motivation to discover meaning is more nuanced than logotherapy predicts (schulenberg et al., 2014). we can imagine, for example, that those who experience life ad meaningful may simply have the desire to seek even deeper levels of meaning. it should also be noted that, like the pil, the song is based on the conceptualization that purpose and meaning are synonymous. $gglwlrqdoo\��)udqno�uhihuuhg�wr�wkh�prwlydwlrq�wr�àqg� purpose as noetic, meaning spiritual. while this term implies a focus on self-transcendence, items in the song do not appear to assess for this. this is another example that calls attention to the need for develrslqj�phdvxuhv�wkdw�pruh�fohduo\�uháhfw�wkh�sxusrvh� in life construct and differentiate it from meaning. other measurement tools such as the meaning in life questionnaire (mlq; steger et al., 2006), assesses for the presence and search for meaning in individuals’ lives. the mlq has been found to have high internal consistency and it has been suggested that wkh�0/4�6�vxevfdoh�uháhfwv�)udqno·v�:loo�wr�0hdqlqj� theory that the search for meanings is man’s greatest motivation (frankl 1959; macdonald et al., 2012). additionally, the instrument is less likely to be conschultz 11 founded because it allows respondents to use their own criteria for what they considered meaningful, as opposed to what researchers decided is meaningful (macdonald et al., 2012). researchers have also suggested that with mlq, steger et al. (2006) were able to disentangle the meaning in life construct from confounding factors such as depression, life satisfaction, anxiety, and religion (bellin, 2012; steger et al., 2006). the two-factor structure of the mlq also allows the search for and presence of meaning to be measured independently, allowing for better exploration of the relationship between the presence and search for meaning in life (bellin, 2012; steger & kashdan, 2007). the mlq would be a good scale to administer in conjunction with measures of purpose in life to explore the relationship between purpose and meaning. the daily meaning scale (dms; steger, kasdan, & oishi, 2008), like the mlq, assesses the presence of meaning, but differs in that it is designed to capture changes in meaning. despite the small empirical basis of the dms, scores have shown good daily reliability, convergent validity and high internal consistency. the instrument has also been highly correlated with the mlq-presence subscale (steger, kashdan, & oishi, 2008). consisting of two items, the brevity of the dms enables it to be easily administered via different modalities such as e-mail or text. given its psychometric soundness, low response burden and ease of administration, the dms would be ideal to use in longitudinal studlhv� wkdw� lqyroyh� dvvhvvlqj� áxfwxdwlrqv� lq� phdqlqj����� measurement tools such as sources of meaning and meaning in life questionnaire (some; schnell, ������� wkh�6rxufhv�ri �0hdqlqj�3uràoh� �6203��5hker & wong, 1988), the schedule for meaning in life evaluation (smile; fegg et al., 2008), the meaning essay document (med; ebersole & devogler, 1981), and the meaning in life depth instrument (mild; devogler & ebersole, 1981) are appropriate for those interested in exploring the sources from which individuals derive meaning. the some was developed over four years of quantitative and qualitative research on meaning in life, undergoing several hyroxwlrqv� ehiruh� lwv� àqdo� irup�� ,w� kdv� frqvlvwhqwo\� been found to be a reliable indicator of where peosoh�jhqhudwh�dqg�àqg�phdqlqj�lq�wkhlu�olyhv��'dpjvlr� et al., 2013b; schnell, 2009). while the some carries advantages over other measures of meaning because it covers a wide breath of meaning sources, purpose in life in life in not included in any of the higher-order dimensions that the scale evaluates. the some could be useful in probing for dimensions of purpose in life and perhaps better elucidate the relation between purpose in meaning if administered with a purpose in life measure. similar to the some, the somp assesses the sources and degree of meaning in one’s life by asking participants to rate how important each source of meaning is to them. these items were selected based on an extensive review of extant literature through which commonly cited vrxufhv�ri �phdqlqj�zhuh�lghqwlàhg��5hnhu��������lq� order to represent individuals’ implicit theories of what makes life meaningful in their daily lives under ideal circumstances. however, the somp has not been widely accepted in psychological circles, most likely due to the limited amount of meaning domains �'dpjvlr�hw�do�������e���7krvh�orrnlqj�wr�sureh�iru� more implicit theories of meaning would be wise to utilize the scales like the smile, med, or the mild, all of which require participants to list and rank areas that provide meaning to their lives. the smile, a self-report measure, also asks participants to rate the importance and current level of satisfaction with each meaning source and satisfaction. in scoring, levels and weights are assigned independently of each index. this allows for a nuanced understanding of the role sources of meaning play in individuals’ lives. )ru�h[dpsoh��d�shuvrq�pd\�eh�vdwlvàhg�lq�d�sduwlfxlar life meaning domain and assign little importance to it, while they may assign a lot of importance and have high satisfaction in another area of their life. similarly, the med and the mild ask participants to identify and rank sources of meaning, but differ in that they are interview protocols that can provide richer data without the restrictions designated categories of meaning via an open-ended format. the remaining measures reviewed have different uses in terms of investigating purpose and meaning in life. the sense of coherence scale (soc; antonovsky, 1983, 1987), the life regard index (lri; battista and almond, 1973; debats et al., 1995), and the life $wwlwxgh�3uràoh�²5hylvhg��/$3�5��5hnhu��������phdmeasuring purpose in life 12 sure constructs similar to purpose in life and would be useful in evaluating the roles of different components of purpose in life such as goals and meaning. other scales such as the constructed meaning scale (cms; fife, 1995) and the meaning in suffering test �0l67��6wdufn��������dvvhvv�phdqlqj�lq�vshflàf�frqtexts such as individuals coping with serious illness. these scales would be useful in understanding how other factors such negative life circumstances affect one’s sense of meaning in life. although not a direct measure of purpose in life, the self-transcendence scale (sts; reed, 1991) explores a concept that has been consistently implicated in the purpose construct. the sts has been used empirically in diverse populations, demonstrating widespread applicability. if administered with a measurement assessing purpose in life, the sts could provide more about the relationship between self-transcendence and life purpose. schultz 13 � table 1: measures of purpose in life� instrument name description sample items theoretical framework constructs explored frankl questionnaire (fq; 1959) self-report, 13 items, 3-point likert scale; designed to assess the degree of presence of purpose among patients and to test the will to meaning assumption “do you feel like your life is without purpose?”: (1) no or very low level of purpose—(3) high purpose in life present will to meaning assumption (1959) purpose in life, meaning in life purpose in life test (pil; crumbaugh and maholick 1964) self-report, 20 items, 7-point likert scale; different response anchors for each item “my life is…”: (1) empty, only filled with despair— (7) running over with exciting things “in achieving life goals, i…”: (1) made no progress whatsoever— (7) progressed to complete fulfillment will to meaning assumption quality of life, goals, death, choices, and retirement (frankl, 1959) purpose in life, goal seeking, goal achievement, contentedness with life, existential vacuum, search for adventure, futuristic aspirations, internal-external locus of control, selffulfillment, life view (shek, 1988) seeking of noetic goals (song; crumaugh 1977) self-report, 20-items, 7-point likert scale; designed to be a unidimensional measure of motivation to find purpose in life “over my lifetime i have felt a strong urge to find myself”: (1) never— (7) constantly “i seem to change my objective in life”: (1) never— (7) constantly will to meaning assumption purpose in life, goal seeking, goal achievement, contentedness with life, existential vacuum, search for adventure, futuristic aspirations, internal-external locus of control, selffulfillment, life view (frankl, 1959) life purpose questionnaire (lpq; hablas & hutzell, 1982) self-report, 20 items, dichotomous response format (agree/disagree); designed for geriatric, neuro-psychiatric patients, and special populations “i am not prepared for death”: agree— disagree “i have discovered many reasons why i was born”: agree— disagree will to meaning assumption unidimensional measure of life purpose and meaning ryff’s scales of psychological well-being purpose subscale (ryff 1989; ryff and keyes 1995) self-report, 20-,14-,9-, and 3items versions, 6-point likert scale; measure of purpose in life representing one of six dimensions of psychological well-being “i enjoy making plans for the future and working to make them a reality”: (1) strongly disagree— (6) strongly agree purpose in life – positive functioning with the presence of goals, intentions, and a sense of direction, all of which contribute to the feeling that life is meaningful (1989) purpose in life purpose in life scale (pils; robbins & francis, 2000) self-report, 12 items, 5-point likert response format “my life seems most worthwhile”: (1) agree strongly— (5) disagree strongly will to meaning assumption purpose in life life engagement test (let; scheier et al., 2006) self-report, 6 items (3 positive, 3 negative), 5-point likert scale “the is not enough purpose in my life”: (1) strongly disagree— (5) strongly agree purpose in life – extent to which a person engages in activities that are personally valued (p.291) purpose in life revised youth purpose survey (ryps; bundick et al., 2006) semi-structured interview protocol “what are some of the things that really matter to you? imagine you’re 40 years of age, what will you be doing? what will be important to you? why?” purpose “a stable and generalized intention to accomplish something that is at once meaningful to the self and leads to productive engagement with some aspect of the world beyond the self” (damon et al., 2003) values, beliefs, faith, career, service, family, political/social interests, other hobbies or leisure, country existence of purpose in life subscale (epil; law, 2012) 7 items selected from the pil based on relevance to lives of early adolescents “my life is…”: (1) empty, only filled with despair— (7) running over with exciting things will to meaning assumption existence whether life is perceived to be enthusiastic versus boring, exciting versus monotonous, or new versus unchanged measuring purpose in life 14 table 2: measures of constructs similar to purpose in life instrument name description sample items theoretical framework constructs explored sense of coherence scale (soc; antonvosky 1983, 1987) 29 and 13 item versions, 7point likert scale, 3 dimensions “when you think about your life, you very often…”: (1) feel how good it is to be alive— (7) ask yourself why you exist at all “do you have the feel that you are in an unfamiliar situation and don’t know what to do?”: (1) very often— (7) very seldom or never sense of coherence – a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement (p.19) comprehensibility, manageability, and meaning life regard index (lri; battista and almond 1973; debats et al. 1995) 28 items, 2 subscales: framework – measures presence of life goals, fulfillment subscale measures progress towards life goals “i have a very clear idea of what i’d like to do with my life”: (1) disagree, (2) i have no option, (3) i agree “i don’t really value what i’m doing”: (1) disagree, (2) i have no option, (3) i agree positive life regard an individual’s belief that he is fulfilling a life-framework or life-goal that provides him with a highly valued understanding of his life framework – a meaningful life framework or goal by which people understand the purpose of their existence fulfillment – the sense of fulfillment that accompanies realizing framework life attitude profile-revised (lap-r; reker, 1992) 48 items, 7-point likert scale, yields 6 dimensions and 2 composite scores “i have a mission in life that gives me a sense of direction”: (1) strongly disagree— (7) strongly agree will to meaning assumption purpose, coherence, choice/ responsibleness, goal seeking, death acceptance and existential vacuum schultz 15 table 3: measures of meaning in life instrument name description sample items theoretical framework constructs explored meaning in life questionnaire (mlq; steger et al., 2006) 10 items, 7-point likert scale, 2 subscales: presence of meaning (mlq – p) & search for meaning (mlq-s) “i am seeking a mission or purpose for my life:” (1) not at all— (7) absolutely “i understand my life’s meaning”: (1) not at all— (7) absolutely meaning the sense made of, and significance felt regarding, the nature of one’s being and existence (p. 81). level of presence and search for meaning daily meaning scale (dms; steger, kashdan, & oishi, 2008) 2-item and 4-item versions, 7point likert scale, 2 subscales presence of meaning and search for meaning “how meaningful does your life feel?: (1) not at all— (7) absolutely” “how much do you feel like your life has purpose?”: (1) not at all— (7) absolutely” meaning the sense made of, and significance felt regarding, the nature of one’s being and existence level of presence and search for meaning personal meaning index (pmi; reker, 1992) 16-items scale derived from the summation of the purpose and coherence dimensions of the lap-r “i have a mission in life that gives me a sense of direction”: (1) strongly agree— (7) strongly disagree meaning the sense made of, and significance felt regarding, the nature of one’s being and existence sense of purpose and coherence personal meaning profile (pmp; wong 1998) 57 items with 7 subscales, assesses one’s sense of personal meaning in their life “i engage in creative work: (1) not at all— (7) a great deal “i seek to glorify god”: (1) not at all— (7) a great deal meaning cognizance of order, coherence and purpose in one’s existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfillment achievement, religion, selftranscendence, relationship, intimacy, fairness, and selfacceptance sources of meaning and meaning in life questionnaire (some; schnell, 2009) 151 items measuring 26 sources of meaning and positive and negative dimensions of meaning: 1) meaningfulness, a sense of fulfillment, based on significance, coherence, and belonging, and 2) crisis of meaning, the view that life is empty and has no meaning; 4 higher order dimensions, 6point likert scale “i feel pain from finding no purpose in my life”: (1) totally disagree— (5) totally agree meaningfulness – a fundamental sense of meaning, based on an appraisal of one’s life as coherent, significant, directed, and belonging self-transcendence: explicit religiosity, spirituality, unison with nature, social commitment, generativity, care, health; selfactualisation: individualism, challenge power, development, freedom, knowledge, achievement, creativity, selfknowledge; order: reason, morality, tradition, practicality; well-being and communality: fun, wellness, harmony, attentiveness, love, community sources of meaning profile (somp; reker & wong, 1988) 17-items assessing the sources and degree of meaning in one’s life evaluating four different domains of meaning: selftranscendence, collectivism, individualism, selfpreoccupation; 7-point likert scale “being of service to others”— (1) not at all important— (7) very important “leaving a legacy for the next generation”—(1) not at all important—(7) very important meaning as made through making choices, taking actions, and entering into relationships self-transcendence: sources that transcend the limits of the self, ultimately involving cosmic or ultimate meaning; collectivism: sources that focus on the betterment of the group, with an emphasis on service to others and dedication to a larger societal or political cause; individualism: sources that focus on self-growth, development, and the realization of one's potential; selfpreoccupation: sources that meet and satisfy the immediate needs of the respondent schedule for meaning in life evaluation (smile; fegg et al., 2008) self-report measure that assesses individual meaning in life; three-part process: 1) asks participants to list three to seven areas that provide meaning to their lives, 2) rate the importance of each area on a 5-point likert scale, 3) respondents indicate on a 7point likert scale their current (1) somewhat important— (5) extremely important (-3) very unsatisfied— (+3) very satisfied will to meaning assumption meaning = cognizance of order, coherence and purpose in one’s existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfillment (reker & wong, respondent-generated; family, leisure time, friends, partner, animals/nature, work, pleasure, spirituality, health, well-being, altruism, house/garden, finances, altruism, hedonism measuring purpose in life level of satisfaction (3 satisfaction indexes) 1988, p. 221) meaning in suffering test (mist; starck, 1983) assesses perception of the degree of meaning found in unavoidable experiences of suffering; 2 parts: 1) 20-item self-report measure, 7-point likert scale, yielding 3 subscale scores 2) open-ended response format “i believe suffering causes a person to find new and more worthwhile life goals”: (1) never— (7) constantly will to meaning assumption subjective characteristics of suffering constructed meaning scale (cms; fife, 1995) 11 items related to impact of illness on respondents’ sense of identity, interpersonal relationships, and perceived future; 4-point likert scale “i feel my experience with cancer has made me a better person”: (1) strongly agree— (4) strong disagree will to meaning assumption meaning the individual’s perception of his/her ability to accomplish future goals, to maintain the viability of relationships, and to sustain a sense of personal vitality, competence, and power within the context of everyday living as it has been altered by occurrence of an event. sense of identity, interpersonal relationships, perceived future 16 meaning in life measure (mlm; morgan & farsides, 2009) 23 items with 5 subscales encompassing cognitive, affective, and behavior components of the meaning in life concept; 7-point likert scale “i find it satisfying to think about what i have accomplished in life”: (1) strongly disagree—(7) strongly agree “i really value my life”: (1) strongly disagree— (7) strongly agree will to meaning assumption purposeful life: a sense of having clear goals, aims, and intentions; valued life: a sense of life’s inherent value; accomplished life: a sense that personal goals are being achieved or fulfilled; principled life: a sense of having a personal philosophy or framework through which to understand life; exciting life: an enthusiastic orientation that views life as exciting, interesting, or engaging meaning in life scale (ml; warner & williams, 1987) 15-items, self-report, 5-point likert scale; interview consisting of life satisfaction and other life measures “believing in god is...”: (1) not at all meaningful to me— (5) the most meaningful thing in my life meaning in life a sense of purpose, beliefs, and statements of faith enhanced through personal commitment and emotional support from others, religious affiliations, and/or purposeful activities in life believing in god, being around people, coming to terms with illness, looking forward to each new day, participating in religious activities, giving affection to loved ones, receiving love and support, life is useful and worthwhile, activities and hobbies, doing things for mvself, support from otherpatients, life full of good times, setting daily and long-term goals, philosophy meaning in life measurement tool (mlmt; lee et al., 2002) 63-items, 4-point likert scale; intended to measure meaning in life “i think i have more virtues than drawbacks”: 4 likert points not labeled will to meaning assumption self-awareness, self-acceptance, futuristic aspiration, valuelessness, purpose in life, contentedness with life, role awareness, experience of love, love in family, commitment and self-transcendence meaning essay document (ebersole & devogler, 1981) open-ended format, participants to describe and rank 3 most important sources of meaning, as well as to list experiences associated with each meaning source n/a no definition; instrument designed to clarify the meaning in life concept understanding: trying to gain more knowledge; relationship: an interpersonal orientation including family, friends, and romantic relationships; service: a helping, giving orientation dealing with people in the abstract); belief: living according to one's beliefs— level of satisfaction (3 satisfaction indexes) 1988, p. 221) meaning in suffering test (mist; starck, 1983) assesses perception of the degree of meaning found in unavoidable experiences of suffering; 2 parts: 1) 20-item self-report measure, 7-point likert scale, yielding 3 subscale scores 2) open-ended response format “i believe suffering causes a person to find new and more worthwhile life goals”: (1) never— (7) constantly will to meaning assumption subjective characteristics of suffering constructed meaning scale (cms; fife, 1995) 11 items related to impact of illness on respondents’ sense of identity, interpersonal relationships, and perceived future; 4-point likert scale “i feel my experience with cancer has made me a better person”: (1) strongly agree— (4) strong disagree will to meaning assumption meaning the individual’s perception of his/her ability to accomplish future goals, to maintain the viability of relationships, and to sustain a sense of personal vitality, competence, and power within the context of everyday living as it has been altered by occurrence of an event. sense of identity, interpersonal relationships, perceived future schultz � religious, political, or social; expression: expressions of self through such things as art, athletics. music, writing, etc.; obtaining: emphasizes obtaining possessions, respect, and responsibility; growth: emphasizes a striving towards developing potentials, obtaining goals; existential-hedonistic: includes general expressions that pleasure and daily life are most meaningful meaning in life depth instrument (devogler & ebersole, 1981) participants rank a list of 8 commonly cited sources of meaning from most to least personal importance and write a brief essay about the level of significance of most importance meaning source has to them (1) “write in detail about the thing that you find gives you greatest meaning in your life. use the back of the page if necessary. tell why this is meaningful to you and try to provide an example of it." (2) "support to the best of your ability why you feel your meaning in life is deep or not deep. use examples, tell how much you are involved (or not); in general, try to convince me that you know what you are talking about." no definition; instrument designed to clarify the meaning in life concepts 5 levels of depth in meaning: highest, above average, average, below average, lowest 17 � religious, political, or social; expression: expressions of self through such things as art, athletics. music, writing, etc.; obtaining: emphasizes obtaining possessions, respect, and responsibility; growth: emphasizes a striving towards developing potentials, obtaining goals; existential-hedonistic: includes general expressions that pleasure and daily life are most meaningful meaning in life depth instrument (devogler & ebersole, 1981) participants rank a list of 8 commonly cited sources of meaning from most to least personal importance and write a brief essay about the level of significance of most importance meaning source has to them (1) “write in detail about the thing that you find gives you greatest meaning in your life. use the back of the page if necessary. tell why this is meaningful to you and try to provide an example of it." (2) "support to the best of your ability why you feel your meaning in life is deep or not deep. use examples, tell how much you are involved (or not); in general, try to convince me that you know what you are talking about." no definition; instrument designed to clarify the meaning in life concepts 5 levels of depth in meaning: highest, above average, average, below average, lowest discussion � 7kh� àhog� ri � sv\fkrorj\� surylghv� d� vwuxfwxuhg� approach to studying the ambiguous and subjective concept of purpose in life. probing how purpose in life is measured through the exploration of instruments that seek to explore this construct may enhance our understanding. given the sheer volume of scales and instruments developed to measure life purpose and related concepts, this review is a testament to the increasing focus on the topic in psychology and its relevance to physical and emotional well-being. limitations while these efforts to understand purpose in life have been numerous and comprehensive, there duh� qhyhuwkhohvv�pdq\�ádzv� dqg� vkruwfrplqjv� wkdw� pdnh� wkh� frqvwuxfw� gliàfxow� wr� ixoo\� fdswxuh�� 6rph� researchers question the dimensionality of certain scales, such as ryff ’s scales of psychological well-being (rpwb; ryff, 1989), claiming that the glphqvlrqv� duh� ádzhg� gxh� wr� frqfhswxdo� ryhuods�� other measures, such as the purpose in life test (pil; crumbaugh & maholick, 1964), have been criticized for having confounding and value-laden variables. these and infrequent use of some measures which could hinder generalizability to other populations, demonstrate the need for the development and thorough reconsideration of how measures of purpose in life are constructed and how it is assessed. implications the extant literature provides us with ample information concerning purpose in life and how it functions to affect mental health and its role in optimal human development. however, the discrepancies in conceptual clarity and measurement of deàqlqj�sxusrvh� lq� olih� krog� ydvw� lpsolfdwlrqv��%hwwhu� measurement tools could help parse out different dimensions of the construct and potentially identify new ones. enhanced measures could also enable researchers to better understand the relationships between these dimensions and the larger purpose construct (e.g. meaning vs. purpose). more sophisticated tools could also perhaps differentiate between external sources of purpose and internally derived-sense of purpose (created vs. found) or explore different types of purpose such as career, familial, religious, or service-oriented purposes. obtaining a more nuanced understanding of purpose in life would help better understand how it affects mental health. givhq� wkh� lqfuhdvlqj� folqlfdo� vljqlàfdqfh� ri � sxusrvh� in life, these implications should not be ignored. future research renewed interest in the topic of purpose in life is certainly encouraging, especially given the substantial impact and role it plays in physical and mental wellbeing. however, rapidly growing literature based on ydulrxv�ghàqlwlrqv� dqg�phdvxuhv�ri �sxusrvh� lq� olih� can create more questions than answers. given the glvfuhsdqflhv�lq�krz�sxusrvh�lq�olih�lv�ghàqhg��lw�fdq� leave one wondering how an ambiguous concept can be measured. first, it would be wise for researchers and theorists to work towards a consensus on a more vxfflqfw� ghàqlwlrq� ri � sxusrvh� dqg� olih� dqg� phdqing in life to allow for better operationalization of the concept. accordingly, more longitudinal studies measuring purpose in life 18 should be conducted in order to develop better models of purpose in life and how it potentially changes over time. while purpose in life has been studied in different age populations, such as children (damon, 2009), adolescents (e.g. bronk 2011, 2012; damon, 2009; francis & burton, 1994), adults, the elderly (e.g. boyle et al., 2009), and the oldest-old (e.g. nygren et al., 2005), few longitudinal studies exist. as noted by bronk (2014), these span only a few weeks or a few prqwkv��7r�gdwh��rqo\�rqh�vwxg\�vsdqv�ryhu�àyh�\hduv� (bronk 2011, 2012; damon, 2009), which followed youth through adolescence to emerging adulthood. additionally, as observed by the author, a majority of purpose in life research appears to have occurred in western populations; purpose in life can be manifested much differently in eastern cultures. additionally, while some instruments have been translated into different languages (e.g. brazilian sources of meaning in life questionnaire, some-br; damásio et al., 2013; chinese purpose in life test, c-pil; shek et al. 1987), their administration has been minimal, necessitating further cross-cultural research to account for cultural differences. additional directions for research include further exploring the relationship between purpose and meaning in life, investigating the role of life events and circumstances in the development or change in purpose in life, or analyzing whether different items of measurements load the components of purpose in life outlined by bronk (2014). while it should be noted that instruments suffer from discrepancies and lack of clarity of the purpose in life construct, improvements to measures can be made. the development of measures of purpose in olih� frxog� dovr�ehqhàw� iurp�d�pxowlprgdo� dssurdfk� in which both quantitative and qualitative methodologies are employed. this integration would allow for researchers to bridge the gap between theories of life purpose and the subjective, lived experiences of individuals. additionally, more sophisticated scales that have the ability to capture more dimensions of purpose in life at the same time. this sentiment is echoed by bronk (2014), who claims that while some existing survey measures assess for the meaning, commitment, and goal-pursuit dimensions of purpose in life, many leave out the self-transcendence component of the construct because it can be difàfxow�wr�fdswxuh��7kh�ghyhorsphqw�ri �phdvxuhv�wkdw� include more dimensions of purpose in life would give researchers further insight into the concept. conclusion this review has several limitations. first, a formal meta-analysis was not performed due to inconsistencies of measurement and limited quantitative data. additionally, the author was the sole reviewer of articles. multiple reviewers may enhance the review by providing different perspective, enhancing the rigor of the study, and establish inter-rater reliability. the instruments reviewed represent a considerable effort to explore a complex topic that has been the source of inquiry for centuries. while it is clear wkdw� wkdw�pruh� uhvhdufk�qhhgv� wr�eh�grqh�� wkh�àhog� holds great promise. it is hoped that better and more frqvlvwhqw�phdvxuhphqw�zloo� \lhog�pruh� vshflàf� lqformation on how purpose in life functions to impact health and well-being, ultimately resulting in the development of new mental health interventions. references $ádnvhlu�� $egxod]l]�� �������� 5holjlrvlw\�� 3huvrqdo� meaning, and psychological well-being:a study among muslim students in england. pakistan journal of social and clinical psychology, 10(1), 27-31. allport, gordon. 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(1992). on the relation between meaning in life and psychological well-being. british journal of psychology, 83, 133-145. microsoft word vol10_rose_avk_09-13-08.doc 15 graduate student journal of psychology copyright 2008 by the department of counseling & clinical psychology 2008, vol. 10 teachers college, columbia university issn 1088-4661 outcome of a spanish immersion pilot workshop for psychology professionals and students tina m. rose indiana university of pennsylvania jamie e. brass indiana university of pennsylvania kimberlee d. derushia indiana university of pennsylvania latino individuals constitute 14.4% of the u.s. population and are projected to reach 20% of the population by 2010. with this rise in population, more culturally and linguistically proficient health professionals are needed. in response to this need, the spanish-language immersion and cultural competence pilot workshop was developed. this workshop provided participants intensive spanish language training and presentations on aspects of the latino culture that are particularly relevant to mental health professionals. participants in the workshop completed a preand post-test questionnaire on their experiences, knowledge, and attitudes about spanish language and latino culture. analysis of these questionnaires revealed that participants’ attitudes and knowledge of spanish and latino culture were significantly different after the workshop. the latino population currently represents the largest minority group in the united states, consisting of approximately 42.7 million individuals, or 14.4% of the total population (u.s. census bureau, 2006). the term latino is an amalgam used by the u.s. census bureau to indicate individuals of cuban, mexican, puerto rican, south american, or central american descent (grieco & cassidy, 2001). the latino population is estimated to be the fastest growing subpopulation in the u.s. with a 3.3% increase from 2004 to 2005 and a projected growth to 20% of the total population by 2010 (u.s. census bureau, 2006; u.s. census bureau news, 2006). as the latino population increases, it is likely that a corresponding increase in mental health professionals with cultural competency to work with this group will be needed. although this group is currently most populous in southern and coastal states, it appears that, with growing immigration rates, emigration to other areas of the u.s. may also increase. as latino individuals move into areas that are not currently heavily populated by this group, such as rural and northern areas of the u.s. (bender & harlan, 2005), it will tina m. rose, jamie e. brass, and kimberlee d. derushia, graduate students in the department of psychology at indiana university of pennsylvania, would like to thank the center for applied psychology and dr. husenits of the department of psychology for the support and encouragement in conducting the workshop. correspondence concerning this article should be addressed to tina m. rose at 220 uhler hall, indiana university of pennsylvania, indiana, pa 15705. become important to provide health professionals in a variety of fields with the tools necessary to serve this population. recent articles in the literature indicate that 50% of latino individuals who seek mental health services do not return after the initial visit (dingfelder, 2005) and 88% of latino children currently in need of help do not receive mental health services (stamor, 2006). research suggests that the ability of consumers to clarify their thoughts and meaning (guttfreund, 1990), utilize familiar phrases such as spanish dichos (zuniga, 1992), and provide rich emotional expression (santiago-rivera, 1995) in their native language may enhance the effectiveness of therapeutic services, resulting in a greater retention rate for mental health services. additionally, arrendondo (1991) recommends that counselors should have a working knowledge of latino culture and the social, economic, political, and historical influences on the consumer and consumer’s family development. in order to investigate the needs and preferences of the consumer, fraga, atkinson, and wampold (2004) surveyed asian american, european american, and hispanic undergraduate students using paired comparison questionnaires that assessed domains of multicultural competencies established by sue, arrendondo, and mcdavis (1992). the results of the investigation indicated that the respondents preferred some multicultural competencies over others. some of the variation in the preference may be attributed to self-reported ethnic identity (fraga et al., 2004). hispanic respondents indicated a preference for multicultural competencies in the domain of understanding sociopolitical rose, brass & derushia 16 factors that impact ethnic minorities and the impact of race and culture on the consumer and services rendered. training that addresses cultural competence and language proficiency is one of the most important avenues to providing the tools necessary to work effectively with all minority populations, but particularly with latino populations (bender, clawson, harlan, & lopez, 2004; biever, et al., 2004; williams, 2005). a needs assessment conducted by our lady of the lake university in san antonio, texas revealed that formal training consisting of 16 training sessions over a period spanning from 4 weeks of intensive inperson training to 3 years of online training might be the best method to meet the needs of the students and professionals in the area (biever, et al., 2002). biever and colleagues (2004) conducted a series of investigations surrounding the training needs of mental health professionals and found courses that covered bilingual (spanish/english) assessment and therapy in addition to courses in cultural variables would be most helpful. moreover, the participants in this assessment indicated that the translation of technical words, such as those found on a typical psychological intake report, is one of the most difficult aspects of providing adequate services to bilingual (spanish/english) consumers (biever et al., 2004). although the studies by biever and colleagues (2002; 2004) point to the utility of formal training methods to provide professionals with the necessary tools to provide effective services, formal training may not be feasible in all locations because of the time and cost associated with it. hence, workshops that condense training into smaller segments of time may be an alternate avenue to provide a balance between the constraints of time and cost and the need for training in cultural competency. in general, workshops appear to be a promising form of education with positive results in the literature for training medical students (liddell, davidson, taub, & whitecross, 2002), providing mental health professionals with basic skills such as motivational techniques (deviva, 2006), and providing psychoeducation (foley et al., 2006; hays & katchen, 2006). liddell and colleagues (2002) concluded that with medical students in australia, a 3-hour tutorial provided in the third year of medical training increased participants’ competency in performing certain procedures (e.g., suturing) in the fifth year. the medical students in the experimental group participated in a practical skills workshop where they observed live and video demonstrations of procedural skills and were able to practice the basic procedural skills (e.g., giving an injection, suturing) on a model. participants were given feedback on their performance of those skills and additional instruction if necessary, leading to the increased competency seen in the fifth year (liddell et al., 2002). deviva (2006) explored the efficacy of a workshop designed to provide health care professionals in clinical psychology, counseling psychology, social work, medicine, and nursing fields with techniques to enhance motivation in resistant or ambivalent consumers presenting with a variety issues (e.g., substance use, obesity). the participants of the workshop included both graduate students in training and practicing professionals holding a post-baccalaureate degree. deviva (2006) varied the length of the workshop (i.e., 6-hour versus 3-hour). participants were randomly assigned to the workshop length, except for two cases in which scheduling conflict occurred (deviva, 2006). the 6-hour workshop included more examples, elaboration of concepts, and practice time than the 3-hour workshop. otherwise, the same didactic information (e.g., research and theory on resistance and ambivalence, five motivational themes) was presented and practiced in both the long and short workshops. preand post-analogue role-plays were used to assess participants’ skills. the results of the study indicated that participants in both the long and short workshops increased in workshop-consistent behavior, suggesting that the professionals increased their motivational skills when interviewing resistant or ambivalent consumers (deviva, 2006). williams (2005) investigated the effect of an intervention workshop designed to increase cultural competency for social workers. the workshop took place over 4 weeks. participants were provided with didactic instruction (i.e., lectures, discussions, analyses of case studies and videos) and role-playing opportunities on multicultural concepts (e.g., influence of worldviews, acculturation theory, power and privilege in the helping relationship) during a weekly 3hour workshop. the author evaluated several outcomes (e.g., multicultural awareness, knowledge, skills, and ability to identify and integrate salient multicultural factors in a case conceptualization) with an intervention group and a comparison group using quantitative and qualitative analyses. the comparison group participated in cultural activities (e.g., exposure to print and poster materials, participation in activities to develop more sensitivity to diversity at an organization) but did not participate in workshop activities. the quantitative results of the study indicated that both the intervention and control groups improved on scores of multicultural awareness, knowledge, and skills; with workshop participants scoring significantly better on outcomes of multicultural awareness than the comparison group. thus, mere exposure to another culture may improve cultural competency. moreover, racial minority status contributed to higher ratings on the multicultural case conceptualizations at both pretest and posttest (williams, 2005). qualitative results provided evidence that the workshop was beneficial to participants and provided a safe learning environment that was supportive for workshop participants. these results suggest that personal experiences and didactic instruction play an important role in increasing cultural competence (williams, 2005). an important finding in the research is that workshops that utilize an immersion format when providing training of the spanish language produce effective results (bender et al., 2004). immersion formats are successful because they require participants to engage with the language that they are learning via multiple formats, such as having all lessons conducted in that language and having participants speak to each other only using the language the are learning. reoutcome of a spanish immersion workshop 17 searchers examined immediate and one-year outcomes of a workshop designed to provide language training for health professionals. outcomes were assessed via employee, coworker, and employer evaluations of workshop participants. the results of the analysis revealed that, from the perceptions of the employee, employer, and coworker, language skills and cultural competency were improved, as was quality of care for immigrants (bender et al., 2004). an important finding was that participants continued to pursue avenues to maintain and promote personal language competency (e.g., listening to audio tapes, reading spanish language health newsletters, continued use of spanish language with family and coworkers) at the one-year follow up (bender et al., 2004). the research literature on workshops, both in general and specifically for language and cultural competency skills training, suggests that workshops have potential to service a wide range of professionals in various locations, allowing them to reach individuals from around the country (bender et al., 2004). given the positive results presented in the literature, workshops appear to be a successful form of training that could be adapted and implemented in a variety of areas, including spanish language and cultural competency. an assessment of need in 2005, a clinical psychology doctoral program at a rural western pennsylvania university began to see an increase in the number of requests for assessment and therapy for consumers who spoke spanish as their primary language. in light of the census data suggesting an increase in latino and spanish speaking populations, the need for a workshop to provide training in spanish language skills and general latino cultural competency was assessed. the needs assessment indicated that respondents, including professors and graduate students in mental health fields, saw a benefit to speaking spanish, and had worked with latino consumers in a professional capacity. additionally, respondents felt that they would personally and professionally benefit from additional cultural competency training (brass, 2006). over 50% of the respondents indicated a desire to receive spanish language training, but expressed a reluctance to devote more than one weekend and over $200 for the training (brass, 2006). given these results, the spanish-language immersion and culture competency pilot workshop (slicc) was developed. the slicc workshop included elements such as spanish language lessons and cultural presentations that covered topics such as dispelling common latin myths, working with interpreters in the therapy room, and understanding barriers to seeking help. activities that have received previous research attention (bender et al., 2004) such as role plays and time for participants to practice their language training with each other were implemented in an effort to optimize the time of the interested participants while acknowledging the time intensive nature of the types of training that are needed to gain skills in an additional language and in cultural competency. designing the pilot program the slicc workshop was designed and conducted as a pilot program in order to bring awareness of the need for training, to investigate the desire of participants to engage in longer training, and to test methods of providing information effectively with the intention of potentially developing a longer, more intensive training program. over the course of a 3-day weekend, the slicc workshop addressed the overarching goal of supplying mental health care professionals with cultural and linguistic competency training. table 1 presents the schedule for the workshop and demonstrates how presentations on cultural competency were interwoven with language instruction. table 1 schedule for slicc workshop day time activity noon-1:00 registration 1:00-4:00 language block 1 4:00-4:30 break fri 4:30-5:30 presentation choice 8:30-11:30 language block 2 11:30-1:00 lunch 1:00-2:00 presentation choice 2:15-5:15 language block 3 sat 5:30-6:30 presentation choice sun 8:00-8:30 breakfast & language practice 8:30-11:30 language block 4 12:00-1:00 presentation choice 1:00-1:30 wrap-up the main goal of the language immersion section of the workshop was to provide an introduction or broadening of language abilities for mental health professionals. this goal included increasing familiarity with the spanish language, particularly with emotionally expressive words, psychological oriented words (such as those typically found on a psychological intake evaluation), and inquires about the need for translators from the consumer. each participant was provided with 12 hours of instruction in basic or intermediate level spanish. in order to keep costs low for the pilot program, instructors were recruited through the spanish department at the university. each instructor was an advanced undergraduate student who had traveled abroad for at least one semester to a spanish speaking country and had taught elementary school spanish as part of his or her degree requirements. many of the instructors were double majors in spanish and education or spanish and psychology and expressed an interest in furthering their teaching skills. rose, brass & derushia 18 instructors were compensated for their time through a cemmrat grant. placement into the basic and intermediate language training groups was based on the spanish language experience of the participant. most of the participants at the workshop reported that they had only basic experience with the spanish language, spanning from no spanish language experience at all to having taken a course in high school many years previously. participants in the basic level were divided into groups of three or four based on their selfreported level of spanish exposure. this resulted in several small groups that were able to focus at the level of learning that best suited the participants. only five of the participants requested intermediate language training. to ensure that participants in the intermediate level were all at the same level of experience, they were presented with a set of 18 oral spanish questions addressing a variety of intermediate topics such as ¿qué tiempo hace hoy? and ¿qué estás haciendo ahora? throughout the course of the workshop, the basic spanish language instructors focused on providing participants with the ability to introduce themselves to a spanish speaking consumer and to be able to ask and answer basic questions such as the name of the consumer, basic contact information, the nature of the problem, and if they would like translator services to be provided. the intermediate spanish language instructors focused on teaching participants to conduct a psychological intake evaluation in spanish and incorporate the use of emotionally laden words and topics. for the cultural competency aspect of the slicc workshop, the main goal was to provide culturally specific information and training to participants through the use of presentations. to solicit presentations, a general call for presentations was sent to local mental health professionals and graduate students. in response to this request, the workshop was able to offer 10 different presentations to participants. this resulted with several choices in each time slot. participants were able to select the topics that best met their needs. the topics of the presentations included the use of a translator in mental health settings, the implications of the holiday los dias de los muertos (the day of the dead) for grief work, specific concerns for clinicians working with latino populations, and dispelling myths associated with the latino culture. ancillary goals included provision of other basic information (e.g., the growth rate of the latino population) and coverage of a breadth of material to maximize time and training for workshop participants. at the end of the workshop a 30-minute “wrap-up” session was held to gauge participant reactions to the workshop and discuss how future workshops could be improved. measuring the outcome although the utility of spanish language training programs has been investigated previously, more information is needed to determine the optimal way to provide this training. additionally, it was the authors’ experience that in rural pennsylvania, it is difficult to find training for mental health professionals who speak no spanish but would like to learn the language and become linguistically competent. it was with these two goals in mind that the current study was conducted with the intention of gathering information about the utility of the slicc workshop. thehe authors implemented a utilization-focused outcome approach to assess the slicc workshop. this approach focuses on real world application of information that is being evaluated (patton, 1997), or in the case of the slicc workshop, how participants will be able to apply the knowledge they gained over the course of the workshop to their everyday experience in mental health settings (patton, 2002). the purpose of this study was to gather information for use in the development of future programs and as such, no formal hypotheses were made. the target population was mental health professionals with the outcomes defined as increased knowledge of latino culture and increased awareness concerning how to provide adequate mental health services for individuals of a latino background. indicators of this outcome were assessed via self-report measures designed for the study. the remainder of this article outlines the outcome evaluation of the slicc workshop, discusses those elements of the program that were found useful and those that were not, and provides feedback on elements that may need to be revised or removed in future training programs of this type. it is hoped that information gathered during this study can be used to inform future investigations and workshop development. method participants all individuals registered for the workshop were asked to participate in the outcome study and were presented with an informed consent form and the pre-test questionnaire during the registration phase of the workshop. of the 20 registered individuals, 10 individuals completed the preworkshop measure, but only 7 of those 10 completed the post-workshop measures. individuals who completed both measures were retained for further analyses. the three participants who did not complete the post-workshop measure were excluded from the analyses so that the authors could get a more accurate sense of change related to participation in the workshop. all participants were working professionals and graduate students ranging in age from 2065 years old. the sample consisted primarily of caucasian females, with 71.4 % of the sample identifying as caucasian or european-american (n = 5) and 85.7 % of the sample identifying as female (n = 6). additionally, african americans (n = 1) and latinos (n = 1) comprised 14.3% of the sample, respectively. graduate students (n = 5) represented 71.4% of the sample and those conducting therapy as a primary work activity represented 57.1% of the sample (n = 4). the participants indicated that they were from a city (n = 3; 42.9%) or rural area (n = 2; 28.6%). two respondents identified as being from a town or suburb. the three particioutcome of a spanish immersion workshop 19 pants who did not complete the post-workshop measure were not significantly different on any demographic characteristics from the individuals who responded to both measures. measures a brief questionnaire was designed by the authors to assess demographics as well as pre-workshop experiences, attitudes, expectations, and skills. the measure consisted of questions assessing demographics, knowledge of and attitudes towards latino culture, awareness of need for competent professionals, and perceptions of workshop effectiveness. demographic questions assessed basic characteristics of the workshop participants (e.g., age, gender, and education). questions to tap prior experiences, skills, and expectations included: “on a daily basis, i work with minority individuals,” “for work, i interact with latino individuals,” and “i believe that this workshop will assist me in my future work or training.” possible responses to the questions varied and included yes/no, true/false, multiple choices, or likert-scaled options. examples of items used to tap attitudes towards and knowledge of latino culture included: “latinos are lazy” and “family is important in latino culture.” two items assessing knowledge of spanish culture regions (i.e. “i can name the regions in north america that have spanish heritage, including areas in the u.s.), and the growth of the latino population (i.e., “approximately how large is the latino population in the united states?”) were included in the measure and were true/false and multiplechoice response, respectively. it is notable that the attitudes portion of the preand post-test was derived in part based on biases and stereotypes of latinos. stereotypes were selected based on a brief search of the internet for common stereotypes presented in the popular media concerning latinos. approximately 100 sites were browsed for information on common stereotypes. tallies of stereotypes were taken with the stereotypes mentioned the most retained for the measure. given the influence the popular media has on professionals and laypeople alike, it is judged that the stereotypes repeated most frequently in the media may have the most impact on attitudes towards latinos. the attitudes formed about latinos may impact the working relationship between the mental health professional and the consumer. thus, the stereotypes that were repeated most frequently (e.g., “latinos are lazy”, “latinos rarely complete high school or go to college”) were included in the measure. items assessing attitudes toward and knowledge of latino culture were used as a proxy to gage self-reported effectiveness of the workshop components (e.g., presentations) in providing individuals with more positive attitudes towards and knowledge of latino culture. items tapping awareness of need included: “language comprehension is important in understanding meaning”, “the latino population in the u.s. will grow significantly in the next 10 years”, “there is a need for mental health professionals who have skills to work with minority clients”, and “latinos have the same amount of access to mental health services as other groups.” for all items assessing attitudes towards and knowledge of latino culture and awareness of need for competent professionals, responses were based on a 5-point likert scale ranging from strongly disagree to strongly agree. two composites of the responses were devised with higher scores indicating more positive attitudes towards and knowledge of latino culture and increased awareness of need for individuals competent to work with latino individuals. appropriate items were reversed scored and all items included in the composites were summed. the composite assessing attitudes towards and knowledge of latino culture included 13 questions with a range of 13 to 60. the summed composite for the awareness of need included 7 questions and ranged from 7 to 35. cronbach’s alpha for the pre-workshop measure was .67. demographic questions were omitted from the reliability analysis. the post-test questionnaire paralleled the pre-test questionnaire and was designed to assess self-reported competency level, the benefit of the conference as a whole, awareness of need, and attitudes towards and knowledge of latino culture. all items assessing awareness of need and attitudes towards and knowledge of latino culture remained the same for the post-test questionnaire. the post-test measure also included questions that tapped respondents’ perceptions of workshop effectiveness (e.g., “this conference added to my training or experiences with latinos,” “i believe that this workshop will assist me in my future work or training”, “i feel prepared to work more effectively with latino/a consumers”). responses to the aforementioned questions were limited to true/false options. questions assessing the conference as a whole asked the participant to rate the spanish classes, cultural presentations, and conference on a 5-point likert scale (i.e., not beneficial to highly beneficial). three composites of the response were devised with higher scores indicating higher perceived benefits from workshop andmore positive attitudes toward, knowledge of, and awareness of need in working with latino consumers. given the questions assessing awareness of need and attitudes toward and knowledge of latino culture remained the same across the preand post-workshop measure, the same two composites devised for the pre-workshop measure were calculated for the post-workshop measure. an additional composite was calculated to include items that assessed respondents’ perceptions of the effectiveness of the workshop and interest in participating in another workshop. the composite included 8 questions. four questions were rated on a 5-point likert scale (i.e., classes on spanish, presentations about latinos and latino culture, practice sessions, conference as a whole). four questions were rated as true/false (i.e., “this workshop met my expectations of expanding my knowledge of latinos.”, “this conference added to my training or experience with latinos.”, “i feel prepared to work more effectively with latino/a clients.”, “i would attend another conference on rose, brass & derushia 20 latinos or other minority groups.”). the composite scores could range from 8 to 28. cronbach’s alpha for the postworkshop measure was .57. procedures all registrants for the spanish-language immersion and cultural competence pilot workshop were asked to participate in the outcome research. ten respondents completed the demographic questionnaire and the pre-test questionnaire in a pencil and paper format during the opening activities of the workshop. a week following the workshop, participants were contacted by email through student voice, a web-based survey company, to complete the post-test survey. the respondents were instructed to disregard the email if they did not complete the pre-test questionnaire. a code number that the participants chose for themselves was used to match preand post-test questionnaire responses while still providing confidentiality for all respondents. seven individuals completed the post-workshop measure. it is unknown why more participants did not complete this measure, but it is hypothesized that time constraints played a role. results responses given by individuals (n = 7) who completed both the pre-workshop and post-workshop measure were retained for analyses. descriptive statistics provided valuable information on the characteristics of the sample including participants’ experiences with latino individuals. specifically, individuals who completed the measures were well educated with 71.4% (n = 5) indicating that they have been studying or working in the field for 3-7 years and 28.6% (n = 2) working for more than 8 years. in general, many respondents reported that they do not work with minority individuals on a daily basis (n = 6; 85.7%); however, the one participant who provided information on working with diverse populations reported that africanamericans were the most frequently (n = 1; 5.6%) workedwith population. when asked if they encountered individuals who speak little or no english, most participants indicated that they typically do not encounter these individuals, with only 42.9% (n = 3) saying that they have encountered non-english speaking individuals in their work. when respondents encountered individuals whose primary language was not english, the languages spoken by the other individuals were identified as chinese (n = 1; 5.6%) or spanish (n = 1; 5.6%). more specific to our interests, only 28.6% of respondents (n = 2) reported that they interact with latino individuals on a daily basis, with individuals reporting that the latino individuals with whom they interacted are primarily from mexico. one-third of respondents indicated that they have had little or no training in working with latino individuals prior to this workshop. prior to beginning workshop activities, all respondents expressed a belief that participating in the workshop would be beneficial to them. preliminary data, in the form of anecdotal evidence provided to the authors during the wrap-up portion of the workshop, suggested that the pilot workshop was successful. participants stated that through the cultural competency sections of the workshop, they had gained knowledge concerning aspects of latino culture and that they felt better prepared to work with latino clients in their mental health settings. parametric tests were initially explored for analysis of the data. although the normal probability p-plot suggested that normality was achieved, the small sample size leads the researchers to question whether the assumption of normality was met for the parametric test. thus, a wilcoxon signedrank test was used to investigate differences between preand postworkshop attitudes towards and knowledge of latino culture and awareness of need. the wilcoxon signed-ranked test looks at change for one group of subjects measured on two different occasions (pallant, 2005). differences are classified as positive, negative, or tied. the wilcoxon signed-rank test considers information about both the sign of the differences and the magnitude of the differences between pairs. the wilcoxon signed-rank test incorporates more information about the data; hence, it is more powerful than the sign test. the pre-workshop composite, attitudes towards and knowledge of latino culture, was paired with the postworkshop composite. the pre-workshop composite, awareness of need, was paired with the post-workshop composite. the results of the analysis indicated that the workshop did lead to some change in attitudes towards and knowledge of latino culture (z = -2.226, p < .05), but not awareness of need. an examination of the composite scores for each individual indicated that six individuals reported gaining more knowledge and positive attitudes about latinos. one individual reported no change in knowledge or attitudes about latinos. in order to investigate how beneficial the workshop elements were a composite score of the workshop ratings was devised based on the sum of appropriate workshop related items (e.g., classes on spanish, presentations, workshop as a whole). the scale ranged from 8-28 with higher scores indicating more beneficial ratings of the workshop elements. the mean of this scale (m = 25.4, sd = 2.70) indicated that participants found the elements of the workshop beneficial and felt that the training received at the workshop would assist them in working effectively with latino consumers in the future. all elements of the workshop (i.e., classes, presentations) were rated as beneficial with no rating mean below a 4 on a 5-point likert scale. moreover, the respondents revealed that they believed that the workshop met their expectations and that they would attend another, similar, workshop in the future. discussion the results of the analysis indicated that the slicc workshop was effective in providing mental health profesoutcome of a spanish immersion workshop 21 sionals and students with some of the skills necessary to work effectively with latino and/or spanish-speaking consumers. given participants in the workshop volunteered for the workshop, the lack of significant difference on measures of awareness of need may suggest the sample was already aware of the need for individuals competent to work with latino individuals. although the sample was small, the preliminary data provided by the respondents can be used to assist in designing future workshops and trainings of this nature. the preliminary data suggests that all of the elements of the workshop were beneficial, thus, all elements outlined should be retained, and likely expanded, in future trainings. in addition to the elements included in the pilot workshop, the authors recommend that other interested individuals or groups consider including practice sessions, guided by bilingual individuals or individuals skilled in working with latino populations, in any workshops that are developed. we believe that such practice sessions will allow participants to gain hands-on experience in utilizing the skills learned in other aspects of the workshop. previous training models that included application of spanish language skills contributed to participants’ reports of an increased sense of competency in using spanish language interventions (biever et al., 2002). the results of the slicc workshop are consistent with prior literature on the effectiveness of workshops in addressing goals of increased cultural competency (e.g., bender et al., 2004; bender & harlan, 2005; williams, 2005). this suggests that some skills in language and cultural competence can be gained in a short-term training program. furthermore, although not formally evaluated, it is possible that participation in a workshop of this nature may fuel participants’ desire to learn more, encouraging them to seek out other training opportunities in language and in cultural competence, a hypothesis which, if found to be true, would help to overcome limitations of learning language in a short-term training. the evaluation of the slicc workshop faced several limitations. most notably, the low number of participants that chose to participate in the outcome study resulted in a small sample size, making definite inferences difficult. in addition to a small sample size, the high face validity of the assessment instrument meant that if they so chose, the respondents were able to rate both the workshop and their own personal attitudes in a manner consist with politically correct viewpoints, rather than according to their actual experiences or beliefs. moreover, the design of the study lends itself to several internal validity threats. the lack of readily available measures designed to test the efficacy of a short-term language immersion workshop resulted in the necessity of using a measure without previously established reliability and validity guidelines. the ability to confidently measure the competency of participants both preand posttest in a non-face valid way would increase the validity of the results. the effect of the pre-test could have impacted the post-test such that results suggest familiarity with the questions rather than any change brought about by participation in the conference. however, patton (1997) suggests that pretests may prime learning while a posttest may reinforce learning. thus, it is unclear whether the preand postmeasures were influenced by familiarity or enhanced learning. furthermore, with only one dependent measure it is difficult to account for other effects that could have produced the same results (e.g., familiarity with measure or regression to the mean). the addition of a control group and several dependent measures when designing future trainings may help to attenuate these effects. regardless of potential limitations, the preliminary results of this study suggest that further development and assessment of language and cultural competence workshops is warranted. as the rate of immigration and bilingualism increases in the u.s,. more professionals may be called upon to work with consumers who are not familiar with the english language or with the culture of the u.s. an understanding of the specific concerns facing these types of populations may be crucial in the future, and developing workshops such as the pilot program described here may become an increasingly important training aspect. references arredondo, p. 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(2009), mortality rates were 4.0% for anorexia nervosa and 3.9% for bulimia nervosa. pro-eating disorder websites have been studied in recent years for their impact on body image and eating disorder pathology among viewers. this paper is a review of current literature about pro-eating disorder websites, which provide nutritional information, images of thinspiration (a portmanteau of the words thin and inspiration), and message boards for social interaction, all with the goal of promoting eating disorders. the content and emerging themes of pro-eating disorder websites are discussed in this paper order to understand the context of the interaction between website and viewer. next, the social interaction that takes place on these sites is examined in order to understand the nature of social support and social exclusion existing on these sites. finally, studies that have investigated the effects of pro-eating disorder viewership on affect, body image, and eating behavior are discussed. introduction pro-eating disorder websites host communities of individuals who engage in disordered eating and use the internet to discuss their activities (wilson, peebles, hardy, & litt, 2006). csipke and horne (2007) conceptualize two definitions of the term pro-eating disorder in the context of internet communities. the first defines the term as a willingness to accept that an individual has an eating disorder without seeking to encourage that individual to find treatment, and may imply an aim to motivate or enable continuation of disordered eating behavior. the second definition characterizes the term as the understanding of eating disorders as lifestyles rather than disorders. both conceptions of the term will be examined throughout this paper. eating disorders are a pressing concern in the mental health community. in a sample of 10,123 adolescents it was found that 0.3% suffered from anorexia nervosa (an) and 0.9% suffered from bulimia nervosa (bn; (swanson, crow, le grange, swendsen, & merikangas, 2011). according to crow et al. (2009), mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa (data was collected between 1979 and 1997 at an eating disorder clinic with assistance from the national death index). in addition to their high mortality rates, eating disorders are difficult to treat and represent a biopsychosocial illness whose causes are often elusive (polivy & herman, 2002). according to the current diagnostic and statistical manual of mental disorders (5th ed.,; dsm–v; american psychiatric association, 2013), an is characterized by a refusal to maintain a weight that is 85% or more of what is expected, disturbance in the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight, and amenorrhea. there are two distinct types of an: restricting type and purging type. restricting-type patients are characterized by their insistence on eating very little, whereas purging-type patients regularly engage in binge eating and purging. it is important to note that an purging type is distinct from bn, though vomiting and the use of laxatives are common to both; the distinction lies in the context in which purging takes place—whether it is during an episode or anorexia or bulimia (anorexia and bulimia nervosa, n.d). the diagnostic and statistical manual of mental disorders (5th ed., dsm–5; american psychiatric association, 2013), defines the diagnostic criteria for bn as regularly eating more food in a given period of time than a person normally would and a concurrent loss of control over eating. in addition, compensatory efforts such as purging or fasting are employed to counteract the effects of binge eating and self-evaluation is overly dependent on body weight and shape. the binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for three months. bn has two distinct subtypes: purging and non-purging type. purging type patients correspondence concerning this article should be addressed to: hadley a. johnson, 158 cambridge ave., hy weinberg building, room 302; garden city, ny 11530. email address: hadleyjohnson@mail.adelphi.edu. 71 regularly engage in self-induced vomiting or the misuse of laxative, diuretics, or enemas. non-purging type patients fast or over-exercise to compensate for binge eating, but they do not engage in the same compensatory efforts as purging type patients. binge eating disorder (bed) is similar to bn in that binge eating is at the core of the disorder; however, individuals with bed make no inappropriate compensatory efforts to counteract the high caloric intake. as a result, this disorder is sometimes associated with obesity. because the focus of this paper will be on websites that promote weight loss through inappropriate or unhealthy means, bed will not be discussed in relation to online communities. the lifetime prevalence rates of an and bn are 0.3% and 0.9%, respectively (swanson, 2011). among adolescents the 12-month prevalence rates are 0.2% for an and 0.6% for bn and the median ages of onset are 12.3 and 12.4 years, respectively (swanson et al., 2011). eating disorders stem from myriad causes and it is impossible to identify one event or condition that leads an individual to develop an eating disorder. influences that may shape the development of an eating disorder include sociocultural factors (e.g., media and peer influences; nasser, 2010; paxton, schutz, wertheim, & muir, 1999), body dissatisfaction and concern about weight (killen et al., 1996), and cognitive and biological factors (fairburn, 2001). this paper will examine the role of community within the context of pro-anorexia (pro-ana) and pro-bulimia (pro-mia) websites in the reinforcement of disordered eating habits. pro-eating disorder websites are available to anyone with internet access and are often hosted by large and well-known domains. a study of 711 children and adolescents in 7th, 9th, and 11th grade found that 12.6% (n = 90) of the girls and 5.9% (n = 42) of the boys had visited pro-anorexia websites (custers & van den bulck, 2009). a separate survey of 76 patients who had been treated for eating disorders in an outpatient clinic showed that 35.5% had visited pro-eating disorder sites (wilson et al., 2006). csipke and horne (2007) found that among a group of 151 individuals with eating disorders, 54 (36%) initially found the websites via the internet or search engines as opposed to finding them through the media or by word of mouth. there is evidence that searching for pro-eating disorder content is a popular phenomenon, with over 100,000 monthly searches on google.com for each of the search terms “pro-ana,” “thinspo,” and “thinspiration” (lewis & arbuthnott, 2012). interestingly, the term “pro mia” is less frequently searched, with less than 100,000 searches per month. though the reasons for this are unclear, it is possible that the “ana” identity is viewed as more desirable than the “mia” identity. one limitation of this study is that it measured the frequency of searches, which does not account for a single user searching multiple times for pro-ana terms. since several searches likely reflect the same individuals conducting multiple searches, the number of people searching for pro-eating disorder content is unknown. website content in order to understand how pro-eating disorder websites influence an individual’s eating behavior and self-concept, it is first necessary to examine what these websites offer. pro-eating disorder websites offer content that ranges from images to information on weight loss to interactive features. each of these types of content will be examined in this section of the paper. images pro-eating disorder websites offer a variety of content on the topic of weight loss. one notable type of content is the use of images. the occurrence of eating disorders has been linked to a thin ideal body type associated with western culture (nasser, 2010). eating disorders have been found to be more prevalent in western than in non-western countries (prevalence rates ranged from 0.3% to 7.3% in female subjects in western countries compared to 0.46% to 3.2% in female subjects from non-western countries) while disordered attitudes about eating appear to be increasing in non-western countries (makino, tsuboi, & dennerstein, 2004). social class (as characterized by education and wealth) has also been implicated in the rising prevalence of anorexia nervosa (darmon, 2009), possibly because thinness and frailty are equated with high social status and differentiation from lower classes (brumberg, 1988). in a culture where johnson 72 nutrition and wealth are abundant, the slim body type becomes idealized and is over-represented in the media. however, exposure to the media is so widespread that polivy and herman (2002) argue that if such exposure were the sole cause of eating disorders, then it would be difficult to explain why anyone in cultures that are not deprived would not be eating-disordered. while it is undeniable that images of thin models and actresses portray unrealistic representations of the human body, they cannot be sole factors in contributing to the number of eating disordered individuals. thinspiration consists of words and images intended to promote weight loss. according to lapinski (2006), thinspiration can be conceptualized to comprise three categories: triggers, reverse triggers, and distractors. triggers are designed with the intention of motivating or reinforcing eating disordered behaviors; triggering content may include models, actresses, or women suffering from eating disorders who have achieved a very thin body type. in a systematic study of content on 180 active pro-eating disorder websites, it was found that 85% contained thinspiration material. known fashion models were most frequently shown (66% of sites included at least one photograph of a model), followed by celebrities (57%), non-celebrities (44%), and athletes (12%; borzekowski, schenk, wilson, & peebles, 2010). when “real” women post pictures of themselves (particularly “before” and “after” images) they are simultaneously seeking recognition for their weightloss achievement while serving as inspiration for other women. “real” is the descriptor given to these women, who may also be referred to as “normal” on the websites in order to distinguish them from models, dancers, or celebrities (borzekowski et al., 2010). in the “before” pictures, women are typically either normal or overweight and the “after” pictures show dramatic weight loss. there are several desirable markers that indicate the idealized level of weight loss, including visible collarbones, hipbones, and a “thigh gap.” a sub-type of thinspiration, or “bonespiration” (abbreviated as “bonespo”), has emerged to promote the desirability of a skeletal appearance. “bone pics” are pictures of emaciated women and digitally manipulated pictures of models to make them look skeletal (bardone-cone & cass, 2007). in contrast to triggering images that celebrate a thin figure, images of overweight women are often presented as thinspiration content in order to serve as a reverse trigger. thus thinspiration not only promotes the idealized thin body type, but also publicizes the feared heavy body type that readers try to avoid (dalley & buunk, 2009). in a study involving 134 female participants, it was found that frequent dieting is primarily motivated by a desire to avoid an overweight identity, rather than by a desire to acquire the favorable thin identity (dalley, buunk, & umit, 2009). though frequent dieting may be considered clinically distinct from an, this is a significant finding that may lead to a new way of conceiving of extreme weight loss since it appears to represent a flight from the unfavorable as opposed to a race toward the favorable. while the desire to avoid an overweight identity may be powerful, reverse triggers appear to be in the minority of thinspiration content. lastly, distractors offer methods of reducing or ignoring the hunger impulse. distraction content includes pictures of “food porn,” or images of decadent food shown to induce satiation. another common distractor is content urging an individual to exercise or drink water to reduce hunger (lapinski, 2006). tips and tricks “tips and tricks” are strategies intended to promote weight loss. in a survey of 20 pro-eating disorder websites, norris et al. (2006) found that 67% of these websites contained “tips and tricks” material. wilson et al. (2006) found that among 76 individuals diagnosed with an eating disorder who visited pro-eating disorder websites, 96% reported learning new weight loss or purging techniques from these sites. tricks typically included methods of hiding weight loss and techniques for creative calorie avoidance. for example, so-called “negative calorie” foods, which are believed to require more energy to digest than is supplied by the nutrition, are often promoted as a way of satiating hunger while burning calories. it appears that pseudoscience and “guesswork nutrition” are mixed indiscriminately with true nutritional facts (martin, 2005, p. 157). according to a content study of pro-eating disorder websites, more than 70% (n = 126) offered i will not eat! a review of the online pro-ana movement 73 dieting strategies, including specific dietary regimens and advice on fasting; 68% (n = 122) listed “safe” foods or charts with low-calorie food; 50% (n = 90) offered tips on purging or the use of laxatives or diet pills; and 43% (n = 77) offered advice on how to hide an eating disorder from others (borzekowski et al., 2010). the study identified certain portions of text that characterize the extremes of severity and intricacy of these tips. on the seemingly harmless end of the spectrum is an example such as: “sit up straight. you’ll burn at least ten percent more calories sitting upright than reclining.” on the severe end is: “to purge: you can start off with two fingers or a toothbrush — 3 fingers if nothing is happening. next, rub the back of your throat; you should feel sort of a buttonish thing at the back. well, you need to push it!” (borzekowski, 2010). while “tips and tricks” are principally associated with advice of how to lose weight, pro-eating disorder websites frequently offer other tips on how to conceal weight loss from concerned family, friends, or medical professionals. findings of a content analysis of pro-eating disorder websites that illustrate this phenomenon include: “wear nail polish to hide the discolouring [sic] in your nails for lack of nutrients” and “do anything you can to make yourself weigh more [before a doctor’s visit]” (harshbarger, ahlersschmidt, mayans, mayans, & hawkins, 2009). website features interactive features have been found on 79% (n = 142) of pro-eating disorder websites (borzekowski et al., 2010). interactive tools vary by website and might include discussion boards, message boards, personalized diet or exercise-related tools, or ways of posting comments or artwork. tumblr allows users to “reblog” another user’s comment or photo, thus propagating the original post and exponentially increasing its influence. interactive features enable users to share their progress as measured by weight loss, measurements, or days fasting, and to engage in member-against-member competition (mccabe, 2009). interactive features aid in sustaining communities that function similarly to cliques, which are characterized by shared interests, exclusion, and competition within the group, and have been shown to have a negative impact on body image and disordered eating (paxton et al., 1999; wilson et al., 2006). another feature of many pro-eating disorder websites are disclaimers. norris et al. (2006) observed that warnings and/or disclaimers before entry into the web pages were posted on 58% (n = 7) of the websites. these disclaimers included asking non-eating disordered persons to leave the website, acknowledging that the website supported the proana movement and prohibiting persons under the age of 18 to enter without parental consent. this prohibition is not enforceable, however, and teenagers are able to access the sites. for their study on the examination of pro-anorexia website exposure and moderating effects among female undergraduates, bardone-cone and cass (2007) created a prototypical disclaimer based on an extensive search of pro-eating disorder websites. the disclaimer read: this is a pro-ana site. if you are recovering from an eating disorder or hate the fact that pro-anas exist, i suggest you leave! now!!! this site is for those who feel that anorexia is a life-style, and that we should have a choice to leave ana or take comfort in that which defines us. warning!!! some material may be triggering. some disclaimers are written within the context of anorexia as a medical illness, as opposed to a lifestyle. the moderator of one website posted: if you’ve come here to “learn” to be anorexic or bulimic, then you really need to leave. eating disorders are painful, life-destroying creatures that are not worth their cost. they are not cool or glamorous. they are not a quick fix. they are not a diet. they are a living, breathing hell. but once you’re in, you’re in. you’re in until it either kills you or destroys your life so much that you have to break free. so stay out. stay back. stay sane (strife & rickard, 2011). emerging themes eating disorders as a lifestyle choice many themes have emerged as common among pro-ana disorder websites. a central theme appears to be the concept of eating disordered behavior as a johnson 74 lifestyle rather than an illness that requires treatment. while the theme of lifestyle choice seems apparent to visitors who are not pro-ana, only 20% of pro-eating disorder sites explicitly state the opinion that proanas view eating disorders as a lifestyle choice (borzekowski et al., 2010). the discrepancy between public perception and stated intention of site moderators in the portrayal of eating disorders as a lifestyle choice may lie in the definition of the phrase, “lifestyle.” csipke and horne (2007) described two perceptions of the word “lifestyle” in this context. the first understanding of the word describes a lifestyle as a chosen manner of living one’s life and entails embracing a set of values that characterize the lifestyle—perhaps even promoting them. according to the second perception, an eating disorder is not adopted by choice. rather, it is a lifestyle in the sense of “a way of life” that pervades every aspect of the person’s thoughts, perception and action. while the promotion of eating disorders as a lifestyle choice is prominent among pro-eating disorder websites, it is not espoused uniformly by all sites. a study by csipke and horne (2007) found that 54% of pro-ana website users recruited through a mental health charity in the united kingdom (n = 80) viewed anorexia and bulimia as clinical disorders; however, a significant number of respondents validated the concept of eating disorders as a lifestyle adopted by choice it is likely that website creators conceptualize the phrase “lifestyle choice” differently from mental health professionals. in a grounded theory study of pro-eating disorder websites, norris et al. (2006) found that only one website (out of a sample of twelve) viewed an as a lifestyle choice, whereas almost one half of the website creators viewed their website as a means of supporting individuals with eating disorders. the type of support offered by these sites varies widely, and may range from connecting individuals to treatment options to promoting eating disordered behaviors. offline isolation and online community issues involving isolation and community are prominent on pro-eating disorder websites. norris et al. (2006) observed that “befriending the eating disorder leads to isolation from others,” and that pro-ana website users attempt to fill that void through interaction with other eating-disordered individuals. users describe the need for isolation on 60% of the sites, as exemplified by one user’s comment: “obese fatties around that want me to be just like them” (borzekowski, 2010). when an individual becomes isolated, he or she may find that the disorder creates conflict with other individuals. tierney (2006) found that outpourings of anger or frustration towards “outsiders” (e.g., parents or doctors) were common and that outsiders were regarded as unaware of the nature and benefits pro-anas associated with their behavior. results of two studies suggest that the sense of social isolation increases as an eating disorder progresses, thus necessitating higher levels of interaction with other users as the disorder becomes more severe (serpell & treasure, 2002; serpell, treasure, teasdale, & sullivan, 1999). one user described her sense of isolation: unless you have a friend with ana, outsiders are not going to understand. boyfriends are not so great to confide in, [because] if they really love you, they won’t accept your starving for perfection; same goes with true friends (gavin, rodham, & poyer, 2008, p. 330). discussion boards provide users with a space in which their identity is supported, accepted, and understood – something users believe cannot be achieved offline. one user posted: “i am so glad that i can come here and vent to you guys because you are so supportive and you never make me feel bad about myself ” (gavin et al., 2008, p. 329). pro-ana communities may serve a limited therapeutic role for individuals who are not ready for therapy or who feel rejected by the medical community by providing the opportunity for individuals to express themselves in a supportive, anonymous setting (petterson & rosenvinge, 2002; wilson et al., 2006). juarascio et al. (2010) found that pro-ana groups on facebook and myspace contained positive social interactions between participants. csipke and horne (2007) suggest that social support is available on these sites and that visiting the sites can have a positive effect by drawing visitors out of isolation. however, there is a distinction to be made between two types of visitors: passive and active. passive users do not interact with others during their usage of these sites, whereas active users utilize the sites’ ini will not eat! a review of the online pro-ana movement 75 teractive tools to connect with others. the findings of csipke and horne (2007)’s study suggest that active participation on pro-eating disorder websites and seeking the support and friendship of other visitors can have a positive perceived impact on individuals as they experience greater social support. csipke and horne (2007) do not suggest that active users are immune to the dangers of pro-eating disorder websites. they argue that the harmful information shared during these interactions counteracts the positive gains from social support. active users may be vulnerable to a different set of dangers than passive users because active users are more likely to utilize the social support to motivate each other to engage in pro-eating disorder behavior. while it is clear that active users and passive users experience the sites differently, it is unclear which factor leads individuals to become more symptomatic: isolation (passive users) or motivation to become eating disordered (active users). issues of social isolation are frequently raised on social networking sites (juarascio, shoaib, & timko, 2010). posters request advice about family and relationship problems, which sometimes, but not always, surrounded eating disorder issues; posed questions and entered into discussions of sexuality; and shared life problems. one user shared her problem that simultaneously involves a romantic relationship and her eating disorder: “sometimes i really want to tell my [boyfriend] about this because secretly i want him to be supportive but i know he would never understand (gavin et al., 2008).” upon joining a new group, individuals may introduce themselves with statistics that describe their weight, age, and height. for example, one member introduced herself to the group through the following post: name: [removed]. height: 5’3, high weight: 160 (i was pregnant), low weight: 85, current weight: 98, goal weight: i’ll never be content w/ any number to be honest (juarascio et al., 2010, p. 7). other introductions to the group included information such as relationship status, years with an eating disorder, and reason for joining the group. in contrast with the unemotional tone of introduction and disclosure, statements of support and friendship tended to be highly emotional. examples included members requesting friendship due to feelings of extreme loneliness and isolation, advice or feedback about relationships, and emotional support. for example, when one member mentioned having to attend a holiday party, another member responded, “you can do it!!! just think of the end results! it’s been hard for me. holidays are hard, so much food thrown in your face all the time! you are strong!” (juarascio et al., 2010, p. 7). it was common to offer to communicate outside of the social networking site, such as on the phone, via email, or chat. despite the positive gains from social interaction, discussion boards provide information that often runs counter to recovery, including sharing tips and tricks to hide disordered eating behaviors from health care professionals, family, and friends, thereby staving off hospitalization and professional support. though social support may be gained online, isolation from offline sources of social support (family, friends, community, etc.) will inevitably increase as the disease progresses (gavin et al., 2008). claims to authenticity antagonism toward “wannarexics” seems to be common among pro-ana groups (boero & pascoe, 2012). the term describes individuals who are perceived to emulate eating disorders and visit pro-ana websites hoping to adopt the attitudes, behaviors, and weight loss results they promote. the antagonism directed at wannarexics may represent the struggle between online exclusivity and offline isolation. in their study, borzekowski et al. (2010) found that 32% (n = 57) of the sites had an overt tone or statement directed to “wannabes.” both polite and antagonistic statements were identified. one polite statement was, “if you are looking to become anorexic or become bulimic by being here then please leave.” one example of a harsh statement was: if you want to lose weight, go on a diet fatty. one is either ana/ mia, or not. it is a gift and you cannot decide to have an eating disorder. so if you are looking for a way to lose weight, s-s-sjohnson 76 sorry, junior!! move on, try jenny craig (borzekowski et al., 2010, p. 1528). requests for tip giving may be met with reluctance or antagonism. when one poster in a myspace group requested tips on how to purge, another member responded: ugh don’t even try to do it. i went through trying and failing to be able to throw up for a couple months. yeah i can do it now but sometimes it happens even when i don’t want. i hate doing it but i can’t stop. its’ [sic] not worth starting and it’s not cool that you are asking for this kind of advice here. it sounds like you don’t even really have an eating disorder (juarascio et al., 2010, p. 8). group members routinely challenge wannarexics on their lack of knowledge around weight-loss strategies. boero and pascoe (2012) suggest that users may demand the self-representation be authentic in order to maintain a sense of community. authenticity is assured through a series of group rituals, such as weigh-ins and posting pictures, which allow users total claim to a pro-ana identity while depriving others of it. the relationship between isolation offline and exclusivity online is a topic that merits further study. when users fail to participate in group activities they are met with scorn and suspicion from other members. posting pictures that show dramatic weight loss are an important part of proving an authentic pro-ana identity and the use of celebrity thinspiration instead of a self-portrait invites criticism. one member posted: you can always pick the wannabes, the ones with only skinny celebs in their pictures and a whole ton of pro-ana crap on their myspace. i bet if you asked them why they don’t have any pictures it would be because they “just like started being ana like 5 weeks ago” (boero & pascoe, 2012). sometimes users attempt to smoke out interlopers by issuing alerts: …there is deffy one person on this site, who you can just tell has not got an ed. i know, you cant tell over the web, but you can by her comments & her stupid posts on the subjects etc. a number of people on my msn who visit this site have also spoken about her on numours(sp) occasions, so i know for a fact, i am not the only one who has noticed this…(giles, 2006). the antagonism toward wannarexics suggests that the community boundaries on these sites are closely monitored and protected. giles (2006) notes that if anorexia is about attempting the unachievable, then it is not surprising that anorexics set such high standards for admittance to their community. it seems that these statements have important implications for the maintenance of the ana identity and possibly serve to compensate for offline isolation. implications for eating-disordered behavior the danger in these tips and tricks that appear on these websites is not only the content of their message, but also in their prominence on pro-eating disorder websites. cultivation theory, developed by communication scholar george gerbner, posits that when messages are pervasive and repeated, individuals with higher exposure levels are more likely to accept the conveyed messages as normative (borzekowski et al., 2010; gerbner, 1998; heath and bryant, 2000). thus individuals who frequent these websites may come to view methods of extreme dieting and exercise as normal behavior rather than symptomatic of an eating disorder. research suggests that even modest exposure to pro-eating disorder websites may encourage significant changes in caloric intake and increased disordered eating behaviors, and that even greater exposures to these websites by at-risk females may contribute to the development of eating disorders (jett, laporte, & wanchisn, 2010). in this study, undergraduate females with no history of eating disorders and a bmi greater than 18 were assigned to one of three conditions. the exclusion of women with eating disorders makes this study unique among others studying the effects of pro-ana viewership. the first condition was exposed to pro-eating disorder websites for a total of 90 minutes, the second condition to health and exercise websites, and the third condition to tourist websites. all particii will not eat! a review of the online pro-ana movement 77 pants were asked to keep food diaries prior to and following exposure to one of the three types of websites. the pro-eating disorder websites were chosen because they included the ana creed, tips and tricks on how to be anorexic or bulimic, and thinspiration. eighty-four percent (n = 21) in the pro-eating disorder condition reduced their weekly caloric intake by an average of 2470 calories. in contrast the participants in the other conditions did not reduce their caloric intake by a significant amount. even though 84% of subjects in the pro-eating disorder group reduced their caloric intake, only 56% perceived that the websites influenced them to reduce their food intake (jett et al., 2010). this discrepancy speaks to a lack of insight regarding influences on body image and eating habits. the age of participants represents a weakness of this study since pro-ed viewership begins up to a decade earlier (custers, 2009). using a younger sample might yield a more relevant understanding of the effects of pro-ana viewership. in addition, keeping food diaries may have cued participants into the true nature of the study and sensitized participants to their food intake, which may partially explain the decreased caloric intake among the sample that was primed to weight-loss through viewing pro-ana websites. lastly, the long term effects were not studied which may represent an ethical problem. researchers followed up with participants three weeks after exposure in order to assess eating disordered behavior and attitudes as a result of the study (and found none). however, it remains unclear if viewing pro-ana content even for a short period of time has lasting effects. a prospective study found that viewing pro-anorexia websites led to greater negative affect, lower self-esteem, and lower satisfaction with appearance as well as an increased likelihood of identifying oneself as heavy, of exercising, of thinking about one’s weight, and of engaging in image comparison (bardone-cone & cass, 2007). fourteen percent (n = 33) of this study’s participants had a score of 20 or above on the eating attitudes test (eat-26), which suggests the presence of an eating disorder. lastly, individuals who frequent pro-eating disorder websites report higher levels of body dissatisfaction and eating disturbances (harper, sperry, & thompson, 2008). this does not suggest a causal relationship between pro-eating disorder websites and body dissatisfaction and eating disturbances, rather it suggest a correlation. competition among users and social comparison features prominently in pro-ana communities (rouleau & von ranson, 2011). competition in the area of extreme weight loss can be conceptualized by the work of albert bandura, whose social cognitive theory proposes that modeled behaviors are more likely to be imitated when message receivers can relate to the model and perceive rewards with the communicated behavior (bandura, 1989). with this model in mind, it is easy to see how copying other users’ behavior leads to a culture of “one-upmanship” that fosters competition. csipke and horne (2007) found that 19% (n = 29) of pro-eating disorder website users reported that the sites were harmful because of their promotion of competition and disordered eating among users. thus individuals who view others’ extreme weight loss as achievable and desirable are more likely than others to adopt the behaviors modeled by their online peers. it appears that competition and self-comparison among members of an online group may be a motivating factor in the maintenance of eating disordered behaviors. discussion the pro-ana community seems to struggle with many internal conflicts and contradictions that may be considered from a psychodynamic perspective. these internal conflicts and contradictions allow for the conceptualization of eating disorders as a spectrum disorder with poor body image at one end and clinical an at the other (patton, 1988). in the pro-ana community there is a marked struggle between online exclusivity and offline isolation. it appears that the construction of an authentic class of anas is formed in reaction to low levels of social support offline. while a user may feel alone and detached from her offline community, she may be valued by others for her contributions to an online community where she finds high levels of social support from other users. in order to be accepted online, a user must prove his or her ana identity or be cast out as a wannabe. there does not appear to be a space for users who are in the beginning stages of the disease or who have not fully adopted the missions and goals of a website. projohnson 78 ana websites provide more than a collection of tips and tricks and thinspiration –they also provide a validation arena for exploration of the pro-ana identity. another struggle within the pro-ana community is whether to consider the eating disorder a “gift.” the conception of anorexia as a gift reinforces the exclusion of wannabes by telling them they can never adopt the ana identity and thus do not belong. the confusion about anorexia as a boon or damnation is felt not only at the community level but also at an individual level. within this struggle the question of control arises: does a user enjoy the gift of an eating disorder at will or does the eating disorder control and trap the user? are authentic anas able to use and dispose of the pro-ana identity or are they trapped within it? while users may feel they can control their bodies through anorectic behaviors, they may also feel that anorexia has seized control of their identities, bodies, thoughts, feelings, and actions. lastly, there is confusion about where the proana identity lies. an individual may be pro-ana or she may be controlled by a pro-ana influence. some website users refer to anorexia as a personified being (called ana), who is portrayed as controlling, demanding, and perfectionistic, and is frequently distinct from an individual’s view of the self. separating oneself from ana may be a defense that allows an individual to preserve her identity while accommodating the influence of the disease. alternatively the pro-ana identity may be so internalized that there is no separation between oneself and ana. the fact that ana and mia are female names gives rise to the conception of ana and mia as female influences that may be friends, enemies, or both simultaneously. the pro-ana community experiences many sources of internal conflict that are an extension of conflicts experienced on an individual level by users with anorexia. conclusion while the nature of pro-eating disorder websites has been elucidated over the past decade, there remains the problem of how to counteract the risk to users of accessing these websites. in response to public pressure, some internet platforms have shut down pro-eating disorder websites. while this temporarily thwarts access to these websites, it is not a permanent solution. for example, in the early 2000s yahoo! and msn shut down several pro-eating disorder websites at the urging of media, clinicians, and professional organizations (hammersley & treseder, 2007). however the websites reemerged on other platforms or behind the guise of “pro-recovery” websites, which frequently offered the same content found on pro-eating disorder websites (lewis & arbuthnott, 2012). in addition, there is the question: is shutting pro-eating disorder websites in the best interest of public health? lewis and arbuthnott (2012) note that searches on “suicide methods” yield both relevant content and a sidebar with contact information for a crisis hotline, which may be an effective intervention to suicide ideation. thus one possible strategy would involve offering eating disorder treatment information in addition to the pro-eating disorder websites when a user searches for certain keywords, such as “pro-ana” or “thinspiration.” for their study on users’ opinions of pro-eating disorder websites csipke and horne (2007) recruited participants online. the majority of respondents (84%, n = 127) reported having an eating disorder. their study found that a large group of participants (41%, n = 61) visited pro-eating disorder websites several times a day, and sixteen participants (11%) visited them at least once a day. only nine participants reported having visited a pro-eating disorder website only once. if an individual enjoys the community found on websites, then he or she may benefit from websites that genuinely support recovery and do not allow pro-ana content. this is a potential avenue of treatment to be considered by clinicians as well as a topic to be studies by researchers who wish to understand the effects of pro-recovery websites on formerly eating-disordered individuals. future studies should seek to identify moderators that strengthen the effects of pro-ana viewership. studies should also investigate at what point over the course of an eating disorder an individual is most likely to first access pro-ana sites. the answers to both of these questions could lead to a more nuanced understanding of the relationship between pro-ana viewership and the maintenance of an eating disorder, which could have implications i will not eat! a review of the online pro-ana movement 79 for primary interventions as well as a more accurate portrait of an individual’s eating disorder etiology. while this paper reviewed studies on the role of pro-eating disorder websites in relation to the sustainment of eating disorders, the role of these sites at the beginning of a disorder has yet to be elucidated. while it is unlikely that viewing pro-eating disorder websites would be the sole cause of an eating disorder, it would be worthwhile to investigate their role among individuals who have yet to develop an eating disorder, but are tentatively experimenting with eating disordered behavior. understanding the role of pro-ana viewership at different stages of an eating disorder will enhance treatment of eating disorders, as well as provide new avenues of research. references american psychiatric association. 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(2006). surfing for thinness: a pilot study of pro– eating disorder web site usage in adolescents with eating disorders. pediatrics, 118, e1635-e1643. i will not eat! a review of the online pro-ana movement 14     graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university  impact of an elderspeak in-service training on resident well-being, selfesteem, and communication satisfaction lonnie s. bradford and christian m. end xavier university reinforce negative stereotypes of aging, deprive older adults of meaningful interactions, and erode their well-being. a brief communication in-service training based on williams, kemper, and hummert (2003) was presented to nursing home staff to replace elderspeak with more helpful communication behaviors. resident staff interactions were coded, and impact of the training on -esteem, and well-being was assessed across three time periods. a separate unit of untrained staff and residents served as a comparison group. significant reductions in the proportion of interactions containing features of elderspeak were observed for the trained staff, along with significant increases in resident satisfaction, well-being, and self-esteem. (1994), is an undesirable yet common speech modification directed at older adults. also known as patronizing speech (ryan, giles, bartolucci, & henwood, 1986), or secondary baby talk (caporael, 1981), elderspeak consists of several characteristic psycholinguistic features, including the use of childish terms (e.g., good girl), over inclusive pronoun our bath), the use of terms of endearment in place of formal names (e.g., sweetie), a higher pitch and slow singsong tone of voice, as well as several other speech adjustments (for a review, see ryan, hummert, & boich, 1995). the primary goal of the present study was to examine if nursing home staff can successfully reduce their use of elderspeak following a brief in-service training, and if so, explore if this reduction will help according to the communication predicament model of aging (ryan et al., 1986), elderspeak is problematic because it reinforces stereotypes of aging and reduces opportunities for older adults to engage in more meaningful communication, undermining their well-being and selfconcept (ryan et al., 1995). additionally, many components of elderspeak such as reducing sentence length, slowing speech rate, or speaking using a higher pitched voice do not confer communication benefits to older adults, and may actually undermine their confidence in their ability to communicate (kemper & harden, 1999). speech modifications such as increasing pitch and prosody may also be counterproductive, given that the most common form of hearing loss affecting older adults actually reduces                                                                                                   correspondence concerning this article should be addressed to lonnie bradford, xavier university, department of psychology 3800 victory parkway cincinnati, ohio 45207, email: bradfordl@xavier.edu. sensitivity to higher-frequency tones (van-rooij & plomp, 1990). while there is considerable complexity in how older adults actually regard elderspeak (nelson, 2005) compared irritating and patronizing (giles, fox, & smith, 1993). further, older adults may rate those who use elderspeak less favorably (gould & dixon, 1997; latourette & meeks, 2001). though it is not clear how these unfavorable perceptions might relate to caregiver outcomes such as job related stress, a case study by cunningham and williams (2007) provides preliminary support for the hypothesis that behaviors to care. when considering the negative consequence elderspeak may hold for older adults, seeking to reduce the use of this speech behavior has considerable merit. an intervention to reduce elderspeak has previously been evaluated in nursing home settings. in two separate studies, williams et al. (2003, 2005) conducted an in-service program to review communication barriers for older adults while sensitizing staff members to the key features of elderspeak. the results of these studies are very encouraging; following the inservice training, significant reductions were observed in inappropriate collective pronouns, and shortened sentence length. in addition, in both studies, the experimenters rated the immediate post-training conversations between the staff and the residents as less controlling, and more respectful than the pre-training recordings. further, williams et al. (2005) found that maintained at two-month follow-up. while both of these studies demonstrated that a brief in-service could neither study addressed the impact their intervention had on the nursing home residents. considering the complexity of elderspeak in-service training   15 resident outcomes following such training would provide a greater understanding of the success and significance of the intervention. consistent with previous research by williams et al. (2003, 2005), the current study sought to evaluate whether a brief communication training can reduce staff member use of elderspeak. specifically, the present study sought to develop a training program that demanded less staff time, was effective in increasing awareness of elderspeak, and prompted nursing home staff to reduce their use of elderspeak. the other objective of the current study was to evaluate whether the training program conferred any benefits to nursing home residents, specifically in terms of improved communication satisfaction, self-esteem, and well-being. staff outcomes knowledge gain, attitude, and the intention to change behavior are variables that have previously been identified as important mediators of behavior change following communication trainings (francke, garssen, & huijer abusaad, 1995). knowledge gain, in particular, is commonly assessed in intervention research and is thought to be an behavioral changes in continuing education (kiener & hentschel, 1989; warmuth, 1987). according to reasoned action theory, the intention to demonstrate a particular behavior is closely related to actual behavior (fishbein & ajzen, 1975). that is, the greater the intent, the more likely it is that a person will actually change their communication behaviors. thus, we tested the following hypotheses: 1) nursing home staff will show a significant increase in knowledge and ability to identify elderspeak at the end of the in-service training indicated by positive change between pre and post-test ratings on the communication evaluation tool (williams, 2001); 2) trained staff will show an increase in behavioral commitment and positive attitude towards training when comparing the sample mean to the midpoint score as measured by the affective learning scale (als; andersen, 1979); nursing home staff in a unit that has undergone training will: 3) reduce their use of elderspeak at both posttraining assessments (within group hypothesis), and 4) when compared to staff not receiving the training (between groups hypothesis). resident outcomes to evaluate the merits of an elderspeak intervention more fully, it is important to understand what impact such training has on the experiences of the nursing home residents. as elderspeak may reduce opportunities for meaningful communication and lead older adults to experience decreased self-esteem and well-being (ryan et al., 1995), measures were selected to assess these variables. thus we tested the following additional hypotheses: 5) residents will show an increase in older adult well-being as measured by the mental health inventory-5 (mhi-5; veit & ware, 1983), self-esteem as measured by the rosenberg self-esteem scale (rosenberg, 1989), and communication satisfaction as measured by the feelings of understanding/misunderstanding scale (fum; cahn & shulman, 1984) at both post-intervention assessment points; 6) residents residing in the unit that receives elderspeak training will report significantly higher wellbeing, communication satisfaction, and self-esteem at both post intervention assessments than the unit that does not receive the training. m ethod participants nursing home staff. the study was conducted at a large retirement community in rural ohio. twenty-five staff members participated in the in-service training on a voluntary basis and were compensated with a $20 dollar gift certificate. eighty-three percent of staff in the selected unit completed the training. staff members serving as the control condition (n = 31) were taken from a separate unit within the same retirement community. due to facility concerns over the privacy of the staff, specific demographic data were not collected. in general, the majority of staff that completed the training was certified nursing assistants (81% cnas), predominantly young adult to middle aged (staff age data not collected), caucasian (92%), and female (92%). residents. all nursing home residents in the selected treatment and control units of the facility were eligible to participate. of the total number of residents in the selected units, 83 (51%) agreed to participate. the resident attrition rate during the five months of the study was 18.75% for the treatment unit and 17.14% for the control unit, leaving data from 39 residents in the treatment unit, and 29 residents in the control unit in the final analyses (n = 68). the two nursing home units were chosen on the basis of similarities in size, level of care, and resident demographics. no significant differences were found between baseline age, gender composition, or mental status (see table 1). after an in-person briefing on informed consent, each resident was given a short quiz to ensure he or she understood the costs and benefits of participation and that withdrawal could occur at anytime without penalty. for their participation, residents received $2 each time they completed the questionnaires. e lderspeak intervention the elderspeak in-service training created for this study had a firm basis in the empirically supported theory of reasoned action (tra; fishbein & ajzen, 1975). the components of behavioral change: 1) intent, with a goal of 2) attitude, with a goal of fostering a positive attitude bradford & end     16   toward the topic and recommendations provided by the training; and 3) subjective norms, that is, creating an atmosphere in the unit that recognized elderspeak as an undesirable speech accommodation. since knowledge gain has also previously been identified as a salient factor contributing to the actual behavior change of nursing home staff (francke et al., 1995; kiener & hentschel, 1989), it was also assessed. the intervention was conducted by the primary author (graduate student) during a single 90-minute classroom session, offered at either the end of the day shift or prior to the start of the afternoon shift. the objective of the intervention was to assist the nursing home staff in becoming aware of elderspeak, identify the characteristic features of elderspeak, and foster an understanding of how patronizing communication can impair communication and negatively affect the well-being of older adults. in-class exercises included outlining the characteristics of elderspeak, distinguishing elderspeak from neutral speech, and viewing and critiquing written and video vignettes individually and as a group. short video segments allowed staff participants the opportunity to identify features of elderspeak and affirming communication in videotaped vignettes. program evaluation applied knowledge. knowledge gained from the intervention was measured using the procedure outlined by williams (2001). at the start of the program, staff participants observed a short videotaped nursing home interaction and then rated the video using the communication evaluation tool (williams, 2001). the original tool was modified to consist of two items asking staff to describe the effectiveness and appropriateness of the interaction on a five-point scale, and eight items asking them to identify the presence or absence of specific same form to rate the videotaped interaction again. pre-test and post-test ratings for each item were compared to assess the effectiveness of the intervention in increasing staff knowledge of elderspeak. attitude and intention to change behavior . the affective learning scale (als; andersen, 1979). the als is a 20-item measure asking staff participants to rate their attitudes towards the intervention content and subject matter. this scale attempts to capture both the attitude towards the training, and the attitude towards the behavioral -point likert-scale along a bipolar continuum with endpoints such as valuable or worthless. scores on the als range from 20 to 140, where a higher number indicates greater behavioral commitment and positive attitude toward the training. internal consistency reliability for the current study was high (alpha = .94). behavioral changes. concealed naturalistic observation was used to evaluate if staff members reduced their use of elderspeak. two trained research assistants (ra), who were blind to both the treatment and control conditions, completed the observations. prior to the inservice program, each ra observed 15 unique interactions between staff and residents occurring in the common areas of the nursing home units. a total of 30 observations were coded for each group of staff (treatment and control). an interaction was operationally defined as the complete verbalizations of the staff member from the beginning to end of the exchange with the resident. all observations took place in the shared public spaces of each unit where any visiting public could potentially overhear the interaction. with irb and facility approval, staff members were unaware their interactions were observed and coded until completion of the study. the same procedure was followed for three-week posttraining observations, and three-month follow-up. each observed interaction was rated on a seven-item checklist. research assistants indicated whether they observed specific communication behaviors in the interactions including baby talk, high pitch voice, shortened sentences, diminutives, over inclusive pronouns, and tag questions. table 1 description of residents (n = 68) resident demographics trained unit (n = 39) control unit (n = 29) p-value age m(sd) 84.87(8.44) 84.21(6.58) .73 sex male 9 10 .30 female 30 19 ethnicity caucasian 37 29 .21 other 2 0 mental status m(sd) 4.01(1.77) 4.48(1.45) .35 elderspeak in-service training   17 if any of the six psycholinguistic features were observed in the interaction, the entire interaction was counted as a -rater reliability estimates were obtained on a sample of 15 staff resident interactions for each of the coded psycholinguistic features interpretation for categorical data developed by landis and koch (1977) was used to interpret the coefficients. the inter-rater reliability for global elderspeak was found to be high, kappa = 1.00 (p < 0.001), with 100% agreement. inter-rater reliability estimates for each of the individual psycholinguistic features ranged from kappa = 0.29 to 1.00 agreement for shortened sentences. resident m easures communication satisfaction. feelings of understanding /misunderstanding scale. (fum; cahn & shulman, 1984). the fum is a 16-item measure on a 5point likert-scale ranging from never to always representing the degree to which each adjective reflects how a person felt after attempting to communicate with a specific target. the fum includes eight adjectives to measure the perception of being understood and eight adjectives to measure feelings of being misunderstood. a levance to the current study. a composite score was calculated with a range from -32 to +32, where higher scores indicate a greater degree of perceived understanding. a high degree of internal consistency reliability was found in the current study (alpha = .89). self-esteem. the rosenberg self-esteem scale state version (rosenberg, 1989). this 10-item measure asks participants to indicate their degree of agreement on a 4point scale where higher scores indicate higher self-esteem. this instrument has been used widely in the literature and has a high reliability, and correlates with a number of selfesteem related constructs. internal consistency reliability for the current study was good (alpha = .81). w ell-being. mental health inventory 5 (mhi-5; veit & ware, 1983). the mhi-5 is a 5-item measure of psychological well-being that requires participants to respond to questions regarding the frequency of their the time were you a happy per -point scale. to increase clarity and ease of use for the residents and for the measure to correspond with the other dependent measures, item scoring was reversed so that it ranged from 1 (none of the time) to 6 (all of the time). higher scores indicate the experience of psychological well-being and the absence of psychological distress. this scale has well-established reliability and validity (berwick et al., 1991). internal consistency reliability for the current study was good (alpha = .84) with a test-retest reliability over a three-month period in the control group of 0.73. baseline mental status. six-item screener (sis, callahan, unverzagt, hui, perkins, & hendrie, 2002). the sis, a brief six-item screener, was used to compare the mental status of the resident groups. it is composed of three orientation items (year, month, and day) and a three-item word recall task. scores range from zero to six where lower scores are suggestive of greater cognitive impairment. procedure pretraining stage. after receiving a brief explanation of the study and providing consent, residents in both the intervention and control units completed a demographics sheet, a short mental status exam (sis), along with baseline outcome measures of communication satisfaction (fum), self-esteem (rosenberg self-esteem scale), and well-being (mhi-5). all questionnaires were read to the participating interested in studying communication between residents and staff in longunit staff would be completing any type of communication training. trained research assistants, also blind to the study   table  2     proportion  of  staff  identifying  elderspeak  characteristics  in  a  scripted  video  interaction   elderspeak  features   pre-­training  proportion   post-­training  proportion   p-­value   baby  talk   75%   100%   .008*   shortened  sentences     46%   79%   .039*   overinclusive  pronouns   54%   83%   .022*   terms  of  endearment   96%   100%   .50   use  of  high  pitch  voice   100%   100%   1.00   note.  to  assess  knowledge  gain,  staff  members  were  asked  to  identify  listed  features  while  viewing  a  scripted  eldespeak  video.   *mcnemar  binomial  test  indicates  significant  difference  in  pre-­  and  post-­training  proportion  at  p  <  .05.     bradford & end     18   hypotheses, conducted the pre-training field observations a week prior to the start of the in-service training. posttraining stage. after staff members completed the in-service training, the residents completed the measures of self-esteem, well-being and communication satisfaction within three weeks of the conclusion of the training, and again at a three month follow up to assess for change over time. research assistants began the first posttraining field observation three weeks following the training, and performed field observations again at a three month follow-up. results staff k nowledge gain and ability to identify e lderspeak in v ideos (hypothesis one) in order to examine if the training significantly increased the staff members ability to identify elderspeak in videos, a paired sample t-test was used to compare the staff and post-interval data on two items from the training (m = 4.17, sd = 1.77) was significantly reduced post-training (m = 3.20, sd = 1.70), t(24) = 2.83, p < 0.01. further, the preof elderspeak (m = 2.33, sd = 1.89) was also significantly reduced post-training (m = 1.75, sd = 1.36), t(24) = 2.07, p < 0.05. to assess knowledge gain, mcnemar proportions tests were conducted on each of the dichotomous pre-test and post-test responses of the communication evaluation tool (williams, 2003). results indicated that post training, staff members significantly improved in their ability to identify several key features of elderspeak in videos including baby talk, overinclusive pronouns, and shortened sentences (see table 2). staff a ttitude toward t raining (hypothesis two) to determine whether nursing home staff trained in the intervention had a positive commitment and attitude toward the training, a one-sample t-test was used to compare the sample mean to the midpoint score (80) on the affective learning scale. the one-sample t test indicated that the training group had a positive attitude toward the training (m = 130.25, sd = 12.91), t(23) = 19.06, p < .001. staff reduction of e lderspeak to compare the proportion of elderspeak observed in staff-resident interactions after completion of the training with the proportion of elderspeak observed in staff-resident interactions before the training (hypothesis three), twosample chi-square tests were performed on the observational data. the proportion of elderspeak features observed out of 30 interactions for the trained staff group is reported in table 3. results of the analysis indicated that the proportion of observed interactions containing significantly reduced between the baseline and the time 1 post-training observations, 2 (1, n = 60) = 4.34, p < .05 and baseline and time 2 post-training observations, 2 (1, n = 60) = 4.34, p < .05. two-sample chi-square tests were also used to evaluate whether there were differences between the trained group and control group in the proportion of elderspeak over time (hypothesis four). while the proportions of many of the table 3 percentage of interactions containing elderspeak characteristics for trained and untrained staff. trained staff untrained staff features baseline time 1 time 2 baseline time 1 time 2 elderspeak (global)a 57% (17)a 30% (9)b 30% (6) b 53% (16) 47% (14) 46% (13) shortened sentences 13% (4) a 0% (0) b 0% (0) b 13% (4) 13% (4) 6% (2) baby talk 7% (2) 3% (1) 0% (0) 10% (3) 17% (5) 13% (4) terms of endearment 20% (6) a 13% (4) a 0% (0) b 7% (2) 10% (3) 10% (3) overinclusive pronouns 17% (5) a 3% (1) a b 0% (0) b 20% (6) a 13% (4) a b 3% (1) b tag questions 13% (4) 3% (1) 6% (2) 0% (0) 7% (2) 3% (1) high pitch voice 33% (10) a 10% (3) b 13% (4) a b 33% (10) 23% (7) 27% (8) note. values indicate the percentage of times the elderspeak marker was observed across 30 interactions. values in parentheses are the actual number of times the elderspeak characteristic was observed. percentages in the same row and under the same group heading (trained or untrained) that do not share the same subscript are statistically different at p <.05. a elderspeak (global) was coded when staff used any of the target features of elderspeak in an interaction in addition to the specific feature. elderspeak in-service training   19 control condition at time 1 and time 2, results indicated these differences were not significant. resident outcome variables to determine whether there was an impact of the elderspeak training on resident outcomes (hypotheses five and six), specifically, well-being, self-esteem, and communication satisfaction, a 2x3 repeated measures (baseline, post-training time 1, or post-training time 2),, while the dependent variables were the total scores of the self-esteem, communication satisfaction, and well-being scales. the mean and standard deviation of each outcome variable for each group are presented in table 4. results of the manova indicted a significant within-subjects main f(6, 61) = 3.50, p < .001, multivariate 2 = .26; a significant between-subjects main f(3, 64) = 2.77, p < .05, multivariate 2 = .12; and a significant time x group f(6, 61) = 5.82, p < .05, multivariate 2 = .36. the time x group interaction effect was analyzed using two-way (2x3) mixed anova for each dependent variable. all follow-ups were adjusted using the bonferroni correction. inferential statistics were only reported for tests yielding significant results. for communication satisfaction, a significant interaction was observed between group and time (f(2, 132) = 11.62, p < .001, partial 2 = .08), along with significant main effects for both group (f(1, 66) = 8.93, p < .01, partial 2 = .11) and time (f(2, 132) = 5.89, p < .01, partial 2 = .08). the simple main effect for group indicated that the treatment significantly differed at post-training time 1 (f(1, 66) = 17.41, p < .001, partial 2 = .21) and post-training time 2 (f(1, 66) = 13.44, p < .001, partial 2 = .17), and did not differ significantly at baseline. the simple main effect of time was significant for only the treatment group (f(2, 65) = 17.41, p < .001, partial 2 = .21). simple comparisons satisfaction over time indicated a significant increase in communication satisfaction from baseline to time 1 (p < .001) and baseline to time 2 (p < .001). following the same procedure for self-esteem, there was a significant interaction between group and time (f(2, 132) = 7.97, p 2 = .11), and a significant main effect for time (f(2, 132) = 4.32, p 2 = .06). the main effect for group was not significant. simple main effects analysis of the interaction indicated that while there were no significant differences between the two groups on self-esteem at baseline or post-training time 1, the treatment group reported significantly higher selfesteem than the control group at post-training time 2 (f(1, 66) = 8.98, p 2 = .12). the simple main effect of time was significant for only the treatment group (f(2, 65) = 9.88, p 2 = .23). simple comparisons examining the treatment group over time indicated a significant increase in self-esteem from baseline to time 1 (p < .005) and baseline to time 2 (p < .001). follow-up analysis for well-being also revealed a significant group x time interaction effect, f(2, 132) = 4.60, p 2 = .07. the main effects for group and time were not significant. simple main effects analysis of the interaction demonstrated no significant differences between the groups at baseline or post-training time 2; however, the treatment group showed significantly higher well-being than the control group at post-training time 1 (f(1, 66) = 8.98, p 2 = .12). the simple main effect of time was significant only for the treatment group (f(2, 65) = 3.65, p 2 = .10) with simple comparisons indicating significant increase in well-being from baseline to time 1 (p <.05). discussion staff improvements consistent with previous research (williams et al., 2003, 2005), the present study indicates that a brief educational intervention can reduce nursing home staff use of elderspeak. following the in-service training, there were significant reductions found in the proportion of interactions coded for the global presence of elderspeak table 4 mean and standard devia tion for the pui, rse , mhi-5 for intervention and control . intervention group residents control group residents dv baseline time 1 time 2 baseline time 1 time 2 communication satisfaction 14.44 (12.01) a 21.90 (9.56) b 20.46 (10.37) b 13.14 (11.3) 12.31 (9.10) 11.41 (9.65) self-esteem 29.31 (4.26) a 31.18 (3.69) b 31.90 (3.61) b 29.69 (5.03) 29.93 (4.82) 29.01 (4.09) well-being 22.41 (5.58) a 24.33 (4.60) b 23.77 (4.65) a 22.83 (21.51) 21.41 (19.15) 22.03 (13.67) note. values in dicate means and (standard deviations). means in the same row and under the same group heading (intervention or control) that do not share the same subscript are statistically different at p < .05. bradford & end     20   with trends toward reductions on many of the specific psycholinguistic features. specifically, significant reductions in the component psycholinguistic features of elderspeak were observed in both the short term (i.e., shortened sentences and high-pitched voice), and long term follow up assessments (i.e., shortened sentences, terms of endearment, and overinclusive pronouns). moreover, the reductions in elderspeak observed immediately in the three weeks following the training program were maintained over of elderspeak did not change significantly over time with only a single psycholinguistic feature indicating a significant reduction (overinclusive pronouns) over the three months of the study. the success of the program in prompting staff members to make behavioral changes is notable, considering the relatively short length of the inservice training (90-minutes) and the limited success of similar communication programs (kruijver et al., 2000). several factors likely contributed to the overall success of the present program. the shorter, focused, single session trainings provided flexibility in which training session staff of time typically dedicated to staff trainings and meetings. additionally, the current training program was anchored in the tra (fishbein & ajzen, 1975), a specific theoretical framework of behavior change. following the training, staff members significantly improved their knowledge and ability to identify characteristics of elderspeak, harbored generally favorable attitudes toward the in-service recommendations, and reported intentions to change their behavior. while the subjective norms component of the tra model was not formally assessed, a gaining strong support from the facility administrators, department directors, and other professionals in leadership positions who attended the trainings alongside the cnas, and ultimately having the training written into the treatment e a buzz word around the trained unit). while results are resoundingly positive, the study had several limitations. as both the trained and the untrained staff members worked within the same facility, this opens the possibility of a contamination effect wherein staff in the control group could have adopted some of the in-service training practices through communication with their coworkers. however, while there was a significant reduction in overinclusive pronouns observed in the untrained staff at time 2, several factors make this constraint less likely: 1) each unit was geographically separate within the facility with its own common areas, dedicated staff, and director of nursing; 2) untrained staff showed no significant difference in their global use of elderspeak over the three months of the study; 3) three of the psycholinguistic features observed in the untrained staff group actually trended toward increased use while all six features in the trained group trended downward; and 4) any speech adjustments the untrained staff might have made did not seem to be reflected on resident outcome measures. while staff members in the trained condition reduced their use of elderspeak across time, the difference in proportions between the trained staff and comparison group did not differ to a statistically significant degree. given the improvements of the residents on the outcome measures following the training though, these findings may have been related to limitations inherent in the method used to code elderspeak. as the trained coders were blind to the conditions (trained unit vs. untrained unit) they were also blind to which individual staff members had participated in the training. while the vast majority, 83% of the treatment unit staff, completed the training, almost a fifth of the treatment staff did not (17%). the inclusion of interactions between residents and staff members that worked regularly in the treatment unit but never attended the in-service training may have masked a larger reduction in elderspeak. an additional limitation is simply coding for the global of the six target psycholinguistic features were observed in the interaction. coding in this manner left the potential to ignore decreases in the use of multiple characteristics of elderspeak during a single interaction. a final limitation of the observation coding method was the relative infrequency of some of the psycholinguistic features such as subjective nature of others (e.g., high pitch tone). as terms occurred with relatively low frequency at baseline, it was difficult to demonstrate that there was a significant reduction across only 30 sampled interactions even though the trained staff no longer used any of these characteristics at time 2. while recordings were not used in the current study due to facility request, video and audio recordings of interactions could have addressed many of the aforementioned limitations; however, one advantage of using the covert naturalistic observations is a reduction in staff member reactivity. resident outcome and improvements previous elderspeak intervention studies have not goal was to address the impact of the intervention on nursing home resident outcomes, specifically communication satisfaction, self-esteem, and well-being. residents of the unit which received the training showed a significant increase in their communication satisfaction as well as small but significant increases in their self-esteem and psychological well-being. these changes corresponded with staff reductions in elderspeak, and were observed three weeks after conclusion of the training, and for communication satisfaction and self-esteem, were maintained at the three-month post assessment. while there were no baseline differences between the resident treatment elderspeak in-service training   21 and comparison groups on the dependent variables, the resident communication satisfaction observed in the treatment group was significantly higher than the comparison group at both post-training assessments. additionally, the treatment group reported significantly higher well-being three weeks after the training, and significantly higher self-esteem than the comparison group three months later. the communication enhancement model (cem; ryan, meredith, mclean, & orange, 1995) posits that better communication in the form of an individualized approach to empowerment, well-being, and satisfaction with care providers. according to the cem, the well-being of older adults is enhanced when their ability to express themselves is maximized. findings from the present study are elderspeak. while there were no significant changes in the correspondi on outcome measures, a significant reduction in staff member use of elderspeak in the trained condition was associated with increases in self-esteem, communication satisfaction, and at least shortly following the training (i.e., 3 weeks), well-being. in short, as the communication environment improved in the trained unit, so too did the it seems plausible that residents improved on these variables because of a reduction in communication that older adults typically find aversive (elderspeak). educating staff members about elderspeak may have disrupted the cycle of the communication predicament model of aging, allowing residents to achieve more neutral or satisfying types of interactions. additionally, prompting staff members to reduce their use of elderspeak may have necessitated that staff rely on alternative methods of communication that actually enhanced communication with the residents. as previously noted, while significant increases were observed in resident communication satisfaction and selfesteem at both the three-week and three-month posttraining assessments, interestingly, significant changes were observed for well-being only in the short term (three weeks later). this may reflect limitations in the mental health inventory five (veit & ware, 1983) which is relatively brief, and not an encompassing measure of well-being. additionally, it may reflect the observations of williams et al. (2005) that while the staff in their study continued to use fewer of the concrete features of elderspeak at the two month mark, their interactions were rated as more controlling, less respectful, and less caring than immediately following the training. this suggests that changing specific speech behaviors may be only one part of the equation in teaching nursing staff to interact consistently in a way that will convey respect and foster well-being for older adults. m ethodological l imitations while the present study replicated and extended existing elderspeak research, it is important to acknowledge the limitations of the findings. it should be noted that the resident participants of the study resided in a single large long term care facility, and therefore the nursing home environment and the residents themselves may not be representative of the larger population. the present study also employed a quasi-experimental design, as random assignment was not possible. while the use of both a pretest and a comparison group makes it easier to avoid certain threats to internal validity, because the two groups were not randomly assigned, selection bias may have been present. in addition, while it is notable that there were no significant differences between the two conditions in age, gender, and mental status, data on a number of other potentially important resident characteristics were not collected for comparison. further, while the study outcomes varied statistically with the intervention the observed changes in resident satisfaction and self-concept may be the result of alternative explanations. one alternative is that simply offering training to one group of staff and not to the other could have led to changes in the satisfaction benefits in the residents (mayo, 1933). another limitation of the study was the relatively small sample size, with only 51% of eligible residents agreeing to participate, and the high attrition rate (18%) of residents who participated in the study. this opens the possibility of selection or attrition bias. further, the turnover rate for the trained staff was not available, which may be an important factor with regard to the long-term benefits of the training, especially when considering the national annual turnover rate for cnas has been previously reported at 71% (aahsa, 2008). as a result of turnover, efforts to create a better communication environment for residents may have start at the level of initial care provider training, such as including discussions of elderspeak in cna training programs, and be revisited through facility in-services posttraining. directions for future research replication of these results is necessary to increase y of the cpa model. future studies may consider including additional resident outcome measures that correspond to the predictions of the communication enhancement model self-efficacy, and feelings related to the quality of interactions and competence of the staff. qualitative interviews may also provide insight into how explicitly aware residents are of staff behavioral changes. as research indicates that staff elderspeak use is associated with increases in residents disruptive behaviors (cunningham & williams, 2007), future elderspeak bradford & end     22   benefits of their effectiveness and work related stress following the training. additionally, while manova analysis makes it possible to observe a variety of main effects and interactions, it does not allow for as strong assertions of causality as a regression model which controls for confounding variables. future research may benefit from using a more complex model with regression analysis. overall, the training program described in this study indicated that nursing home staff can improve their style of communication to promote resident quality of life. it is hoped that future research will validate these findings and continue to underscore the potentially negative effects of elderspeak have for nursing home residents. references berwick, d., murphy, j., goldman, p., ware, j., barsky, a., & weinstein, m. 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(2005). enhancing communication with older adults: overcoming elderspeak. journal of psychosocial nursing, 43, 2-6.   graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 95 prescription privileges and the ethics code: a modern look into the right to prescribe among applied psychologists gavin ryan shafron california school of professional psychology, san francisco the primary distinguishing element between the practice of clinical psychiatry and applied psychology is the right to prescribe psychotropic medications for psychiatrists and the absence of that right for applied psychologists (clinical or counseling psychologists holding either ph.d, psy.d, or ed.d degrees) (andrews, 2011). since 1995, the american psychological association has made it official policy to pursue such rights for those holding doctoral degrees in applied psychology (ph.ds, psy.ds and ed.ds), much to the resistance of their colleagues in psychiatry (johnson, hay, murray, lucas & tompkins, 2012; martin, 1995). this paper assesses the history and current state of affairs of the debate to further psychologists’ right to prescribe through a review of current literature, utilizing the ethical principles of psychologists and code of conduct of the american psychological association (apa, 2002). this paper adds to the debate as to whether psychologists’ prescription privileges, without the full training in medicine afforded to psychiatrists, falls within a psychologists’ scope of practice. it is argued that, with the current state of policy and training for prescription privileges, the risks appear to outweigh the gains. steps can be taken to ensure proper doctoral training, and continuing education in order for prescription privileges to be viable for applied psychologists. several important considerations reviewed herein must be addressed before such training could be ethically feasible. prescription privileges and the ethics code: a modern look into the right to prescribe among applied psychologists the primary distinguishing factor between the applied practices of professional psychology and psychiatry is the right of psychiatrists to prescribe psychotropic medications (denelsky, 1996; hale, 1995). psychotherapeutic interventions, once practiced primarily by psychiatrists, have now become the domain of applied psychology (denelsky, 1996; hale, 1995), and the practice of psychiatry primarily emphasizes the prescription of medication for the treatment of mental illnesses (andrews, 2011). the two professions are academically distinct, with psychologists earning professional doctorates including the doctor of philosophy in psychology (ph.d), doctor of psychology (psy.d), and doctor of education in psychology (ed.d), all of which focus on research and/or clinical training. psychiatrists, conversely, hold a doctorate in medicine (m.d.), receiving broad-based medical training before completing a psychiatric residency (andrews, 2011; back, book, santos & brady, 2011; stricker, 1975). yet another difference is the salary disparity between applied psychology and psychiatry. though psychiatrists still often out-earn applied psychologists, the field of psychiatry earns comparatively less than all other specialties of medicine. as a result, newly trained medical professionals have chosen psychiatric residencies in greatly diminished numbers in recent years, likely due to the dramatic pay disparity between psychiatry and other m.d. specialties. (andrews, 2011; back, book, santos & brady, 2011; smith, 2012; murray, 2003). this has expanded the debate as to whether prescription privileges, complicated by the comparatively short psychological training which psychiatrists receive in comparison to applied psychologists, should be granted to the increasing numbers of applied psychologists (andrews, 2011; back, book, santos & brady, 2011; murray, 2003). for the purposes of this article, prescription privileges, the right to prescribe, and rxp (rx connoting prescription, and p, connoting privileges) will be used interchangeably. history of prescription privileges in the united states in response to the dwindling numbers of new psychiatrists, the american psychological association (apa) has advocated for the right of psychologists to prescribe psychotropic medications with appropriate preor post-doctoral training and certification (johnson, hay, murray, lucas & tompkins, 2012; martin, 1995). the apa has maintained this correspondence concerning this article should be addressed to gavin ryan shafron, clinical psychology ph.d. program, california school of professional psychology, san francisco. one beach street, suite 100. san francisco, ca 94133-1221. email address: gshafron@alliant.edu. graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 96 stance for the past 18 years, making the pursuit of prescription privileges part of its official policy since 1995 (johnson et al., 2012; martin, 1995). however, this campaign for rxp has been consistently countered by lobbying groups made up of physicians and psychiatrists arguing against such a privilege. the groups have cited numerous issues, the most pertinent of which is a lack of psychologists’ competency to prescribe medications (denelsky, 1996; faust, 2011). the apa ethical standard 2.01 specifically forbids practicing outside one’s “scope-of-practice,” and yet the apa advocates the advancement of psychologists’ right to prescribe (apa, 2002, pg. 4; johnson et al., 2012; martin, 1995). therefore, the main questions of this issue are as follows: does the apa’s promotion of rxp represent a fundamental contradiction in policy given the stipulations set forth in apa’s ethics code? is there such a thing as ‘enough’ training for psychologists to engage in psychopharmacological interventions? are preor-post-doctoral certifications sufficient in the absence of the pharmacological training that is afforded to psychiatrists? further, does this debate reflect the conflicting interests of psychiatry and advancing applied psychology, as psychiatric practitioners see their cohort shrinking and their standing in the mental health field challenged? these will be the questions addressed in this review through an analysis of the current state of the debate, considered within the context of apa’s ethical principles of psychologists and code of ethics (referred to herein as the apa ethics code). the first administrative agency to grant prescription rights to psychologists was the department of defense in 1998 (dittman, 2003). this trial program was designed to test the effectiveness of training of rxp and to make up for the dearth of psychiatric providers in the military (dittman, 2003). this (now terminated) training program is said to have established the proficiency of psychologists as psychopharmacologically trained prescribers (dittman, 2003). further recognizing the proficiency of rxp among psychologists, the u.s. military and indian health service both grant rxp to psychologists with appropriate training (cullen & newman, 1997). since the argument for prescription privileges began, louisiana, new mexico and the territory of guam have all passed laws granting prescription privileges to psychologists. simultaneously, other states struck down majority approval of such laws via gubernatorial veto, whereby the governor of the states blocked voter-approved legislation (faust, 2011). several other states have failed to achieve majority legislative approval. however, mixed legislative results have not prevented advocates from continuing the argument for rxp (faust, 2011). most recently, illinois’ latest bid to legalize rxp for psychologists has failed while ohio’s legislators in support of rxp appear to have no current plan to reintroduce previously rejected legislation (grohol, 2013). the argument for prescription privileges the argument for prescription privileges is grounded in the shortage of psychiatrists entering the profession or already in practice (back, book, santos & brady, 2011; cullen & newman, 1997; martin, 1995). proponents of rxp argue that the reduction of available psychiatrists has made obtaining an appointment with a psychiatrist increasingly difficult, with non-emergency cases often being deferred for weeks or, in some cases, up to nearly a month for appointments (maughan, 2010). furthermore, proponents argue that in rural areas, there may only reside a handful of psychiatrists, rendering new appointments (emergency or otherwise) nearly impossible to obtain. indeed, the strain felt within the field is evident in the increasing number of general practitioners prescribing psychotropic medications outside of their specialty, and potentially outside of their competence (maughan, 2010; mojtabai & olfson, 2011). many within professional psychology argue that the solution to this issue is granting applied psychologists the right to obtain training and legal authority for rxp (martin, 1995). along with the policy of the apa in favor of rxp, several preand post-doctoral training programs have been established at major psychology training institutions, such as alliant international university (aiu, 2012) and fairleigh dickinson university (fdu, 2012). these programs follow the increasingly popular model of integrating psychopharmacological training into clinical and counseling psychology as a post-doctoral master’s program to be followed by applied clinical trainshafron 97 ing (resnick, ax, fagan, & nussbaum, 2011). this model of rxp training is the most prominent of those that have been proposed, whereby only those who engaged in specialized and rigorous coursework would be eligible to administer psychotropic drugs (resnick et al., 2011; smyer et al., 1993). proponents of rxp argue that there is no group of professionals better equipped to prescribe psychotropic medication in the absence of a psychiatrist than applied psychologists (resnick et al., 2011; smyer et al., 1993). this contention is based on psychologists’ preexisting understanding of mental illness thereby (according to this argument) enabling psychologists to provide the best applications for psychotropic treatment. (resnick et al., 2011; smyer et al., 1993). furthermore, proponents envision prescription privileges for applied psychologists as existing within a psychologist’s training model, just as optometrists, podiatrists, and other specialized medical professionals do not have broad-based medical training but are granted limited and highly specialized privileges (smyer et al., 1993). finally, proponents also argue that psychologists are far better equipped to prescribe psychotropic medications than are general medical practitioners, who possess limited understanding of psychology but have become the primary providers of psychotropic drugs as psychiatrists’ numbers have dwindled in recent years (back et al., 2011; cullen & newman, 1997; martin, 1995; resnick et al., 2011; smyer et al., 1993). the argument against prescription privileges opponents of psychologists’ right to prescribe point to a number of factors, including unnecessary risks to patients and additional risks to to the integrity of the practice of professional psychology itself (deleon, bennett, & bricklin, 1997; denelsky, 1996). among the most compelling arguments against prescription privileges is the risk of harm to the patient. physicians are educated in the complex interactions between psychiatric and non-psychiatric medications (denelsky, 1996). opponents of rxp argue that one danger of allowing psychologists prescription privileges is that there is no way to ensure psychologists’ understanding of potentially harmful interactions with patients’ non-psychotropic prescription medications, constituting systemic malpractice (denelsky, 1996; hayes & heiby, 1996). this risk reflects a potential violation of ethical standard 3.04, which states that psychologists are to prevent, avoid, and minimize harm to their patients whenever possible (apa, 2002). it also represents a potential danger to the patient and underscores the possible risks of psychologists with rxp practicing outside their scope of competence (deleon, bennett, & bricklin, 1997; denelsky, 1996; hayes & heiby, 1996). opponents of rxp also argue that the nature of the practice of applied psychology would dramatically change, transforming applied psychologists into lesser-educated psychiatrists and thereby damaging and potentially eliminating the field of clinical psychiatry (denelsky, 1996; moyer, 1995). furthermore, denelsky (1996) suggests that, were psychologists to move increasingly toward prescribing psychotropic medications in lieu of practicing psychotherapy, the resulting gap would put significant pressure on mental health counselors, social workers, and marriage and family therapists to take over primary psychotherapeutic duties. additionally, much in the same way that medicine and psychiatry are dominated by the financial influence of the pharmaceutical industry, some suggest that the field of applied psychology would ultimately succumb to these influences as well if prescription privileges are granted (denelsky, 1996; hayes & heiby, 1996). the fear appears to be that, without the vast knowledge of medication interactions attained by psychiatrists and physicians, psychopharmacologically trained clinicians could be unduly influenced by the marketing tactics of a multi-billion dollar industry, once again reflecting a violation of ethical standard 3.04 (deleon, bennett, & bricklin, 1997; denelsky, 1996; hayes & heiby, 1996). finally, similar to some previous arguments, concerns have been posed regarding how specialty training would take place (bieliauskas, 1992; bütz, 1994; denelsky, 1996; robiner et al., 2002). of particular interest is the question of whether mandates would be imposed at the state level to ensure proper training. further, one wonders whether the addition of such training would be a sufficient pharmacological education. furthermore, would adding a tremendous amount of psychopharmacology classes to alprescription privileges and the ethics code 98 ready rigorous doctoral programs require a sacrifice of core training coursework integral to applied psychology programs? (bieliauskas, 1992a; bütz, 1994; denelsky, 1996; robiner et al., 2002). denelsky (1996) also argues that for any standardized training to occur, numerous programs must be preexisting and established within the field to draw new students. unfortunately, a current reduction in the number of such programs threatens the state of rxp training for psychologists. many programs, such as the post-doctoral master of science in clinical psychopharmacology from the massachusetts school of professional psychology, have closed down due to lack of enrollment (resnick et al., 2011). while the apa policy regarding rxp still stands, investing financially in further education and clinical training after already extensive and rigorous doctoral training may render the rxp specialization prohibitive for many (resnick et al., 2011). it has been argued that legislative policy can only take place once psychopharmacological training has become widespread, which might present a problem if training opportunities continue to be limited (resnick et al., 2011). yet the inverse could also be true; without local laws supporting rxp, it is likely that training programs will continue to struggle to attract and retain students, further endangering the viability of the current training model. beneficence, nonmaleficence, and boundaries of competence principle a of the apa ethics code states that psychologists must “do good,” never risk harm to their patients, and prioritize the rights, welfare, and benefit of the patient and those they encounter both professionally and outside of the professional sphere (apa, 2002, p. 3). this raises the question of whether or not patients benefit from psychologists gaining rxp. if the risks of harmful drug interactions, incorrect prescribing, and poor standards of training are indeed too high, as opponents argue, then rxp would be a violation of principle a. in addition, ethical standard 2.01a states that “psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (apa, 2002, p.4). while those in favor of rxp have outlined a multitude of training options, the consensus within the literature advocating rxp appears to favor a post-doctoral master’s program with a clinical training component focused completely on psychopharmacology, and indeed this appears to be the current dominant training model. (alliant international university, 2012; fairleigh dickenson university 2012; resnick et al., 2011, 2011; smyer et al., 1993). however, in its current form, this format may not be sufficient to ensure competence and thereby reduce the risk of harm when considering potentially dangerous drug interactions between psychotropic and non-psychotropic medications. this is illustrated by the vastly more intensive training both inside and outside of the physiological sphere afforded to psychiatrists. initial rxp training must be sufficient for providers to understand the complex physiological reactions between pharmacological interventions (denelsky, 1996; moyer, 1994). this may require more than the currently outlined post-doctoral training model. moreover, two prominent post-doctoral psychopharmacology programs (aiu, 2012; fdu, 2012) follow a distance-learning model which, given the dangerous nature of drug interactions, may be insufficient to ensure psychologists’ competence (denelsky, 1996; moyer, 1994). this is notable given that no apa-accredited doctoral program allows a predominantly distance-learning approach (clay, 2012). thus, there appears to be a consensus within accreditation bodies that long-distance training is not sufficient for attaining and maintaining necessary clinical knowledge (clay, 2012). this may also be the case with regard to rxp, therefore necessitating a change in the training model. furthermore, insufficient training reflects a violation of ethical standard 2.01, as these programs cannot directly ensure that rxp psychologists are practicing within their boundaries of competence. indeed, ethical standard 7.01 (design of education and training programs) states that psychologists must take steps to ensure that training programs provide the necessary knowledge for competency within their scope of practice (apa, 2002). this is reinforced by apa ethical standard 2.03, which shafron 99 similarly recommends that “psychologists undertake ongoing efforts to develop and maintain their competence” (apa, 2002, p.5). yet, the current framework for rxp training does not maintain any provisions or mandates at the legislative level to achieve pharmacological proficiency (denelsky, 1996). before rxp would be ethically viable, psychologists must be mandated to bolster their rxp proficiency through continuing education, just as they are required to do for ongoing psychotherapeutic proficiency (department of consumer affairs, 2012). yet, the current licensure framework for most states only mandates a number of hours and allows psychologists to choose the form and content of their continuing education, while other states have no continuing education requirements. due to the risks involved with complex drug interactions, continuing education for rxp psychologists must be stringently regulated to ensure the greatest degree of competency in this domain. fidelity, responsibility and standards of care the apa ethics code, principle b, states that psychologists develop a relationship of trust with their patients (apa, 2002). psychologists are instructed to keep the best interests of their patients at the forefront of all of their decisions and to manage any conflicts of interest that could potentially result in the harm of another (apa, 2002). psychologists must ask themselves whether or not it is truly in the best interests of the patient to be pursuing rxp, or whether the pursuit of such privileges is confounded by the desire to add legitimacy and financial profitability to the field of applied psychology. standards of care for clinical practice can be said to relate to the relationship of trust between a psychologist and patient, as appropriate standards of care are necessary to provide assurances to the patient that they are well protected. thus ethical as well as legal considerations to be taken into account seem to be highly interrelated in any argument addressing rxp (shafron & van moorleghem, 2012). the current standard of care for practicing psychologists is the “reasonably prudent professional” convention, meaning that any medical decision should be exercise a reasonable level of caution that an individual of “ordinary prudence” would observe (johnson, 2012; mcway, 2003, p. 45; vaughn v. menlove, 1837 as cited in robinson, 2014, p. 444-445). this convention, however, does not currently specify standards of care pertaining to rxp-licensed psychologists. in the case for rxp, the argument must be expanded to conceptualize the rxp-licensed psychologist as in line with the ‘reasonably prudent psychiatrist’ (johnson, 2009; shafron & van moorleghem, 2012). this conceptualization would require an expanded standard of care from that to which applied psychologists are currently held, given the risks involved with rxp (shafron & van moorleghem, 2012). additional issues could arise if there are multiple standards of care based on different competencies within applied psychology (shafron & van moorleghem, 2012). furthermore, along with doing more to secure the relationship of trust between patient and professional, the added responsibility of rxp requires that psychologists reflect on the same scientific and cultural issues related to pharmacological interventions that psychiatrists must address. these responsibilities include achieving cultural competence. in order for psychologists to earn the relationship of trust outlined in principle b, a psychologist must strive to achieve the utmost cultural competency. cultural considerations the field of applied psychology is increasingly moving toward models emphasizing the understanding of cultural considerations in the application and administration of psychological interventions. for example, many researchers have explored the ways in which cultural background can shape and influence one’s personality and belief system (e.g., bhugra & bhui, 1999). this has been shown to influence patients’ choices of treatment (chapa, 2004), as well as medication compliance (lin, 1996) and even physiological response to medication (bhugra & bhui, 1999; exner et al., 2001). at the level of personality and belief system, it is possible to surmise that some individuals may favor the current model of seeing a medical professional to obtain psychotropic treatment for certain disorders. the possibility of rxp psychologists serving roles prescription privileges and the ethics code 100 traditionally occupied by psychiatrists could be problematic for these individuals, who might be uneasy seeing a psychologist for biomedical concerns. yet the inverse may also be true; individuals who were previously reluctant to see a psychologist for therapy may be more likely to seek psychotherapy as an alternative form of treatment outside of the realm of psychotropic medications if the rxp psychologist becomes a primary source of psychotropic medications. in essence, prescription privileges might serve as a draw for individuals initially seeking psychotropic treatments to become more open to psychotherapy. the rxp psychologist must also be mindful of the physiological effects of medications in different racial and ethnic groups. when reviewing tricyclic antidepressant usage cross-culturally, differences are seen at the physiological level when comparing individuals of asian, indian, and caucasian descent. caucasian individuals have demonstrated lower levels of tricyclic medications within their blood plasma, which has been attributed to differences in rates of hydroxylation between ethnic groups (kilow, 1982). hydroxylation is defined as the introduction of a drug into the body and the process by which it is activated and deactivated (kilow, 1982). additionally, differences have been found between individuals of hispanic descent and other ethnic groups on rates of sensitivity to tricyclic antidepressants (lin, 1995). individuals of hispanic descent have been shown to require lower dosages to achieve the drug’s full effect, but at the same time experience greater side effects while on the reduced dose (lin, 1995). any preor post-doctoral training in rxp must maintain and integrate cross-cultural awareness to the administration of psychotropic drugs. while a review of current literature found no significant differences relating to rxp treatment or outcomes with regard to gender, and lgbtq status, rxp-trained psychologists must still be mindful of potential differences which may exist between these cultural groups. for example, it may be difficult to prescribe medications for very young individuals, as many medications are not approved for those under the age of 18. the rxp psychologist must do more than just understand the basic interactions of psychotropic drugs; there needs to be an overall awareness of any possible contraindications (buelow & chafetz, 1996; shafron & van moorleghem, 2012). conclusion this paper addresses the history of granting prescription privileges to psychologists, followed by a review of arguments for and against rxp within the context of the apa ethics code. the possibility of granting rxp to applied psychologists remains an ongoing debate within the mental health professions. as psychiatry’s numbers diminish due to lack of financial incentive, it is clear that general practitioner m.d.s alone cannot support the overflow of patients who need psychopharmacological treatment, and critics question whether general medical practitioners have the expertise necessary to treat mental disorders. despite the apa’s support of rxp to compensate for the dwindling numbers of practicing psychiatrists, psychologists must only accept such privileges if they can attest that the training afforded to them is fundamentally comparable to the years of pharmacological education provided to psychiatrists. regardless of whether psychologists are permitted only to prescribe psychotropic drugs, their training and continuing education must exceed that of psychotropic medications alone to ensure the well-being of those they treat. such training must also employ the same cultural competencies mandated academically within clinical and counseling psychology, particularly since pharmacological responses have been shown to differ across ethnic groups. striving for patient health, both mentally and physically, must remain central to the field as it moves toward new applications. references alliant international university. 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(1975). on professional schools and professional degrees. american psychologist, 30, 1062-1066. retrieved from http://psycnet.apa. org/psycinfo/1976-24673-001 shafron graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 74 metacognitive therapy for major depressive disorder: development and clinical potential ethan dugas rhode island college adrian wells and colleagues have developed a metacognitive model of psychological dysfunction which shows clinical promise for treating multiple axis i disorders. this paper explores the fundamentals of this model and the self-perpetuating cycle of counterproductive coping behaviors underlying it. several therapeutic techniques that have been designed to interrupt this cycle are described and contrasted with cognitive behavioral therapy (cbt). papageorgiou and wells’ specifications of the general model for rumination and depression are outlined, and empirical tests of a clinical metacognitive model of major depressive disorder (mdd) are described. the metacognitive therapy (mct) treatment package for mdd is summarized. finally, evidence from recent clinical tests that support the effectiveness of mct for treating mdd is discussed. wells’ model appears potent and efficient for reducing anxiety and depression, and his treatment package is a novel approach to combating mdd that should be investigated in further studies. major depressive disorder (mdd) can be particularly difficult to treat when faced with certain treatment-resistant patients.  cognitive behavioral therapy (cbt) and its variants have become first-line psychological treatments for many mood and anxiety disorders, but, when evaluated using the beck depression inventory (bdi; beck, ward, mendelson, mock, & erbaugh, 1961), only 40-58% of depressed patients have been found to recover with such treatment (see e.g., dimidjian et al., 2006; gortner, gollan, dobson, & jacobsen, 1998), and only one-third to one-quarter of patients so treated may remain recovered after 18 months (roth & fonagy, 1996; teasdale et al., 2000; wells, 2009). furthermore, some patients show limited or no response to antidepressant medications (teasdale et al., 2002). british clinician and researcher adrian wells has worked with european colleagues for decades to develop an alternate, informationprocessing model of psychopathology. it is hoped that methods derived from these theories, formalized as the new metacognitive therapy (mct), may provide efficient and efficacious treatment packages for acute and relapse prevention phases of many axis i disorders designated in the dsm-iv-tr, including but not limited to generalized anxiety disorder (gad) and mdd (nordahl, 2009; wells, 2009). metacognition may be conceptualized as an informationprocessing capacity encompassing the monitoring, interpretation, evaluation, and regulation (or control) of mental activities and the contents of consciousness (i.e., thoughts), as well as beliefs about one’s ability to effectively perform these reflective functions (papageorgiou & wells, 2001a; 2003). this paper outlines the development and ethan dugas, b.a., deptartment of psychology, rhode island college, providence, ri. correspondence regarding this article should be addressed to ethan dugas, department of psychology, rhode island college, 600 mt. pleasant ave., providence, ri 02903. email: edugas_5609@email.ric.edu rationale of wells’ metacognitive models as well as core methods designed to address processing deficiencies and counterproductive habits. further, this paper will focus on elaborations of those models to accommodate rumination, and a formulation of mct that specifically targets depression. contrasts with traditional cbt are highlighted, tests of an mdd-specific metacognitive model are reviewed, and recent clinical tests of a formalized treatment package are discussed. in the concluding section, comparisons are made between the mct approach and “third wave” cognitive behavioral therapies which approach cognition similarly but contain more humanistic elements. lastly, implications of the reviewed studies are summarized, and suggestions for further exploration of the efficacy of mct in the treatment of depression are presented. overview of the metacognitive model thoughts and beliefs can be considered actual, direct experiences of the self and the world, perceived via an “object mode” (wells, 2009). however, wells (2009) posits that there is also a “metacognitive mode,” wherein thoughts are experienced as separate from the self and the world, as if observed from a detached perspective. as such, mct is designed to act on the process of thinking and how thoughts are experienced, rather than on challenging the content or accuracy of thoughts as cbt might (wells, 2009; wells et al., 2009). the theoretical underpinnings of mct lie in wells and matthews’ self-regulatory executive function model of psychological disorders (s-ref; 1996). in this schema, cognitive processes operate on three levels, working from the top down to maintain or exacerbate emotional disturbances. a meta-system, possessing its own model of cognitive processing alongside metacognitive knowledge and beliefs that reside in long-term memory, controls and is monitored by a particular “cognitive style” of conscious thought and dugas 75 behavior processing. this style, in turn, biases more automatic, low-level processing, which feeds back into it. a “toxic thinking style” that wells (2009) refers to as the cognitive attentional syndrome (cas) perpetuates disorder through worry and/or rumination, excessive threatmonitoring, and counterproductive coping behaviors (such as avoidance). the cas is maintained by positive meta-beliefs about its components (e.g., “if i contemplate reasons for my negative mood i can find answers”) as well as negative beliefs (e.g., “controlling worry or rumination is impossible”). a typical “a-b-c” model typically espoused by cbt might posit that activating triggers, (a), lead to schemas or belief manifestations, (b), which lead in turn to affective and behavioral consequences, (c). mct adds metabeliefs and the cas to step b, in an “a-m(b)-c” formulation. for example, the trigger (a) of being alone might lead to affective responses (c) of sadness and hopelessness. however, an intervening belief (b) that “things won’t change” may be mediated by metacognitive beliefs (m), such as the belief that rumination is necessary for change, or that emotions must be directly addressed to motivate improvement (wells, 2009). these meta-beliefs, then, serve to discourage more adaptive ways of coping and so unhelpful beliefs are reinforced, in a perseverative loop. to overcome the perseverative effects of the cas, clinicians must work to direct patients into a metacognitive mode of thinking, facilitating improved executive control and cognitive flexibility in order to interrupt and replace detrimental processing habits. major techniques associated with the model one early strategy developed to “unlock” patients from their maladaptive thinking styles was the attention training technique (att; papageorgiou & wells, 2000; wells, 2009). the goal of the technique is to aid anxious or depressed patients in establishing executive flexibility and disengaging from unhealthy levels of self-focused attention. administration consists of explaining the purpose to the patient, and then practicing five minutes of selective attention, five minutes of rapid attention switching, and a brief (1-2 minutes) period of divided attention. the patient is asked to focus exclusively on one of several sounds within the room, beyond the room, or in spatial locations behind, in front, or to the side; to quickly alternate focus; or to try to take in all sounds at once, respectively. in-session practice should continue, but patients are expected to practice alone at least once a day. a key aspect lies in proper understanding – att should not be used as a coping behavior to eliminate negative thoughts. instead, thoughts are not to be resisted during the procedure, but treated as additional “noises” in the mind (wells, 2009). this last concept is a core component of another major metacognitive strategy, detached mindfulness (dm; wells, 2005). in the dm state, a patient is mindful or aware of “cognitive events” without locking attention onto any in particular. this is reminiscent of, but distinct from, the buddhism-derived “mindfulness” practice espoused by thich nhat hanh, jon kabat-zinn, and adherents, which has been described as the nonjudgmental recognition of present thoughts, feelings, or sensations, with focus on increased attention to and acceptance of immediate experience (bishop et al., 2004; see also hanh, 1999; ludwig & kabat-zinn, 2008). critically, during dm, a detached perspective precludes any conceptual or behavioral engagement with thoughts, beliefs, memories, or feelings. furthermore, these mental events are observed from a separated point of view, by imagining a “self” within the mind separate from one’s cognitions and consciousness. this realization of a metacognitive mode of thinking can facilitate more flexible attention. moreover, it supplants the cognitive style of the cas, which consists of self-focused attention and high incidence of conceptual processing and coping behaviors, with little meta-awareness of thoughts as separate entities from the self or reality. indeed, one method of facilitating this mode with patients involves asking them to conjure a mental image of a tiger, allowing it to move freely about the mental landscape while observing its behavior, as a metaphor for negative thoughts. thoughts might also be conceptualized as transient events—mere clouds passing through the mind. patients are asked to try to implement dm on their own whenever they notice a negative thought, in attempt to derail the cas and prevent the triggering of unhelpful beliefs and responses (wells, 2009). in this way, att and dm work in concert to establish flexible attentional control, and to eliminate pathological processing of everyday inputs and resultant thoughts, without working to eliminate the thoughts themselves. specification of the metacognitive model for depression building on these foundational models and techniques, which have been tested in varying forms for many disorders including gad (wells & king, 2006; wells et al., 2010), posttraumatic stress disorder (wells & colbear, 2012; wells et al., 2008), and obsessive compulsive disorder (fisher & wells, 2008; rees & van koesveld, 2008), papageorgiou and wells (2003; 2009) set about devising and testing a clinical metacognitive model specified for depression. the critical feature of the cas in mdd is rumination, which consists of cycling thoughts that revolve around particular themes. these thoughts, such as the repeated, negative pondering of personal problems or self-worth, may be difficult to disrupt (smith & alloy, 2009). while worry has also been associated with many individual manifestations of depression, it is generally considered to be futureor anticipation-oriented (e.g., “what if i never emerge from depression?”). depressive rumination dwells on finding explanations for past behavior or present circumstances (“why am i so abnormal?”), which may in turn generate worry about coping or surviving in the future (wells, 2009). papageorgiou and wells (2001a) employed a semistructured interview (derived from a metacognitive profiling interview; wells & matthews, 1994) to investigate metacognitive therapy for major depressive disorder 76 metacognitive beliefs in a sample of 14 patients, who were diagnosed with recurrent mdd without axis 1 comorbidity using the structured clinical interview for dsm-iv axis i disorders—patient edition (scid-i/p; first, spitzer, gibbon, & williams, 1997). depressive symptoms, as assessed by the bdi, were at the moderate-to-severe end of the scale (m = 31.7, sd = 8.9, range = 21-50). all participants reported having ruminated within a few days of the interview, when asked to “think about the most recent time in which you felt particularly depressed and you were ruminating” (p. 161). the authors found that all participants endorsed positive beliefs about the necessity or usefulness of rumination, as well as negative beliefs that rumination is either uncontrollable and self-destructive, or has serious interpersonal and social consequences. these negative beliefs were in line with the general s-ref architecture of cas activation and maintenance through perseverative negative thinking. therefore, therapy based on a specified mdd model could target these belief categories directly to break the cycle. to elaborate, a positive belief such as “i must ruminate about the past to make sense of it” might trigger the selection of rumination as a coping strategy, which, upon failure to help, may produce negative thoughts such as, “ruminating is a sign of weakness.” this, in turn, may serve to deepen the ruminative state. an external trigger such as a verbal insult (e.g., “you’re a moron”) could result in positive metacognitive beliefs about rumination (e.g., “if i think about it, maybe i can be smarter”), followed by a ruminative cascade (e.g., “how could i have seemed less dumb all those times? why am i so stupid?”). in addition, negative beliefs about rumination (e.g., “i’ll always be useless and can’t think myself smarter”) can add more fuel to the depressogenic cas. in this way, the input, mediated by metacognitive beliefs and rumination, leads to such cognitive beliefs as “i’m stupid,” or “i’m worthless.” these beliefs then elicit affective responses of sadness or hopelessness, and may generate counterproductive behaviors in the future, such as avoiding schoolwork or social interaction, which can perpetuate the cycle (papageorgiou & wells, 2004; wells, 2009). formal tests of model fit papageorgiou and wells (2003) conducted two studies to test the fit of this metacognitive model of rumination and depression. in study 1, 200 adults diagnosed with mdd using the inventory to diagnose depression (idd; zimmerman, coryell, corenthal, & wilson, 1986) completed the ruminative response scale (rrs; nolen-hoeksema & morrow, 1991; roelofs et al., 2009). participants also completed wells and colleagues’ positive beliefs about rumination scale (pbrs; papageorgiou & wells, 2001b; watkins & moulds, 2005), the negative beliefs about rumination scale (split into uncontrollability/harm [nbrs1] and interpersonal/social [nbrs2] subscales; roelofs, huibers, peeters, arntz, & van os, 2008), and a section of the metacognitions questionnaire (mcq; cartwright-hatton & wells, 1997) concerning self-confidence in cognitive functioning. structural equation modeling supported paths from the pbrs to the rrs, which then passed through the nbrs1 and nbrs2 in two paths to reach the idd scores. in other words, positive beliefs about rumination were cross-sectionally linked to ruminative tendencies, which were then related to depression level through the mediation of negative beliefs about rumination. cognitive confidence (as measured by the mcq) was proposed to be a depressogenic byproduct, feeding back into the model to reinforce both negative beliefs about rumination’s interpersonal and social consequences and positive beliefs about its value, as part of a vicious cycle. for example, depression can lead to the metacognitive belief, “my memory is not very reliable,” which could support the negative belief, “my friends and family won’t think i am reliable if i continue to ruminate about my past,” and the positive belief, “i have to keep ruminating to sort my head out.” however, it was unclear if this variable added anything substantive to the model, as a reversal of paths such that pbrs and nbrs2 influenced metacognitive confidence was required to achieve a good model fit, which was not significantly better than a model lacking the mcq variable (δcfi = .01; δχ2(2, n = 200) = 1.4, p > 0.05). papageorgiou and wells (2003) employed the same assessments with a younger, non-clinical sample of 200 psychology students in their study 2. however, the best model fit differed from that in study 1, with a direct path from rumination to depression and no indirect path through negative beliefs about the uncontrollability or harm of rumination, possibly reflecting less impaired metacognition. further, cognitive confidence was only non-significantly influenced by pbrs and nbrs2, with no influence from depression level itself, presumably because of the lower overall levels of depression in the sample. to better assess causality, papageorgiou and wells (2009) conducted a prospective test of the metacognitive model in a nonclinical sample of 164 students (133 female). participants completed the idd, rrs, and nbrs (subscales 1 and 2), and then completed the idd again 12 weeks later. idd scores at time 2 were dichotomized into nondepressed (59.1%) and borderline-depressed (40.9%) categories (see zimmerman et al., 1986 for symptom severity classification). hierarchical logistic regression showed that, when added to the model in step 1, idd at time 1 was a significant predictor of depression severity, correctly classifying 72% of participants into one or the other category and accounting for 17-22% of the variance in idd scores at time 2. the addition of rrs scores in step 2 improved variance estimates to 21-28%, but did not improve classification accuracy. subsequent addition of nbrs1 and nbrs2 scores resulted in 73.8% correct classification and accounted for 24-32% of idd score variance. importantly, only idd at time 1 and nbrs1 were significant predictors of idd severity at time 2 when controlling for other factors. though rrs score approached significance as a predictor, when nbrs1 and nbrs2 scores were added in step 2 in a second analysis, and dugas 77 rrs scores were added as step 3, there was no significant improvement in the model. this suggests that effects of rumination on depression may be attributable to variance shared with negative beliefs about rumination, particularly about to its uncontrollability and harmfulness. while the results did generally support the clinical metacognitive model, and suggested that metacognitive beliefs predict depression level in a way that could be consistent with causation, further work must be done to determine whether the same results are obtained with a clinical sample and a longer retest interval (see also roelofs et al., 2007; yilmaz, gençöz, & wells, 2011). implementation of the mct treatment package for mdd to support further empirical testing and clinical studies, wells (2009) formalized metacognitive therapy for mdd based on the aforementioned techniques and models and presented a treatment manual. first, a patient’s case is conceptualized using, primarily, the major depressive disorder scale (mdd-s), which provides insight into positive and negative metacognitive beliefs and maladaptive behaviors used to cope with depressed mood. the patient is interviewed and a case-specific model of meta-beliefs, ruminative behavior, and depressive responses is generated. the patient is then presented with the rationale for rumination being a counterproductive coping behavior and is introduced to the att as a method of improving awareness and control of ruminative processes. homework is also assigned. detached mindfulness is then presented and demonstrated, along with the suggestion of “rumination postponement.” this entails recognizing when rumination is being triggered, and actively deciding to put it off until a specific time later in the day (rather than attempting to suppress it directly). next, negative beliefs about the uncontrollability and social stigma of rumination are challenged by showing that rumination is interrupted (i.e., controlled) when attention is directed away from the self, and that it is not abnormal to experience fluctuations in mood or energy level. positive beliefs are then tackled by investigating whether rumination actually helps, or in fact makes things worse (i.e., a costbenefit analysis). reasoning intended to reinforce the disadvantages of rumination is used to help eliminate maladaptive threat-monitoring or coping behaviors, and actively exploring the consequences of an increased activity level is encouraged. then, a summary of case-specific depressogenic triggers and counterproductive responses is presented, and new responses and attentional strategies are developed with the patient’s input to replace them. finally, this plan and summary points from all major steps are collected in a therapy blueprint, and booster sessions are scheduled for 3 and 6 months later. treatment can be completed in 5 to 10 sessions at discretion, or a standardized 8. changes in metacognitive beliefs and attentional control may be monitored throughout. tests of clinical effectiveness an initial study of metacognitive techniques for treating depression examined only the att method. papageorgiou and wells (2000) administered the att to four physicianreferred adult antidepressant-stabilized patients with recurrent mdd (2-4 major depressive episodes; mdes) and no axis i comorbidity, as diagnosed with the scid-i/p. bdi and beck anxiety inventory (bai; beck, epstein, brown, & steer, 1988) measures were administered prior to a no-treatment baseline period that ranged from three to five weeks (depending on patient assignment), before beginning weekly att sessions, and at follow-up periods of 3, 6, and 12 months after treatment concluded. participants also completed the short rrs and the mcq before and after treatment and at follow-up assessments, as well as the automatic thoughts questionnaire (atq; hollon & kendall, 1980) and the private self-consciousness scale (pscs; fenigstein, scheier, & buss, 1975). the treatment rationale was explained to participants at the first session and daily homework practice was assigned. both bdi and bai scores for all patients fell within the normal range for the general population (<10) after 5-8 treatment sessions, with stability observed at 3, 6, and 12-month follow-ups. readministration of the scid-i/p at 12 months showed no axis i diagnoses. stable post-treatment improvements were also attained for all patients on the atq, rrs, pscs, and mcq, although the study design did not allow conclusions to be drawn about whether this was a direct result of att or a byproduct of reduced depressive symptoms. furthermore, self-reported ruminative behaviors and unhelpful metacognitions were consistently reduced and stabilized. while the results were encouraging as to the general efficacy of the att for reducing pathological depression and anxiety, the weak pretest/post-test design and small sample size precluded strong conclusions of causality or generalizability. wells et al. (2009) conducted the first clinical study of a complete mct package targeting depression. participants were four medication-free or stably medicated adults with a scid-i/p diagnosis of a primary mde without borderline personality disorder (bpd), with no current psychological treatment program, and with no cbt during the preceding two years. participants did not exhibit psychosis, medical problems, substance abuse, or suicidality. importantly, participants had histories of recurrent or persistent mdd (three of four suffered from lifelong depression since teenage years) and three of four had shown little response to pharmacological intervention, in line with profiles suggesting poor prognosis for cbt treatment (e.g., coffman, martell, dimidjian, gallop, & hollon, 2007). a trained, supervised therapist delivered 6-8 weekly mct sessions of 45-60 minutes each, according to the treatment guidelines described above. the researchers used a non-concurrent multiple baseline design to improve their ability to convincingly attribute post-treatment improvement to the mct package. participants were randomly assigned to baseline periods ranging from three to seven weeks in duration. the hamilton metacognitive therapy for major depressive disorder 78 rating scale for depression-17 (hrsd-17; hamilton, 1960; 1967) and scid-i/p were administered at pretreatment, posttreatment, and 3and 6-month follow-ups. weekly ratings on the bdi, bai, and a custom measure of rumination were collected. questionnaire packages containing the rrs, pbrs, nbrs, and mcq-30 (a short form of the mcq; wells & cartwright-hatton, 2004) were mailed weekly, and all selfreport measures were completed at follow-ups. participants showed relatively stable bdi scores during the baseline phase, with an average pretreatment score of 24.30 (sd = 5.77), and no longer met criteria for mdd at treatment completion (m = 6.50, sd = 3.87). one participant’s dysthymia and another’s gad also became subclinical by 6-month follow-up. scores on the rrs, pbrs, nbrs, and mcq scales were also substantially reduced, with post-treatment levels maintained at follow-ups, suggesting that mct does affect metacognitive and cognitive-process variables underlying depression. an application of stringent criteria to bdi scores requires that recovered patients should no longer meet diagnostic criteria for depression and should have bdi scores ≤ 8 (frank et al., 1991). if diagnostic criteria are not met but bdi scores are above 8, patients may be considered improved. all participants were improved post-treatment and at follow-ups, with three recovered at post-treatment and 3-month follow-up, and two recovered at 6-month follow-up. hrsd-17 remission criteria require scores ≤ 7 for at least three consecutive weeks, while recovery requires scores ≤ 7 for four months with two-week assessments (rush et al., 2006). adjusting the criteria to the timeline of their study, the authors determined that all four participants were in remission after treatment and at 6-month follow-up, and three of four were in remission at 3-month follow-up. three of four participants showed consistent remission and could be considered recovered. the researchers concluded that the treatment, though relatively brief, was well-tolerated, and achieved high compliance and marked improvements in depressive symptomology, despite the presence of potentially cbt-resistant cases. the very small sample was a clear limitation, but there is room for optimism in planning larger controlled trials for depressed samples with varying circumstances. additionally, multiple therapists would allow for measurement of the influence of skill on treatment outcomes, and adherence to manual guidelines could be more formally assessed. in a promising study, nordahl (2009) compared the efficacy of treatment by a brief mct package to that of cbt. though the author had formal training and fifteen years of experience with cbt, he had no previous experience with mct and proceeded using a generalized formulation of the treatment derived from available literature on attention training (wells, 1990), an early manual for gad treatment (wells, 1997), and a general therapy manual (wells, 2000). participants were 30 patients with varied diagnoses undergoing treatment at a norwegian university outpatient facility. the majority of patients had been stabilized on ssris or snris, and 50% had diagnoses of recurrent mdd, while 42% presented with an anxiety disorder according to international classification of diseases, 10th revision (icd10; world health organization, 1992) criteria. the rationale for the study was that a generalized, cost-effective implementation of mct that targets the trans-diagnostic cas might compare favorably to standard treatment practices in a head-to-head trial, particularly in an unfavorable, heterogeneous clinical setting. as in wells et al. (2009), exclusion criteria included severe bpd, psychosis, serious medical problems, substance abuse, and suicidality. a twogroup betweenand within-subjects pre-post test design was employed, with patients randomly assigned to receive either mct or cbt. measures included the bdi and bai, as well as wells’ anxious thoughts inventory (anti; wells, 1997), which was designed to assess changes in worrying and metaworrying (worrying about the uncontrollability and danger of worrying). because patients resumed standard facility treatment programs following the study, follow-up data could not be collected. mct treatment lasted an average of 7.5 sessions, employing the att, dm practice, worry/rumination postponement, and the challenging of negative and positive beliefs about worrying and ruminating. homework was assigned at each session. cbt followed a similar structure, but averaged 10 sessions and consisted of traditional activity scheduling, identification and challenge of automatic negative thoughts and schemas, and self-monitoring and diary-keeping homework (following beck, emery, & greenberg, 1985, for anxiety; beck, rush, shaw, & emery, 1979, for depression). one-way ancovas controlling for pretreatment measures showed significant differences in posttreatment bai scores between mct and cbt groups (f(1,23) = 4.35, p = .05, η2 = .16), significant differences in anti-assessed metaworry (f(1,23) = 6.20, p = .02, η2 = .21), and non-significant difference in bdi scores. posttreatment uncontrolled cbt effect sizes (cohen’s d) compared equably or favorably with those from a study with a similar patient group treated with cbt (westbrook & kirk, 2005) that was chosen as a benchmark, though all effect sizes were very large, mct effect sizes were higher for both bai scores (d = 2.25 vs. 1.74 for cbt) and bdi scores (d = 1.31 vs. 1.21 for cbt). though this mct package did not show a treatment advantage over cbt in this clinical sample, it performed equally well and outperformed it for anxiety reduction. also, this is despite the fact that an implementation of mct specifically tailored to depression was not used, nor wells’ (2009) recent diagnosis-general formulation. further, it is possible that the meta-worry measured and reduced in this study, or beliefs about worry, may overlap with beliefs about rumination as the two constructs have been shown to be at least somewhat related, and were conceptually combined in the original s-ref model (nolen-hoeksema, 2000; wells, 2009; wells & matthews, 1996). nordahl concluded that mct may provide an efficient and accessible form of transdiagnostic treatment that is potentially favorable to cbt. ratings of treatment adherence and independent diagnostic assessment could strengthen future findings. dugas 79 conclusion in sum, adrian wells and colleagues have developed a robust model of metacognitive and emotional dysfunction, with well-defined components that can be targeted and treated individually to break perseverative cycles of anxiety and depression. disorders such as mdd present a disorderspecific form of cognitive attentional syndrome (cas) that acts as a toxic go-between connecting metacognitive beliefs—which are at the top of the self-regulatory executive function (s-ref) model—with the low-level processing of basic inputs. this syndrome forms the core of a perseverative cycle (wells & matthews, 1996; wells, 2009). dysfunctional metacognitions include positive thoughts about the need to engage in unhelpful coping behaviors such as rumination, and negative thoughts about the consequences of doing so that can increase the behavior’s damage. the attention training technique (att) and detached mindfulness (dm) can be practiced to strengthen executive control and direct one’s attention away from the self, allowing for more effective interruption and delaying of rumination, and for the consideration of thoughts from a detached perspective. in contrast to cbt’s emphasis on content, metacognitive therapy aims to switch patients into a “metacognitive mode” of thinking and challenge their thought processing and attentional fixation. mct targets the rationale behind positive and negative meta-beliefs, as well as threatmonitoring and coping behavior. it may be useful to distinguish mct from several conceptually related approaches to therapy, sometimes popularly designated “third wave” cognitive behavioral therapies, which share a focus on acceptance or a mindfulness concept derived from buddhist traditions, as described earlier (hanh, 1999; see bhanji, 2011, for discussion). like mct, these treatment programs emphasize patients’ interpretations of and reactions to their thoughts, rather than attempting to modify cognitions directly. however, wells considers mct an extension of traditional cbt in that it targets specified psychological mechanisms that perpetuate depressive symptoms (wells et al., 2009). in contrast, mindfulnessbased cognitive therapy (mbct; segal, williams, & teasdale, 2012; see piet & hougaard, 2011, for review) was developed primarily to aid in relapse prevention (see e.g., teasdale et al., 2002). attention to the “present moment” is practiced in mbct to facilitate awareness of self-defeating thinking, and to promote acceptance of transient negative thoughts and disengagement from them before they can induce a depressive episode (scherer-dickson, 2004). the approach of acceptance and commitment therapy (act; luoma, hayes, & walser, 2007; see ruiz, 2010, for review) is a similar one, focusing on the power of language and deemphasizing negative self-judgments (bhanji, 2011). dialectical behavior therapy (dbt; dimeff & koerner, 2007; linehan, 1993) shares similar ideas about cognitions and acceptance, but is more oriented to address emotional dysregulation and behavioral extremes, given its original development as a treatment for bpd (see kliem, kröger, & kosfelder, 2010, for review). mct is distinct in its philosophy of logically challenging counterproductive cognitions without a spiritual emphasis or an overt focus on personal acceptance. instead, it employs a precise, customizable model of how metacognition can malfunction, and emphasizes cognition over affect. it is possible that this more mechanistic approach could be advantageous for patients whose circumstances or personalities may make them less amenable to the humanistic elements of third wave therapies. evidence has accumulated for a clinical metacognitive model of depression and clinical tests have begun. wells et al. (2009) showed that an mct package targeting depression may be effective even for difficult cases with recurrent or chronic mdd that have not responded to medication and may be unlikely to benefit from traditional cbt, and observed promising stability at follow-ups. nordahl (2009) showed that even a diagnosis-general mct package may be comparably effective and favorably efficient to cbt in treating depression, in a head-to-head study with patients of varying diagnoses. these promising results should motivate coordinated effort in the future to better determine mct’s potential, including implementation of the depressiontargeting mct treatment package with expert training and supervision in a well-controlled head-to-head study. it would also be useful to examine the efficacy of mct for patients with distinct depression diagnoses and histories (e.g., chronic mdd, dysthymia or double depression, single mde, etc.), and compare responses to treatment. this could allow for deconstruction of the clinical metacognitive model and its techniques with respect to current depressive nosology, and facilitate comparison with cbt and other therapies across case presentations. research groups evaluating other therapeutic techniques and their treatment outcomes could consider adopting one or more of wells’ measures of metacognitions and beliefs about rumination in their studies as additional variables. metacognitive therapy may have the potential to treat and stabilize depressive symptoms in a straightforward, resourceefficient manner. increasingly recognized and respected in europe, mct has yet to garner mainstream support in north america but warrants more extensive investigation. references beck, a. t., emery, g., & greenberg, r. l. 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(1986). a self-report scale to diagnose major depressive disorder. archives of general psychiatry, 43, 1076-1081. doi:10.1001/archpsyc.1986.01800110062008 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 83 collaborative problem solving: is empathy the active ingredient? kevin ashworth, sara tapsak, & susan tinsley li school of professional psychology, pacific university collaborative problem solving (cps) is a cognitive-behavioral model that has gained popularity in the last decade as a promising treatment option for children with oppositional defiant disordertype (odd-type) behaviors and aggression. collaborative problem solving aims to help caregivers identify a child’s skill deficits, understand the role of triggers in maladaptive behaviors, and implement a framework for communicating with a child. while multiple studies provide empirical support for the use of cps in a variety of settings, only one experimental study has been conducted to date that compares cps to a well-established parent-training program (barkley’s behavior management program; bbmp). furthermore, no studies have attempted to identify the mechanisms of change in cps for odd-type behaviors and aggression. based on current literature and clinical experience, the authors hypothesize that the effectiveness of cps for odd-type behaviors and aggression across a range of treatment settings is likely due to its focus on empathy. in the current article, the authors develop a conceptual model of empathy as a mechanism of change in cps for odd-type behaviors and aggression based on relevant literature on cps and empathy as well as clinical illustrations. moreover, the authors present a design to empirically test this hypothesis. collaborative problem solving (cps) is a cognitivebehavioral intervention for children with symptoms of oppositional defiant disorder (odd), such as defiance, disobedience, and hostility towards authority figures (greene et al., 2004). collaborative problem solving is being increasingly recognized as an effective therapeutic modality for working with children with odd-type behaviors and aggression. within the last decade cps has emerged as a dominant treatment modality in residential, day-treatment, and inpatient psychiatric facilities throughout the united states to address these types of behaviors. research in several different settings supports cps as an effective treatment option for children with odd-type behaviors and aggression (epstein & saltzman-benaiah, 2010; greene et al., 2004; greene, ablon, & martin, 2006; martin, krieg, esposito, stubbe, & cardona, 2008; stewart, rick, currie, & rielly, 2009). however, despite the growing evidence for the effectiveness of cps for children with odd-type problems, there is currently a dearth of evidence elucidating the mechanisms of change in the cps model, which limits the validity of the model as an efficacious treatment option. to our knowledge, there is no formal model of change that explains the mechanisms of cps, although some authors have theorized that “plan b” conversations (described below) are essential (greene & ablon, 2006; greene et al., 2004). we hypothesize that the empirical support afforded to cps is largely the result of a focus on empathy, accomplished kevin ashworth, m.a., sara tapsak, m.s., and susan tinsley li, ph.d., school of professional psychology, pacific university, hillsboro, or. correspondence concerning this article should be addressed to: sara tapsak, pacific university school of professional psychology, 190 se 8th ave. hillsboro, or 97123. email: sara.tapsak@pacificu.edu. through the identification of the child’s lagging skills and the use of empathic skills by adults. this theoretical article investigates the use of empathy in cps as a primary change mechanism, above and beyond the other components of the model (i.e., training of skill deficits and identifying triggers to problem behaviors), by providing a rationale for the role of empathy based on a literature review, as well as our clinical experience using the model. to support our claim, we first introduce cps, outline its principal components, and review current research that supports cps’ effectiveness. we then present our hypothesis for empathy as a mechanism of change within the model, as well as literature on the role of empathy in the therapeutic process, its influence on the parent-child relationship, impact on effective communication, and use by mental health staff. next, we provide clinical illustrations based on our clinical experiences, propose a model for empathy as a primary mechanism of change in cps, and end with a discussion of the limitations of this paper. fourth, there is the potential for benefits outside the realm of psychotherapy. specifically, knowing about the process by which maladaptive functioning changes into adaptive functioning may reflect upon the processes underlying different forms of psychopathology and healthy functioning in general. collaborative problem solving collaborative problem solving was developed over a decade ago and introduced in ross greene’s the explosive child, most recently published in 2010. greene highlighted the differences between cps and traditional behavioral models for working with children who have odd-type behaviors. he emphasized the importance of recognizing these behaviors as secondary to skill deficits in different areas of ability. he provided a collaborative method of ashworth, tapsak, & tinsley li 84 communication with children and understanding their concerns, based on a transactional model which posits that problem behaviors result from the incompatibility between characteristics of children and their adult caregivers, instead of employing conventional interventions for behavior change. specifically, greene (2010) shifted the emphasis in this treatment from reward and punishment strategies as contingencies in traditional behavioral therapies (durlak, fuhrman, & lampman, 1991) to understanding the role of triggers in maladaptive behaviors (greene, 2010). as part of this shift, a component of the model is to teach parents to think differently about their children’s behaviors through the identification of specific skill deficits in the areas of flexibility/adaptability, frustration tolerance, and problem solving, and therefore, viewing maladaptive behaviors as the byproduct of these lagging skills required for coping and problem solving (greene & ablon, 2006). there are three identified goals of intervention in cps: (1) to significantly reduce the frequency, intensity, and duration of problem behaviors; (2) to help adults have their expectations met; and (3) to teach cognitive skills that are lacking in the child (green & ablon, 2006). the specific components of cps employed to achieve these goals are described in detail below. components of cps while greene (2010) described the two primary tenets of cps as understanding lagging skills and solving problems collaboratively, we have identified three main components of the model: identifying lagging skills (i.e., skill deficits), identifying the triggers of problem behaviors, and implementing what the authors term the “plans framework” (see figure 1). identifying skill deficits is the first component and step of implementing cps. skill deficits are assessed in the domains of executive skills, language-processing skills, emotion regulation skills, cognitive flexibility skills, and social skills. the developers of cps assert that this assessment helps caretakers understand that the child’s behavior is not intentional or purposeful. furthermore, this step identifies the skill deficits that need to be further developed in the child. after determining skill deficits, the second step of cps is to identify the triggers and pathways of the problem behaviors. in this way, cps strongly focuses on the recognition of antecedents of behaviors and this is typically done using a pathway inventory (created by the developers of cps) and situational analyses. identifying the pathways and triggers is a continuous and ongoing process in an effort to reveal the precipitating factors of current problem behaviors. after the first two steps are completed, consensus is reached with the caretakers about the current understanding of the child’s skill deficits and the triggers of problem behaviors. the third step of cps is implementing the plans framework. according to the developers of cps, adults have three basic, distinct options for how they choose to respond to problems or unmet expectations. as described below, these problem solving strategies are termed plan a, plan b, and plan c. all three options can be effective responses depending on the adult’s goals and the needs and abilities of the child. in understanding these options, the developers of cps contend that adults can begin to categorize and understand their own behavior and reevaluate and prioritize expectations in aid of decreasing problem behaviors, improving interactions between the adult and child, and improving skill deficits. ‘plan a’ occurs when an adult imposes his or her will on a child, typified by such statements as, “follow my directions or else” or “it’s my way or the highway” (greene, 2010, p. 43). greene and ablon (2006) state that traditional parenting approaches usually operate from a plan a perspective, often resulting in explosive behavior episodes and an escalation in parental intensity. for children with odd-type behaviors, this type of interaction typically leads to an episode in which the child can become defiant, hostile, and/or aggressive, potentially damaging the parent-child relationship. it is important to note that greene and ablon (2006) support the use of plan a in situations involving safety concerns. this is in contrast to ‘plan c,’ which involves the parent dropping his or her expectation temporarily, with the aim of decreasing the likelihood of explosive behavior in the moment. plan c is indicated when there is no time for confrontation or conversation; an additional goal of plan c is to reintroduce the dropped expectation at a later time. ‘plan b’ is the ideal problem solving strategy of cps and is a proactive approach designed to assist a child in meeting an adult’s expectations (greene & ablon, 2006). this is done when the child is less frustrated and ample time is available to figure out what got in the way of the child meeting the original expectation. plan b is divided into three steps: (1) empathy (plus reassurance); (2) definition of the problem; and (3) invitation to problem solve the issue. the first step of empathy involves listening to the child’s concern, making the child feel understood, and acknowledging that the child has a legitimate concern. this is generally done by making a neutral observation such as, “i noticed you didn’t do the dishes last night. what’s up?” the neutral statement allows the child to feel less defensive and more open to a dialogue about why he or she was unable to meet the expectation. the empathy step requires the adult to listen to what the child has to say and show his or her understanding by repeating the child’s concern. by listening and responding with empathy, the adult displays a willingness to understand the child’s perspective. the emphasis on empathizing with the child’s experience is crucial and represents a shift away from traditional behavior modification approaches, as contingencies are not unilaterally employed (greene, 2010). collaborative problem solving also proposes that identified skill deficits are improved through plan b conversations, which facilitate learning of cognitive skills through appropriate parent modeling (green & ablon, 2006). collaborative problem solving and empathy 85 the second step of plan b is when the adult provides his or her concerns (i.e., expectations). the problem is now considered defined, as both parties have presented their respective concerns. the third and final step of plan b consists of the adult inviting the child to collaboratively brainstorm solutions to the problem in a way that is possible and satisfactory to both people. for example, the adult might ask the child, “so what is a way that you can watch your favorite show (child’s concern) and be able to complete your chores (adult’s concern)?” a discussion then occurs until they reach a mutual solution that addresses both the child’s concern and the parent’s concern. although the basic tenets of cps appear somewhat simple, implementing a plan b conversation is complex. the first two steps of a plan b conversation focus on connecting with the child and understanding his or her concern. therefore, without the incorporation of empathic skills neither of these tasks could be successful, making the inclusion of empathy in the conversation seemingly essential. empirical support for cps evidence to support cps as an effective model for working with aggression, explosiveness, depression, anxiety, and cps model components identify triggers to problem behaviors plans framework identify lagging skills pathways impose adult expectations ("do this or else") outcomes: avoid problem behavior, adult expectation not met goal: reduce problem behavior drop expectations (for now) goals: impose adult will, child safety outcome: increase in problem behavior plan a executive skills deficits problem behavior adult response social skills deficits language processing deficitss cognitive inflexibility emotion regulation deficits plan c step 1. empathy: attempt to understand the child's concern by listening (e.g., “i see you just threw a chair, what's up?") and reflecting (e.g., "you're mad and frustrated, that sucks.") step 2. define the problem: express adult concerns and restate child's concern (e.g., "ok you're mad. my concern is that someone could get hurt when you throw the chair, and it scares me.") outcomes: decreased problem behavior, improved lagging skills, and met parent expectations (i.e., improved parent-child relationship). step 3. invitation: invite the child to help develop solutions satisfactory to both parties (e.g., "so what's a way you can let me know you're mad and not scare me?") and choose a solution. goal: reduce problem behaviors and teach skill deficits. plan b figure 1. cps model components. the three core components include identifying lagging skills pathways, identifying the triggers of problem behaviors, and implementing what the authors term the “plans framework” (plans a, c, and b) ashworth, tapsak, & tinsley li 86 suicidality in children and adolescents is ample (epstein & saltzman-benaiah, 2010; greene et al., 2004, 2006; martin et al., 2008; stewart et al., 2009). however, the mechanisms of change within it have yet to be defined (callaghan, follette, ruckstuhl, & linnerooth, 2008). to our knowledge, only one experimental study (greene et al., 2004) has shown cps to be as effective as or more effective than barkley’s behavior management program (bbmp), a well-established parenttraining program (barkley, 1997). outpatient studies greene et al. (2004) provided support for the utility of cps with an outpatient population, highlighting the model’s dual focus on parenting skills and cognitive deficits in children and comparing it to bbmp. outcomes were measured using the parenting stress index (psi; abidin, 1995), parent-child relationship inventory (pcri; gerard, 1994), clinical global impression (cgi; national institute of mental health, 1985), and the oppositional defiant disorder rating scale (oddrs), an unpublished rating scale developed by greene to measure parent-child conflict. the cps group demonstrated statistically significant improvement from pre-treatment to post-treatment on the psi and pcri. as the oddrs is an unpublished rating scale, normative data are unavailable and therefore clinically significant change was used to measure outcomes. the cps group produced clinically significant change from pre-treatment to posttreatment and at 4-month follow-up. additionally, scores on the cgi at post-treatment and at 4-month follow-up identified treatment group (cps vs. bbmp) as a significant predictor, with the cps group showing a significantly greater degree of improvement compared to the bbmp group. epstein and saltzman-benaiah (2010) evaluated the feasibility and effectiveness of cps among parents of children with both tourette syndrome and odd. following the implementation of cps, significant changes were seen on the eyberg child behavior inventory (ecbi; eyberg & pincus, 1999), a parent rating scale that assesses the intensity and frequency of disruptive behaviors at home, indicating that parents reported fewer and less intense disruptive episodes, as well as a reduction in stress (epstein & saltzman-benaiah, 2010). mixed inpatient-outpatient study stewart et al. (2009) demonstrated the effectiveness of cps in reducing explosive behavior in a nine-bed residential treatment program. significant differences were seen in the number of “meltdowns,” as defined by scores on the conners parent rating scale (conners, 1997), reported at preand post-treatment. furthermore, these improvements continued at 6-month follow-up. improvements in social skills were also seen post-treatment; however, they decreased at followup, suggesting that these skills require more continuous reinforcement (stewart et al., 2009). these improvements mirror the philosophy of cps, which is to improve the communication and relationship between parent and child. stewart et al. (2009) contended that the changes observed in the study provide support for the effectiveness of cps with a residential population. although significant changes were not found in all study domains (i.e., improved academic performance, enhanced community participation), those directly related to cps (e.g., social skills, decreasing meltdowns, and parent stress) were positively impacted (stewart et al., 2009). inpatient studies greene and colleagues (2006) investigated the use of cps in reducing seclusion and restraint incidents in a child inpatient psychiatric hospital. the number of seclusions and restraints decreased significantly after its implementation. in the nine months prior, the unit documented 281 episodes of restraints. following the 15-month cps training period, the unit documented one incident of restraint. because this was a quasi-experimental study, however, not all extraneous variables were controlled for. martin et al. (2008) attempted to replicate the aforementioned results by evaluating the effectiveness of cps in reducing seclusion and restraint in a 15-bed child psychiatric inpatient unit. they collected data for three years prior to cps implementation, six months during, and 18 months afterward. after cps implementation, the rate of restraint dropped from 263 incidents per year to seven incidents per year, with the mean duration of restraint decreasing from 41 to 18 minutes per incident. seclusion incidents decreased from 432 to 133 per year. summary of empirical support for cps the empirical support for cps warrants acknowledgement within the field for its effectiveness in a wide range of treatment settings. within a relatively short time, the body of literature discussing cps has grown and includes support for its use in both outpatient and inpatient settings. although initially developed to address explosive behavior in outpatient populations (greene et al., 2004), it is becoming increasingly well known for its utility in reducing seclusion and restraint within inpatient populations (greene et al., 2006; martin et al., 2008), as well as an effective model for parenting programs (epstein & saltzman-benaiah, 2010). empathy as the putative mechanism of change in cps we believe it important, given the climate of evidenced based treatments, to attempt to understand the mechanisms of change underlying cps in order to critically evaluate its effectiveness. empathy is clearly present in the implementation of cps, both before and within a plan b conversation. before a plan b conversation can take place, the adult must examine what areas of cognitive ability are lagging for the child (the first component of cps) by evaluating language processing, emotion regulation, cognitive flexibility, executive, and social skills. with this examination and understanding, the adult is better able to develop empathy for the child and to view maladaptive behavior as the result of underdeveloped skills rather than malicious intent. inherent in identifying lagging skills, cps allows adults to see collaborative problem solving and empathy 87 maladaptive behavior empathically (greene & ablon, 2006). for example, believing that a child is refusing to attend school due to his or her anxiety (i.e., a deficit in emotion regulation) is fundamentally different than assuming that he or she lacks motivation, is lazy, or is oppositional. given the latter assumption, the adult will probably attempt to ‘motivate’ the oppositional child by invoking contingencies (i.e., “if you don’t do (x), then…”) to help precipitate the child’s return to school. the former assumption requires adults to shift their understanding of the child, which will likely change how they approach the problem and includes the use of empathic skills (e.g., reflective listening, validation of child’s emotions, and perspective taking) during plan b conversations. although no research has been published on the mechanisms of change in cps, we hypothesize that the focus on empathy is indeed the reason that cps has gained both empirical and experiential support. specifically, we hypothesize that the creation of empathy through the identification of lagging skills and the explicit use of empathic skills by adults is responsible for improvements in the parent-child relationship and decreased problem behaviors, above and beyond the training of skill deficits and identifying triggers to problem behaviors. this paper seeks to conceptualize the effectiveness of cps in the context of its focus on empathy. by examining the current literature on the construct of empathy, we believe that our conceptualization is plausible. empathy in psychotherapy empathy can be defined as a shared understanding of thoughts and emotions between two people or groups of people (pedersen, 2008). as carl rogers stated, “empathy is the therapist's sensitive ability and willingness to understand the client's thoughts, feelings, and struggles from the client's point of view… it is this ability to see completely through the client's eyes, to adopt his frame of reference” (rogers, 1980, p. 85). empathy is essential in conveying caring and understanding to clients (rogers, 1975) and has long been considered a necessary component for psychotherapy to be successful in most, if not all, therapeutic modalities (anderson, ogles, patterson, lambert, & vermeersch, 2009; rogers, 1975). castonguay and beutler (2006) echo carl rogers’ view that the fundamental tenets of empathy are positive regard, listening, and warmth, and see these as the bases of the therapeutic relationship. the literature defining and exploring empathy in a therapeutic context is extensive (greenberg, watson, elliott, & bohart, 2001; martin, garske, & davis, 2000; preston & de waal, 2002; rameson & lieberman, 2009), and therapeutic benefits are seen when empathic responses and empathic approaches to psychotherapy are utilized (rogers, 1975). in a meta-analysis, greenberg et al. (2001) found that empathy was the single best predictor of positive outcomes in therapy. further, they identified four factors that serve as mediators between empathy and positive therapeutic outcomes: (1) empathy as a relationship condition, in which feeling understood helps clients feel safe and increases client satisfaction; (2) empathy as a corrective emotional experience, in which an empathic relationship may help to strengthen the self; (3) empathy and cognitive-affective processing, in which empathy helps promote exploration and meaning and facilitates emotional reprocessing; and (4) empathy and the client as active self-healer, in which empathy helps engage the client and promotes active participation (greenberg et al., 2001). parental empathy in addition to the general support for empathy as an important ingredient in psychotherapy, the presence of parental empathy has been implicated in positive outcomes for children. active listening and empathic responding by parents communicates to children a genuine valuing of and interest in their concerns (kohut, 1977, 1984). by developing a shared connection through empathy, it is possible that the child sees the adult as a collaborator in a shared valued outcome as opposed to a competitor for power (pedersen, 2008). trumpeter, watson, o’leary, and weathington (2008) studied the relationship between perceived parental empathy and love-inconsistency, narcissism, self-esteem, and depression. they found that perceived parental empathy was associated with healthy self-development and adaptive selffunctioning in young adults. schaffer, clark, and jeglic (2009) examined the relationship between empathy, parenting, and antisocial behavior in young adults. their results supported the conclusion that empathy was an important predictor of decreased antisocial behavior. parental empathy has also been shown to be correlated with at least neutral or positive attitudes towards children (moran & diamond, 2008). goubert et al. (2005) defined two types of empathic responses in people who witness distress in others. an empathic concern response is one in which the observer is focused on the distress of another person. in contrast, an empathic distress response is one in which the observer is focused on his or her own experience of distress. both types of responses are associated with helping behavior; however, only the empathic concern response helps to comfort and calm the person in distress, whereas the empathic distress response serves to calm the observer (goubert et al., 2005). penner et al. (2008) demonstrated the association between parental empathy and positive benefits for children undergoing oncology treatment. they reported that increased parental empathic concern was associated with less pain and distress in children. utilizing empathic concern instead of empathic distress helped parents focus on the medical procedure and their child’s wellbeing rather than attending to potential complications and the invasiveness of the procedure. in addition, the empathic concern response helped to ease parental anxiety and distress about the situation (penner et al., 2008). empathy and parent-child communication parental reactions influence children’s emotional responses (fabes, leonard, kupanoff, & martin, 2001). ashworth, tapsak, & tinsley li 88 additionally, disapproving parents likely teach their children that their feelings are wrong and invalid (fabes et al., 2001). by providing empathic responses to a child’s distress, parents validate a child’s concerns and are better able to reduce the intensity of the distress experienced by the child. in an attempt to understand the accuracy (or lack thereof) in empathic conversations between parents and adolescents, sillars, smith, and koerner (2010) identified misattributions made between parents and teens when conversing. they found that parents were more focused on the interaction process of the conversation and teens were more focused on the content of the discussion. furthermore, parents and teens were both unable to identify areas of similarity and difference with respect to positive and negative attributions toward one another when engaging in a heated discussion. these findings provide support for the importance of finding common ground through empathic statements and validating comments. similarly, sillars, koerner, and fitzpatrick (2005) reported that parents who were better able to understand their child’s self-concept (i.e., use empathy) were more likely to communicate openly and frequently with their child. furthermore, high parent-child relationship satisfaction was associated with parental understanding of the child’s selfconcept (sillars et al., 2005). empathy and mental health staff as parents are not the sole providers of care to children, especially in cases of significant behavior problems, it is worthwhile to explore the role of empathy in residential and psychiatric settings. the use of empathy within these settings, specifically between staff members and their patients, is not well understood in the literature. however, predictors of effective and positive psychiatric hospitalizations exist and follow a common theme. coleman, paul, and schatschneider (2007) reported that the amount of attention provided to patients on psychiatric units predicted better outcomes, such as lower chronicity of illness and patient effectiveness. for the amount of attention provided to patients to impact outcomes, staff must be trained in “sociallearning procedures” (coleman et al., 2007), which are likely to encompass skills such as effective communication and empathy. the use of empathy, respect, and communication skills are paramount in the relationship between a psychiatric staff member (e.g., a social worker, nurse, or aide) and patient, particularly because of the power differential between the two parties (holm, 2002). one obstacle to empathy can be the lack of knowledge about rules for expressing feelings (keefe, 1976; strayer, 1987). keefe (1976) reported that one must permit oneself to be free from biases (i.e., stereotyping) that limit empathic responses, a skill that allows patients to elicit empathy from the psychiatric staff. this skill is likely taught during academic training and may not be available to the untrained psychiatric staff member. the delivery of empathy depends not only on the staff member’s ability to understand and acknowledge a patient’s feelings, but also on their motivation to be empathic (holm, 2002; suchman, markakis, beckman, & frankel, 1997). summary of empathy the empirical literature on empathy is vast (greenberg et al., 2001; martin et al., 2000; preston & de waal, 2002; rameson & lieberman, 2009; rogers, 1975). it is clearly established that empathy is associated with positive outcomes in therapy (angus & kagan, 2007; elliott, bohart, watson, & greenberg, 2011). empathy is a necessary component of psychotherapy and has a greater influence on positive therapeutic outcomes than any other factor (greenberg et al., 2001). it is often the first skill taught to new clinicians (morrison, 1995), developed through training and practice, and is reported to be the core value to which therapists return when stuck or struggling with a difficult case (holm, 2002; waller, 2009). for psychiatric staff, empathy is integral to a positive staff-patient relationship (holm, 2002). it is also associated with increased communication between parents and children (sillars et al., 2005), healthy psychological development in children (trumpeter et al., 2008), and overall changes in the ways in which parents interact with their children (moran & diamond, 2008; sillars et al., 2005, 2010). in addition to mental health staff, parents are often involved in the treatment process with their children and effective communication between adult and child requires empathy through listening, respect, and understanding. unlike many traditional treatments for children, which primarily involve behavior modification techniques, cps brings empathy to the forefront as an integral part of the intervention. through our clinical experiences, the positive impact of the creation of empathy and the use of empathic skills within cps has been evident. therefore, two case vignettes are offered in the subsequent section. clinical illustrations clinical practice often serves as the real-world test of the effectiveness of theories and interventions. the following clinical examples, informed by the authors’ own experiences of working with the model, anecdotally illustrate the significance of empathic skills in the implementation of cps. these two examples highlight the value of empathy within cps in clinical practice. vignette 1. the following is a typical case of an adolescent on an inpatient psychiatric unit. prior to the implementation of cps, the general staff consensus and goal was patient safety. historically, staff perceived safety as synonymous with control. therefore, when a patient was not following directions (such as being out of his or her room during “room time”), staff would subsequently demand that the youth comply and follow directions without protest. on occasion, the redirection to return to his or her room would incite frustration in the youth, which would decrease the likelihood that he or she would comply with the request. a conflict would often arise and the youth (who likely struggled with emotion regulation, as most patients on the unit do) would begin shouting, swearing, and/or crying. in response, the staff would continue to direct the patient with verbal commands, elicit more staff, and if necessary physically collaborative problem solving and empathy 89 guide the youth back to his or her room. following the implementation of cps through staff trainings and clinical supervision, however, staff began shifting their attitude about the meaning of safety, patient compliance, and empathy. although patient safety continued to be a priority, it was no longer synonymous with control. thus, when a youth would exit their room during “room time,” a similar direction might be given, “please stay in your room during room time.” a typical response may have been, “no! room time sucks!” in accordance with the cps model, the staff now responded with, “room time sucks? how come?” with the understanding that empathizing with the youth’s concern is paramount, in this case through reflective listening, the staff took time to listen to and understand the youth’s perspective. this approach decreased the youth’s frustration and increased the odds that he or she would engage in a dialogue with the staff member. in the authors’ opinion, the use of empathic skills enabled staff to demonstrate understanding of the youth’s perspective regarding room time. vignette 2. a single mother who attended a cps parenting class facilitated by one of the authors reported that she had struggled to find any help for her 12-year-old adopted son. she described his behavior as violent and aggressive, explaining that she was victim to his abuse and that he had recently punched her in the face, resulting in a broken nose. the mother sat quietly through the hour and a half class taking notes. at the end of the class she asked, “do you think this would really work for my kid?” the author recommended that she return the following week to learn more. after five weeks of consistent attendance in the class, she reported improvement in her son’s behavior and specifically noted a decrease in his aggressive behavior. per her report, she had learned to set expectations while understanding her child’s abilities and most importantly had learned to inquire as to why a behavior occurred, instead of assuming she understood, suggesting an overall increase in empathy for her child. she reported that she had learned to better understand her child and therefore had developed insight into his chronic frustration. she reported that by attempting to understand his perspective she was able to ignore her own assumptions and connect with her son. this understanding and communication style were the catalysts in helping her problem-solve with her child, while at the same time establishing a safe and consistent environment. in our experience, these two examples reflect common outcomes obtained by the implementation of cps. amid learning the model, identifying lagging skills, and learning to collaboratively problem-solve, cps fostered adults’ abilities to empathize with children and is arguably responsible for the shifts in their attitudes and behaviors. once parents and staff were able to view a child as frustrated, depressed, anxious, and/or confused (instead of manipulative, oppositional, defiant, or aggressive), they changed their interaction style, tone of voice, and assumptions about the child. we believe that enhanced understanding and the use of these empathic skills are what increase an adult’s ability to effectively communicate and problem-solve with a child, subsequently promoting behavior changes in the child. the next section proposes a conceptualization of empathy as a primary mechanism of change in cps, as well as recommendations for how this assertion may be empirically tested. proposed mechanism of change and future research as previously stated, cps consists of three components (lagging skills assessment, triggers identification, and the plans framework; see figure 1). despite empirical support on the utility of the model in various settings, there are currently no studies that have dismantled cps, leaving the consumer unclear as to which components are necessary to effectively achieve desired outcomes (for example, a decrease in oddtype behaviors or an improvement in the parent-child relationship). based on our clinical experience working with the model in both inpatient and outpatient settings and our review of literature on empathy, we believe that a primary mechanism of change within cps is empathy, which is created by having adults both understand the child’s lagging skills and utilize empathic skills. in cps, empathy allows adults to better understand a child’s behavior and shift the way they think about them, consequently affecting how they respond to the child’s problem behaviors. by identifying lagging skills in the child, adults are able to appreciate the skills necessary to be successful in life (e.g., social skills, ability to problem solve, frustration tolerance, etc.) and are less likely to view these issues as motivational in nature. thus, the understanding of lagging skills aids adults in developing empathy for children. with this understanding, adults are in turn more likely to respond to their child in empathic ways (i.e., employ empathic skills) by listening, reflecting back and validating the child’s concerns, and attempting to understand his or her perspective. if this occurs, we argue that the child will feel understood, less defensive, and will therefore be more likely to follow adult directives. therefore, the identification of lagging skills (i.e., empathy through increased understanding of child’s lagging skills) in conjunction with adult implementation of empathic skills (e.g., reflective listening, validation of child’s emotions, and perspective taking), which is the first step in a plan b conversation, accounts for the aforementioned desired outcomes (see figure 2). in order to empirically evaluate the mechanisms of change in cps, future research could dismantle cps and examine isolated components. we offer two avenues for doing this. first, the following three treatment groups could be implemented: (1) cps in its entirety; (2) cps without plan b’s empathy piece; and (3) cps with only plan b’s empathy piece. outcome measures could include frequency, intensity, and duration of problem behaviors, as well as ratings of parental stress to assess the parent-child relationship. ashworth, tapsak, & tinsley li 90 additionally, a regression analysis could be run on the group implementing cps in its entirety, examining outcome measures to determine to what extent various components of the model account for outcomes. isolating cps components and evaluating outcome measures in this way could establish a clearer understanding of the role of empathy within the model. limitations we have identified three important limitations to the claims presented in this paper. first, our argument relies heavily on our clinical experiences working with the cps model and on literature describing the positive impact of empathy more generally. while clinical experience is important in furthering understanding, evaluating effectiveness, and inciting future research, it has the inherent limitation of lack of experimental control. consequently, our perceptions of the role of empathy as the change mechanism and literature asserting the value of empathy may have caused us to disregard other explanations of the positive outcomes we observed. in addition, these outcomes were not validated by objective measures. despite this limitation, our clinical experiences raise the important question of what the role of empathy is in cps. a second limitation is that although we argue that empathy is a primary mechanism of change and accounts for desired outcomes above and beyond the other components of cps, we do not offer hypotheses as to the specific role empathy may play in the model (e.g., as a mediator, moderator, or the sole curative factor). expanding our hypothesis to account for the specific types of influence empathy may have would help to better direct future research. finally, it is unlikely that empathy serves as a primary mechanism of change when the goal of cps is to improve a child’s cognitive skills (green & ablon, 2006). for example, the authors of cps state that engaging in plan b conversations improves skill deficits in the child through the experiences of articulating concerns, considering different solutions to problems, and reflecting on outcomes of solutions implemented (green & ablon, 2006). we do not suggest that empathy components (such as understanding lagging skills and use of empathic skills) would explain improvement in cognitive skills and as such, our hypothesis is unlikely to explain this change. however, this identifies another area of the cps model that merits further investigation. conclusion this article develops a rationale for empathy as a primary mechanism of change in cps based on available literature on cps and empathy in psychotherapy, as well as the authors’ clinical experiences. the reviewed literature provides support for the promise of cps as an effective treatment modality for odd-type behaviors and aggression in a wide array of treatment settings. additionally, our clinical experiences have demonstrated that it can be an effective dyadic intervention for parent-child interactions, as well as an effective systemic model for creating change in residential and inpatient settings. collaborative problem solving engenders a climate of empathy by creating understanding within adults that lagging skills may be responsible for a child’s problem behaviors, and requires that adults utilize empathic skills to respond to a child’s behavior. with this knowledge and skill set, adults can shift their expectations of interactions to understand what is going on for the child and respond in empathic ways, instead of attempting, often unsuccessfully, to control the child’s disruptive behaviors. empathy in its own right has been shown to increase communication, change staff’s and parents’ interactions with children, and is associated with healthy psychological development (moran & diamond, 2008; sillars et al., 2005, 2010; trumpeter et al., 2008). it can change how adults interact with children and can increase the likelihood that children feel understood and supported by adults. given the overwhelming evidence of harsh parenting/discipline, low nurturance, and the use of punishment in the etiology of disruptive behavior disorders (bailey, hill, oesterle, & hawkins, 2009; rothbaum & weisz, 1994; thompson, hollis, & richards, 2003), empathy may have a direct impact on improving parent-child relationships and subsequently increase behavioral compliance. figure 2. empathy (denoted by gray coloring) is represented within cps through the identification of lagging skills and in the implementation of empathic skills. executive skills deficits identify lagging skills pathways problem behavior adult response step 1. empathic skills: adult attempts to understand the child's concern by listening (e.g., "i see you just threw a chair, what's up?") and expressing empathy (e.g., "you're mad and frustrated, that sucks.") child believes adult understands them and cares. child is more open to discussion. social skills deficits language processing deficits cognitive inflexibility emotion regulation deficits plan b outcomes: decreased problem behavior, met parent expectations (i.e., improved parent-child relationship) increased adult understanding primary mechanism of change: empathy model collaborative problem solving and empathy 91 collaborative problem solving reflects the value of empathy within its conceptualization of underdeveloped skills as the cause of problem behaviors and by having adults respond with empathic skills (greene et al. 2004, 2006; martin et al., 2008). therefore, the use of empathy arguably creates a fundamental shift in adults’ perceptions of children, leading to positive outcomes. if the use of empathy is a primary mechanism of change within the model, then perhaps it is largely responsible for the success of cps. collaborative problem solving is gaining empirical support and children, families, and organizations are benefitting from the implementation of this model. prudent scientific questioning would dictate, however, that understanding the mechanisms of change within the model is necessary for future replication, generalization, and implementation. it is our hope that future research will seek to clarify the claims presented here. references abidin, r. r. 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(2009). evidence-based treatment and therapist drift. behaviour research and therapy, 47, 119-127. doi:10.1016/j.brat.2008.10.018 18 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university the process of valuing and subjective well-being for trainees robin grumet, marilyn fitzpatrick, lauren yildirim, bethsheba ananng, and megan knoll mcgill university the current qualitative research investigated the process of valuing from an acceptance and commitment therapy perspective, as well as the influence of this process on subjective well-being in novice therapists. sixteen ma counseling psychology students participated in a three-hour workshop that involved didactic and experiential components aimed at facilitating values clarity and values congruent living. a semi-structured interview explored values clarity, behavioral congruence, as well as well-being, including both mood and life satisfaction. consensual qualitative research was used to analyze the interview data. findings indicated that the values clarification process is complex and challenging, and that structured interventions support this process. work demands were a particularly salient barrier to valued living for trainees. the valuing process influenced mood more than life satisfaction and was related to eudaimonic, but not hedonic pursuits. implications for theory, practice, supervision, and future research are provided. a central aim of psychology is to alleviate psychological distress (seligman & csikszentmihalyi, 2000; duckworth, steen, & seligman, 2005). the absence of distress however, is not synonymous with well-being (ryan & deci, 2001; duckworth et al., 2005). well-being can protect against the development of clinical disorders (joseph & wood, 2010). the field of positive psychology has begun to investigate the pathways to foster happiness or subjective well-being (swb) (duckworth et al., 2005; seligman & csikszentimihalyi, 2000; schueller & seligman, 2010). swb is an individual’s perception of wellness and includes positive affect, minimal negative affect, and high levels of life satisfaction (diener, 2000). research suggests that swb is associated with positive physical and psychological health outcomes. findings from a recent meta-analysis of randomized controlled studies in positive psychology interventions suggest that preventative interventions that foster swb can also minimize depressive symptoms (bolier, haverman, westerhof, riper, smit, & bohlmeijer, 2013). research also suggests that using positive interventions to augment swb can protect against the development of depression and other psychological disorders including generalized anxiety disorder and panic disorder (keyes, dhingra, & simoes, 2010; joseph & wood, 2010). there is also ample evidence that high swb is related to good physical health and longevity (diener & chan, 2011). although it is heritable to some degree, evidence from positive psychology suggests that swb is malleable and can be augmented (tay & kuykendall, 2013). determining ways to foster swb is gaining empirical attention in the field of positive psychology (giannopoulos & vella-brodrick, 2011; tay & kuykendall, 2013). seligman has identified three distinct pathways to swb (duckworth et al., 2005; schueller & seligman, 2010). the first, pleasure, consists of experiencing pleasure and positive emotions (duckworth et al., 2005). the second is engagement, which involves immersing oneself in activities that are intrinsically rewarding (duckworth et al., 2005; schueller & seligman, 2010); engaging fully can lead to the experience of flow, which is a mental state characterized by total absorption in an enjoyable and rewarding activity (csikszentmihalyi, 1990). the third pathway, meaning, refers to belonging to and contributing to causes that transcend the self (duckworth et al., 2005). a sense of purpose and override (hidden running head text): grumet, fitzpatrick, yildirim, ananng, knoll act value clarification keywords: acceptance and commitment therapy; values clarification; values behavior congruence; subjective well-being; mood; life satisfaction please address correspondence regarding this article to: robin.grumet@mail.mcgill.ca 19 act value clarification direction in life leads to the creation and pursuit of meaningful goals and results in well-being (frankl, 1997). although all three elements are associated with swb, positive psychology research suggests that engagement and meaning have more robust relationships with swb than pleasure (schueller & seligman, 2010; vellabrodrick, park, & peterson, 2009). the underlying principle of most positive psychology interventions is that swb is enhanced by positive goals and intentional activities (tay & kuykendall, 2013) and that it is trainable (lyubomirsky, sheldon, & schkade, 2005; sheldon & lyubomirsky, 2007). interventions targeting behavioral change are at the heart of evidence-based approaches such as cognitive behavioral therapy (cbt). more recently, intervention research has focused on interventions linking behavioral change to meaning and purpose. one example of such an approach is acceptance and commitment therapy (act), which is a recently developed third wave behavioral therapy (hayes, strosahl, & wilson, 1999). act helps clients learn to accept and embrace difficult experiences in order to live a life in service of their personal values (hayes, luoma, bond, masuda, & lillis, 2006). values are “chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment” (hayes et al., 2006, p. 9). unlike goals, which can be achieved, values can never be fully attained but can be continuously expressed in moment-to-moment behavior. values are freely chosen and intrinsically motivating; they are not adopted from a desire to please others or avoid negative consequences (ciarrochi, fisher, & lane, 2010; plumb, stewart, dahl, & lundgren, 2009; wilson, sandoz, kitchens, & roberts, 2010). act theory posits that value-based actions are associated with positive physical and psychological health outcomes and discrepancies between values and behavior have detrimental effects on health (plumb et al., 2009). research on act indicates that behaving consistently with values is associated with positive wellness outcomes including less psychological distress (ciarrochi et al., 2010; mccracken & yang, 2006), increased life satisfaction (lundgren, dahl & hayes, 2008), and increased self-reports of quality of life (michelson, lee, orsillo, & roemer, 2011; lundgren et al., 2008). a commitment to intrinsically motivated social values has also been linked to positive affect (ferssizidis, adams, kashdan, plummer, mishra, & ciarrochi, 2010). in contrast, when their behaviors are incongruent with their personal values, individuals experience more psychological distress (plumb & hayes, 2008; as cited in plumb et al., 2009; wilson et al., 2010). despite limited research on specific values interventions, preliminary evidence on act indicates that values intervention components serve as mediators to wellbeing outcomes (lundgren et al., 2008). however, the process of valuing is not well understood. in particular, how individuals clarify personal values and the mechanisms of values-behavior congruence, as well as the process through which values-congruent behavior influences swb, require investigation. research suggests that novice therapists are vulnerable to stress and burnout, which can affect both personal wellness and professional effectiveness (skovholt & jennings, 2004; stafford-brown & pakenham, 2012). a non-randomized controlled trial of a group act intervention reduced stress in clinical psychology students in australia (stafford-brown & pakenham, 2012) and also enhanced positive therapist qualities such as selfcompassion. two out of the four sessions offered were devoted to values work (e.g., clarifying values, setting values-congruent goals). however, there are no studies that have examined the process of developing values specifically. the current study investigates the process of values awareness development, values-behavior congruence, and the way that values-congruent behavior influences well-being in therapists-in-training. more specifically, the study investigated the following research questions about psychotherapist trainees: 1) which processes facilitate values clarification? 2) which processes hinder the values clarification process? 3) what processes are associated with values-congruent behavior? 4) which processes hinder values-behavior congruence? 5) how does values work relate to swb? a qualitative approach was utilized to allow for a rich and complex examination of the valuing process, as research of this nature is limited and much needed to elucidate the processes involved in values clarification and enacting valuescongruent behaviours, as well as the relationship between these processes and swb. 20 grumet, fitzpatrick, yildirim, ananng, knoll method participants sixteen female (13 caucasian, 1 south east asian, 1 jamaican, 1 multiethnic) master of arts (ma) students in counseling psychology at a canadian university, completing their first year of studies including a first practicum participated. participant’s ages ranged from 22 to 46 years old (m = 28.38, sd = 6.18). procedures the current study received approval from the university’s research ethics board (reb). informed consent was obtained prior to the start of the study. participants received a three-hour values clarification workshop (conducted by a doctoral student and professor in the counseling psychology program) that included teaching of the act approach to valuing, information about its efficacy, and experiential values clarification and committed action exercises. the values clarification exercises included: 1) a guided visualization where participants imagined their convocation ceremony and envisioned what their ideal life would look like in the interim 2) an independent writing exercise where participants listed things they wanted to stop, start, and continue doing 3) discussion in dyads to identify themes and meaning among the three lists that could help to highlight a value(s). committed action exercises included: 1) working in dyads to set values-congruent goals to be achieved in: 24 hours, 1 week, and 1 month, and 2) making a commitment with a partner and devising strategies to hold one another accountable to goals (e.g., check in emails). participants were interviewed two weeks after the workshop and asked to discuss their experiences during and after the workshop, their process of values clarification and values-behavior congruence, and their sense of well-being, including mood, life satisfaction, pleasure, engagement, and meaning. the interview was semi-structured such that there was a list of open-ended questions referred to by all of the interviewers (in order to ensure that all topics of interest were covered, e.g., process of values clarification); however, the questions were not asked verbatim nor in a particular order. the interview was guided primarily by the salient topics to the participant. the interviews, which ranged from 20 to 45 minutes, were conducted by the first author and two doctoral students in counseling psychology and were transcribed for analysis. data analysis consensual qualitative research (cqr; hill, 2012; hill et. al, 2005; hill, thompson, and williams, 1997) was used to analyze the data. cqr is a qualitative method, which aims for an in-depth examination of individual experiences, as well as a cross-case analysis to identify themes that emerge across participants (hill et al., 2005). it utilizes several coders in order to foster multiple perspectives throughout the process and to achieve consensus regarding the essence of the data (hill et al., 2005). an auditor reviews the work of the primary coding team in order to minimize the possibility of groupthink (hill et al., 2005). there are three steps in this process, including the identification of domains (topic areas), the construction of core ideas (essence of participant statements), and the cross-case analysis (discerning themes across participants). in the current study, the primary research team was made up of one ma student studying counseling psychology (caucasian, female, 26 years old) and two female undergraduate volunteers studying psychology (21 years old, caucasian, and 22 years old, african canadian). the auditor was a 25-year-old, caucasian, female ma student. each team member analyzed the data independently and meetings of all team members were held to reach coding consensus. the primary team generated a baseline domain list of topic areas based on constructs of interest (e.g., mood, life satisfaction, values clarity) prior to beginning analysis (hill, 2012). the three primary team members coded independently to domains, arrived at consensus, and refined the domain list to the final seven domains. the primary coders formulated core ideas of the participant statements for the first three transcripts to ensure consistency and then individual coders constructed core ideas independently and the other two members reviewed them at a consensus meeting. in cqr, core ideas refer to brief phrases that abstract the essence of participant’s statements (e.g., participant feels the workshop provided her with tools to articulate her values, participant uses values as compass for decision making). the consensus version for each participant was audited (to ensure the data was accurately represented 21 act value clarification and placed in the appropriate domains) and the primary team integrated the auditor’s feedback. the primary team then examined the core ideas across cases and grouped core ideas into categories (e.g., positive mood change, enhanced life satisfaction, arrived at clear act value), which is the term for themes in cqr (hill et al., 1997). coders independently developed a category list for each domain and then synthesized their lists, following a consensus process. after an external audit of these lists, the primary team finalized the categories for each domain. the first author calculated if the categories were general (15–16) typical (>9), variant (4–8), or rare (2–3) as per cqr guidelines (hill, 2012; hill et al., 2005; hill et al., 1997). results the results are presented by research question and domain. the process of values clarification is elucidated and participant’s experiences of values-behavior congruence are discussed. finally, the way that participating in this process influenced participant’s swb is elaborated. typical and variant categories are presented; rare cases are only discussed if they inform the research question (see table 1–3). frequencies of categories are indicated in parentheses. domain 1: values clarity the processes that lead to and hinder values clarification are presented first to provide context for other processes and supports. outcomes. participants reported that the values clarification process was helpful (typical), however the depth of the experiences ranged from gleaning subtle insights to making profound discoveries. participants also varied regarding the degree of clarity some described arriving at a clear act value that was characterized by a quality of action (variant). for example, one participant said: “i was sort of surprised to arrive at a core value . . . there was just one and it was actively authentic.” similarly, another participant shared that behaving genuinely is deeply important to her and named this value “freely being.” another participant described her act value as “living appreciatively” and explained it is important for her to consciously engage in gratitude. a couple of participants reported furthering their understanding of a value but had difficulty articulating a clear value (rare). one participant described a process that: really feels like a shadow or like a cloud. you can see it, but as soon as you get to touch it, it kind of disappears or it’s really hard to grasp. that’s what i feel like my values are like. i have the idea, i have the shape in my head, but i can’t really touch it or i can’t really put my finger on it. participants often reported that they had previously engaged in a personal values clarification (typical); learning about act in courses had inspired them to reflect on their values prior to the workshop. others reported being engaged in the process because of personal circumstances (e.g., being older,). participants also expressed new learning about values from the workshop (typical). one participant said: i think the workshop helped in terms of just increasing my awareness about it. i think they’re things that i started to think about . . . learning about values and engaging in that continuous self-reflective process got me beginning to think about it and then this provided more of a streamlined framework for how to think about it instead of just brainstorming on my own. process. overall, participants described the values clarification process as one that is complex, difficult, and requires substantial reflection. for instance, participants found the values clarification process to be challenging at the cognitive level (variant): “it was difficult . . . it took a lot of focus, and thought, and reflection . . . it was like whoaaa! i felt like i needed to get reoriented.” there were also emotional elements in participant reactions to the process: i have that thought process where i’m like spinning out of control and . . . this is really resonating with me, and this is really salient. i know it’s important to me, like connecting with people, and i think that part gets overwhelming. sometimes participants felt frightened: “i think talking about values can be very scary, especially as we’re confused when we’re getting there.” one participant felt drained from the workshop by the process of being constantly engaged and genuine. in spite of its 22 grumet, fitzpatrick, yildirim, ananng, knoll table 1 domains, categories, frequencies, and illustrative core ideas for values clarification outcomes and process domains/subdomains categories/subcategories frequencya core ideas values clarity outcome workshop was somewhat helpful for advancing values clarity t (n = 12) gained awareness of values that mattered and was helped to build upon this awareness. arrived at clear act value v (n = 5) discovered values gratitude in workshop and wants to live more appreciatively. further clarity, did not get to core value r (n = 3) was aware family domain was important and explored this in dyad, got to certain layers, but difficulty identifying core act value. previous values awareness t (n = 11) has thought about values before and feels identifying values is an ongoing process. some new learning relative to values from workshop t (n = 9) aware of some values before, workshop helped her clarify more. minimal/no learning relative to values r (n = 2) well-developed values clarity prior to participating. process inspired further reflection on values post workshop v (n = 6) continued reflecting on identifying her value post-workshop but not enough processing time and it eventually “faded away.” time as barrier to values clarification process, which is complex v (n = 6) clarified value was about connection with others but was unable to fully flesh it out due to time constraints. process was challenging and overwhelming v (n = 5) process was difficult and required a lot of focus and reflection. felt overwhelmed and needed to “reorient.” helped articulate values r (n = 3) workshop has given her tools to articulate her values. highlighted values conflict/ hierarchy r (n = 3) realized values social connection more than other things. still wants to do well academically but feels like less of a perfectionist now. supports to process working in dyads/verbalizing about values facilitated values clarification v (n = 6) aware of values related to wellness before workshop, was able to explore more by discussing it with partner. values conceptualization changed to act v (n = 6) workshop changed way thinks about values; found the adverb and quality of action element interesting and values made more sense to her after learning this. workshop exercise “start, stop, keep doing” was helpful for values clarification v (n = 5) the “things i want to stop, start, keep doing” exercise was helpful; was able to see how these three things relate. a t = typical, v = variant, r = rare. 23 act value clarification difficulties, it seemed worthwhile: a participant noted that she was “emotionally overwhelmed” during the session but also that it was “an amazing and enlightening experience.” participants explained that a lack of sufficient time was a barrier to achieving values clarity, in this complex process (variant). several participants were only able to clarify the domain of their value and uncover some layers. one indicated that her value related to social connection, but explained: “the problem was that we didn’t have enough time in our dyad for me to really flesh mine out, which i think it’s why i’m in a weird head space about it.” another reported being able to identify her value was related to family and she “uncovered some layers” but was unable to articulate related actions. another participant noted: “ . . . i would’ve been very surprised if i had [achieved clarity]. . . . i’m in therapy right now and i’m kind of thinking, if i get there it might be in a longer process.” although they were not always successful in identifying core values, they indicated that the workshop inspired immediate reflection on values (variant) however some noted that they soon became distracted by other responsibilities. supports to the process. participants appreciated structured and concrete ways to think about values, and that these type of activities support the values clarification process. an activity enumerating the things “i want to start, stop, and keep doing” was nominated as helpful for values clarification (variant). one participant said that in looking at the things she wanted to stop doing she was able to realize that she had the tendency to be pessimistic and that considering values allowed her to recognize that she wants to be more appreciative. working with a partner was useful in achieving clarity (variant): “i was able to identify it and to kind of just talk about it. and i think the more you talk about it, the more it makes it concrete, and more attainable.” participants also described how understanding the relationship of values to action facilitated values clarification (variant). one participant noted: to think about how its embodied or experienced in your life when maybe you haven’t acted in accordance with that value or the times that you have . . . it made it more of a concrete thing than just an abstract term that we throw around. domain 2: values-behavior congruence participants described both cognitive and behavioral processes leading to values-based actions and the barriers and supports to this endeavor. cognitive processes. participants began to engage in a number of cognitive processes in which the importance of the relationship between values and behavior became more salient. half of the participants came to understand that congruence is beneficial or that incongruence is detrimental (variant). some believed that acting congruently would make their lives “easier and less emotionally draining.” others had already experienced positive outcomes of congruence for example reductions in stress and burnout. one participant explained that although her behavior was not congruent at the time, “i think that if i actually put my values into action, i would be less burned out.” another participant believed that if she were to act congruently in the future: . . . then there will be that part of me that’s more fulfilled, which will be more nourishing and hopefully give me the space to really manage all the other things better, instead of feeling kind of constantly drained and in need of something that i’m not really getting. one participant described how when she acts incongruently, she feels a sense of guilt or dissonance but when she acts congruently she feels “ . . . whole, and more like herself.” participants reported gaining recognition of valuesbehavior incongruence as a result of participating in the values clarification process (variant). more specifically, they reported becoming aware of the areas of their lives where their values and behaviors were incongruent. one participant said: “for me it really highlighted the voids in my life and the things i wanted to make more full and live more authentically.” several of these participants also reported that the recognition of incongruence highlighted the need for behavioral change. for instance, one participant said: “i think for me was an eye opener because it was like yeah i really do need to start implementing these things in my life because there is not a balance.” participants also indicated that their sense of mindfulness was enhanced as a result of trying to enact values-congruent behaviors (variant). one participant 24 grumet, fitzpatrick, yildirim, ananng, knoll table 2 domains, categories, frequencies, and illustrative core ideas for values behavior congruence outcomes and process domains/subdomains categories/subcategories frequencya core ideas values behavior congruence cognitive insight congruence is beneficial and incongruence is detrimental v (n = 8) expresses insight that living in congruence with values makes life easier and less emotionally draining. recognition of incongruence v (n = 6) areas of incongruence were bought to awareness and helped her realize desire to begin implementing values congruent behaviors. increase in mindfulness v (n = 5) more self-aware and has made conscious efforts to choose values-congruent behaviors when she becomes aware of a challenging choice in the moment. use of values in decision making v (n = 5) uses values as a compass, which guides her decision making. motivation for behavioral change v (n = 4) workshop gave motivational push towards achieving her goals. behavioral effort/steps toward congruence t (n = 10) in process of trying out different behaviors to see which make her feel better. trying to implement more quality time with friends and see how that makes her feel. discussed successful efforts in congruence v (n = 8) feels successful in implementing values related to spending time with friends. difficulty implementation congruent behavior despite efforts/steps taken r (n = 2) after workshop, has been taking steps to ensure she can adhere to her goal (e.g., setting up yoga things beforehand) but she is still struggling to adhere to her health rituals. engaged in values congruent behavior prior to workshop v (n = 5) had been making a conscious effort to behave according to values for several years. was exposed to act valuing in the academic context too. barriers work demands t (n = 11) often behaves incongruently with values because in prioritizing school, her values are put on hold. lack of energy r (n = 3) set goals after the workshop but did not achieve them or make an effort to, attributes this to burnout. feels burnout is a barrier because when she feels burned out she does not want to do anything, which then contributes to further burnout in a “vicious cycle”. desire to look good/please others r (n = 2) there are times where she has acted in a manner incongruent with her values due to a desire to please others. 25 act value clarification explained: “i’ve been really trying to be more mindful when i do activities . . . trying to be more in the room . . . more present in the moment.” another described making an effort to stay present in leisure activities, despite her tendency to become consumed by her responsibilities: when i catch myself thinking, okay what do i have to do later i try to snap myself out of it and just go back to that moment and not think about all the other stuff. because it’s going to be there regardless of whether you think about it or not . . . i think the workshop helped me do that . . . just being more aware. another participant indicated that she is more conscious of moments where her behavior and values are incongruent leading her to question the purpose of her behavior and try to reframe her thinking. participants also described motivation for behavioral change as a result of the values clarification process (variant). regarding self-care, one participant stated: i sit there and think about it all the time, but i don’t actually do anything about it and i think the workshop really made it real for me . . . i should be starting to implement some things. and it’s funny because since the workshop i actually have. another described how she has struggled to implement values-congruent behaviors and continues to think about this: “even though i haven’t done it, i’m still trying in my head to make more realistic goals.” several participants also described using their values as a guide to making decisions (variant). one participant described values as a “guiding framework” to making big decisions. behavioral processes. participants reported taking some steps—big or small—to implement valuescongruent behaviors (typical). half of participants described successful efforts (variant), such as completing goals set in the workshop. others discussed more general steps such as intentions, or plans devised with a therapist or spending more quality time with friends. participants often reported having been intentionally engaged in values-congruent behavior before the workshop (typical). some of these individuals experienced less impact from participating in the workshop. domains/subdomains categories/subcategories frequencya core ideas conflicting values r (n = 2) does not know how to live “everyday values”, as feels that bigger values conflict with “everyday values. supports dyads helped congruence v (n = 8) checking in with partner was helpful. was thinking of not doing what she said she would but then realized she would have to tell her partner she did not do it. feelings of accountability v (n = 7) saying her goal out loud to her dyad partner gave her a sense of accountability. help with ideas for implementation r (n = 2) talking with her partner helped her to come up with a successful solution to implement one of her goals. writing/verbalizing ideas about values related behaviors r (n = 3) writing down the things she wants to do/not do is helpful, as she feels more responsible for acting on it. breaking goals down in to smaller steps/shorter time frames r (n = 3) felt the short-time frame helped her achieve goal; long-term goals can be scary to implement due to the commitment required. a t = typical, v = variant, r = rare. 26 grumet, fitzpatrick, yildirim, ananng, knoll barriers to congruent behavior. participants often reported barriers in one typical and three rare categories. participants indicated that work demands were barriers (typical). two participants explained that schoolwork and the pressure to be perfect served as barriers to values-congruent behaviour. two participants explained that although they are in school for a values-related purpose, it interferes with their ability to engage in congruent behaviours: “i feel like i know there is a purpose here and i love being in school . . . but it also does take a lot away from other areas in your life.” although work demands emerged as the most common barrier to values-behaviour congruence, some rare categories warrant discussion. values conflict was nominated as a barrier to congruence (rare). for example, one participant explained how her value of self-care and caring for others can sometimes create a conflict. some participants also discussed that a lack of energy or feeling burned out served as a barrier to living out their values (rare). finally, the desire to look good or please others was mentioned as a barrier to values-congruent behaving (rare): i realized lately that i really tend to adapt to others and i feel like i kind of lose myself sometimes too, like by trying to please others and trying to be kind of a superwoman . . . i find i don’t really stand my ground. supports for congruent behavior. participants also discussed how exercises that involved articulating intended values congruent actions, and breaking actions in to manageable segments facilitated values-congruent behavior. the particular supports discussed emerged as several variant and several rare categories. participants highlighted how having a partner gave participants a sense of accountability to the goals they set and supported values-congruent behaviors (variant). occasionally a partner helped another to generate ideas for values-congruent action (rare). verbalizing or writing about values made things seem more concrete and helped move some toward action or increased their commitment (rare): “i kind of feel more responsible for acting on it, now that i wrote it down . . . ” lastly, participants explained that breaking their goals down in to smaller steps and shorter time frames was helpful (rare). for example, one participant attributed success in achieving a goal to the short-term time frame; long-term goals were scary because of the commitment required. values and subjective well-being (swb) domain 3: mood participants often reported a positive mood change following the workshop (typical), however, there was variability regarding the attributions for positive changes. some nominated value-behavior congruence as responsible for the change (variant): “i think it’s more the actions that i took according to the things that i realized in the workshop.” one participant explained that exercising was a behavior related to her value of “freely being” and had a positive impact on her mood: “it’s been consistent in terms of the time that i put toward it, and it’s a huge influence on my mood . . . i just feel like the energy and the positivity was just coming from that.” another participant described values clarification as a catalyst: “the workshop had an impact . . . my other courses had an impact, my relationship with my boyfriend had an impact . . . i think the workshop and this process have kind of got the ball rolling for me.” domain 4: life satisfaction participants saw values-behavior congruence as increasing life satisfaction or incongruence as decreasing it (variant): i think it is enhancing it for sure . . . one of my values is family and sometimes when i am torn between homework or spending time with my kids for example, it helps me make that decision and i’ll spend time with my kids and in the end i am happy i did . . . the fact that i am using my values as a sort of compass enhances my life and my decision making. another participant explained that being in the counseling psychology program enhances her life satisfaction because it is congruent with her values. several individuals reported an enhanced sense of life satisfaction following the workshop (variant). two of these individuals explained that life satisfaction was enhanced due to an increased effort towards values-congruent 27 act value clarification behavior following the workshop. one of these participants stated: i’m more satisfied with my life right now . . . i’ve been really focusing on my relationship with my partner and we’ve been having an amazing two weeks . . . we’ve been really reconnecting, . . . just talking about it made me realize my values were a little off and that i want to be more present. several rare categories in the life satisfaction domain warrant mention. participants discussed a relationship between gratitude, valuing, and life satisfaction (rare). for instance, one participant explained that the values clarification process had increased her sense of gratitude and enhanced her life satisfaction: . . . school can be miserable, but i’m here for a reason. i have made that choice, i think learning how to reframe the things in my life that are sometimes a bit negative, trying to see the silver lining or be more grateful for the things i do have has kind of helped with my life satisfaction. additionally, three of the participants explained that they were satisfied with their life on a broad scale, despite daily stressors that diminished immediate satisfactions (rare): i know i want to be in school. i wanted to come to this program . . . so that’s good, i got in, i’m here. but . . . it takes away from all those little things that would probably make my everyday life a lot more satisfying. . . . so the workshop was kind of thinking about the things i can do while i’m in school to make things more enjoyable. domain 5: pleasure the only categories within the pleasure domain were rare (see table 3). domain 6: engagement participants reported seeing a relationship between flow and living out values (variant): “when i’m in those flow moments i’m not really, thinking of my values. but i guess what i’m doing gives me satisfaction because it fulfills my values.” another participant talked about the relationship between engaging and pleasurable activities: “it was helpful to think about the things that give me immediate gratification and made it less likely for me to do them . . . engaging activities are more in line with values than pleasurable activities.” another participant explained that she identifies one of her values as “living passionately or taking the time to live.” when she is in the moment, she feels that she is nourishing this value like times when she and her children draw together. domain 7: meaning half of the participants endorsed the idea that living out values contributes to a sense of meaning (variant): “an inherent part of valuing is the meaning it gives.” the fact of being in a counseling psychology program was one expression of values, for example contributing to the lives of others brings meaning by enacting a value related to kindness. discussion the valuing process although the participants of the study typically experienced new learning about values, the results underline the idea that values clarification is a complex process, involving both cognitive and emotional challenges. the complexity of the values clarification process (rogers, 1964; stewart, 1975) and the abstract nature of the construct (hitlin & piliavin, 2004; maio, 2010; eyal, sagristano, trope, liberman, & chaiken, 2009), have been well documented. these participants reported that exercises such as listing things they wanted to stop, start, and continue doing were helpful because they made the concept more concrete and tangible. discussing values aloud with a partner also helped to structure the process and address the difficulties of working with an abstract and vague construct. these findings are in line with levitt and colleagues (2006) who found that clients found structured interventions in individual therapy productive for developing insights; unstructured interventions allowed them to avoid emotional topics. similarly, research from group psychotherapy suggests that structured exercises can enhance engagement, communication, and problem solving and lack of structure can contribute to anxiety and hinder progress (johnson, 2009). given the emotional challenges of the values clarification process, the help provided by structuring may have reduced the ambiguity of the task and the anxiety associated with it. lessening the 28 grumet, fitzpatrick, yildirim, ananng, knoll table 3 domains, categories, frequencies, and illustrative core ideas for subjective well-being (swb) outcome and process domains/subdomains categories/subcategories frequencya core ideas mood positive mood change t (n = 9) workshop had an impact on her mood through realizations that influenced her actions after the workshop. attributed to valuesbehavior congruence v (n = 6) feeling better since workshop and attributes the difference in mood to changing her behavior to be more congruent with her values. attributed to other factors r (n = 3) attributes positive mood to weather and academic session in the summer being less heavy. negative mood change r (n = 2) mood was initially lowered, as a result of discovering incongruence between her values and behavior. does not feel it had an impact on her mood in the long term because the incongruence realization inspired her to think of ways to change her behavior. for unspecified reasons, participant 2 reports feeling more burnt-out, fatigued, a more negative mood and decreased concentration but does not feel that this is related to the workshop. emotional experience during/immediately after the workshop r (n = 3) felt very emotional, as a result of discovering incongruence during the workshop. life satisfaction expressed insight valuesbehavior congruence increases life satisfaction/ incongruence decreases life satisfaction v (n = 6) feels that when she lives out her values in the future she will have more life satisfaction. enhanced life satisfaction since workshop v (n = 4) since the workshop, her life satisfaction is “moderately higher,” although it is hard to quantify. she states that she has more stability across domains, as she is making a conscious effort not to let school override everything else in her life. she is trying to create more balance by working out and spending more time with family and friends. described relationship between life satisfaction, gratitude, and valuing r (n = 3) life satisfaction hasn’t changed dramatically since workshop. however, her increased sense of gratitude (e.g., appreciating her choice to be in graduate school even when things are difficult) since the workshop has helped with her life satisfaction. 29 act value clarification domains/subdomains categories/subcategories frequencya core ideas valuing helps create balance in life r (n = 3) made effort to “challenge” her current balance, as well as create more balance in life since workshop. broad life satisfaction despite daily stressors r (n = 3) expresses insight that when looking at her life broadly she is satisfied, as she is pursuing an educational path congruent with her values, but is not satisfied with her everyday life. being in school interferes with her ability to do other things she values (e.g. working out, volunteering) but she would not change that because she is satisfied with her overall direction. pleasure no change in way thinks about or engages in pleasurable activities since workshop r (n = 3) pleasure seeking behaviors, or the way that she thinks about them have not changed much since workshop. increased frequency of pleasurable activities since workshop r (n = 3) does not think workshop changed the way she thinks about pleasure seeking activities consciously, but notices that she has been trying to create a better balance in her life and increasing the amount of hedonistic activities (e.g., tv, partying). less rigid/feels less guilty about doing pleasurable things since workshop r (n = 2) feels that workshop influenced her pleasureseeking behaviors in that she is less rigid and is taking time to do things she enjoys. pleasurable activities require less effort than meaningful ones and done more often r (n = 2) feels that hedonistic activities require less planning and effort than meaningful activities; she engages in them because they are less daunting than other things and she knows they feel good. engagement sees relationship between flow and living out values v (n = 6) feels that engaging activities are more in line with values than pleasurable activities. no change in way thinks of/experiences flow sine workshop v (n = 6) does not feel that the way she thinks about or experiences flow has changed since the workshop. rarely/never experience flow v (n = 5) does not feel workshop had impact on engagement; does not recall flow moments since childhood. therefore does not see connection between values and flow r (n = 3) does not experience flow in her everyday life; therefore does not see a connection between valuing and engagement. meaning living out values contributes to a sense of meaning v (n = 8) notes that for her, values and meaning go together; if she acts based on her values it adds meaning to her life. 30 grumet, fitzpatrick, yildirim, ananng, knoll overwhelming nature of a complex task can help to sustain engagement in the process. when considering the process of translating values to action, the results of the current study indicate that both cognitive and behavioral processes are involved. this is consistent with the values literature, which suggests that values need to be cognitively activated in order to be enacted and to influence information processing and behavior (higgins, 1996; kruglanski, 1996; as cited in verplanken & holland, 2002; maio, 2010). in the current study, participants reported that through the process of trying to implement their values, they became more conscious of their behavior and were better able to recognize incongruence. this provides support for the idea that values must be activated. through this process, participants reported an enhanced sense of mindfulness, or present moment focus, which might be an example of this cognitive activation process. this particular finding is interesting because although mindfulness was not explicitly taught in the workshop, it is a fundamental component in the act model (hayes et al., 2006). research indicates that automatic processing tends to limit our ability to consciously choose values-congruent behaviors from moment to moment, however mindfulness can help us to intentionally choose values-congruent actions (brown & ryan, 2003; shapiro, carlson, astin, & freedman, 2006). in other words, mindfulness supports values-congruent behavior. the findings suggest, however, that valuescongruent behavior can support the development of mindfulness. perhaps a bidirectional relationship exists such that values-behavior congruence enhances mindfulness, due to the cognitive activation required in this process, and in turn mindfulness further supports the activation of values-congruent behaviors. despite indicating that values-behavior congruence was desirable, participants typically reported barriers to behavioral implementation. frequently reported barriers were work demands and the time for values work. these findings echo the self-care research, in which time is the most frequent barrier to psychology graduate students’ practice of wellness activities (el-ghoroury, galper, sawaqdeh, & bufka, 2012) or between workshop exercises (pakenham & stafford-brown, 2013). as values are intended to be expressed in moment-to-moment behavior (hayes, pistorello, & levin, 2012), trainees require more help to connect this process to their current dayto-day life. also of note, it was typical of participants in the current study to report being previously engaged in a form of valuing prior to participating in the workshop. this included reflection to clarify values, as well as an effort to implement values-congruent behaviors. many of these participants shared that this process began upon being exposed to act theory. the findings indicate that teaching act to trainees in an academic domains/subdomains categories/subcategories frequencya core ideas workshop helped to envision what they want/would bring meaning in the future r (n = 2) workshop helped her think of what matters in a broadened way, and consider her future and “the grand scheme of things.” currently not engaging in much meaningful activities but have ideas about sources for meaning in future (related to values) r (n = 2) the workshop impacted the way she wants her future life to be. feels it is difficult to achieve a sense of meaning while in school and sees herself developing this sense more in the future. sees her sense of meaning being related to her values in the future. sources social connection v (n = 6) workshop really resonated with her and made her aware that meaning and purpose comes from living out her value of social connection. helping others r (n = 3) derives meaning from becoming a counselor and feels that through helping others in her work she can live out her values. a t = typical, v = variant, r = rare. 31 act value clarification context might instigate a personal values clarification process. this experiential process might be beneficial both on an individual and professional level. values and subjective well-being values clarification and values-behavior congruence was related to eudaimonic (meaning and growth-based) but not hedonic pursuits (pleasure-based) for participants; half endorsed the idea that living out values contributes to a sense of meaning in life. kashdan and mcknight (2013) found that having purpose in life was positively associated with meaning in life and positive emotions. though purpose in life is not synonymous with values, the authors indicate that the constructs are very closely related (kashdan & mcknight, 2013). living according to values may enhance a sense of meaning and this may be the mechanism through which valuing enhances swb. act posits that living a values driven life can produce a sense of meaning and purpose (plumb et al., 2009) and the findings support this idea, however further investigation is needed to support the causal relationship between values and meaning. in the current study, participants typically reported positive changes in mood that they attributed, partially or completely, to increased efforts toward values-behavioral congruence. this relationship is consistent with the act literature; for instance, behavioral commitment to intrinsically motivated social values has been associated with positive affect (ferssizidis et al., 2010) and a perceived incongruence between behavior and personal values has been linked to negative mood states, such as dejection (maio, 2010), agitation (maio, 2010), anxiety and depression (nordin, wasteson, hoffman, glimelius, & sjoden, 2001). only a few (n = 4) participants reported enhanced life satisfaction. these findings are similar to ly and colleagues (2012) who assessed the impact of a mobile act intervention on life satisfaction among non-clinical participants after four weeks and found no significant changes. life satisfaction is a more stable construct than mood (kashdan & nezlek, 2012; nezlek, 2005; laurenceau, troy & carver, 2005) so that the effect of a single intervention was insufficient to create a level of change to affect life satisfaction. several participants indicated that although their life satisfaction did not change, they understood how values-congruent behavior congruence could ultimately enhance it. the few participants who experienced enhanced life satisfaction attributed it to either increased efforts in values-behavior congruence or an increase in gratitude due to the values clarification process. research suggests that gratitude has a robust, positive relationship with life satisfaction (emmons & mccullough, 2003; park, peterson, & seligman, 2004; wood, joseph, & maltby, 2008). this area requires further investigation. limitations several limitations to the current study warrant discussion. first, two weeks is a brief period for important change. more extended follow-up over time is needed. secondly, given that this was a pilot intervention study, the values intervention has not yet been empirically validated (e.g., by using a randomized controlled trial design). in addition, although the cqr method utilizes multiple coders and an external auditor to minimize researcher bias, the first author is a counseling psychology graduate student and may have biases regarding the experience of valuing and wellness in trainees. it is also important to acknowledge that some of the researchers (including students and a professor in the department) and participants had previous interactions being in the counseling psychology program. this might have created a sense of demand for a particular experience in the study for some participants. finally, it is important to note that the sample was self-selected; therefore, participants may share important characteristics that are not well understood. previous engagement in values clarification might therefore be an artifact of our study, either because participants had previous exposure to act in the counseling program or because they are innately reflective. future studies should aim to examine whether the experience of participating in this process is different for individuals without previous exposure to act. implications and future directions overall, the findings suggest that values clarification is a complex and challenging process, which requires much time and reflection. it might then be worthwhile to extend the workshop and offer it over a series of several sessions, as this format has been found to be effective for similar types of interventions (staffordbrown & pakenham, 2012; shapiro, brown, & biegel, 2007). the findings suggest that it is essential to teach 32 grumet, fitzpatrick, yildirim, ananng, knoll individuals to express their values in their moment to moment behavior, even if in small ways. given the difficulties involved in activating values-congruent behavior, values interventions could benefit from a greater emphasis on addressing barriers to valued living. with regards to swb, the findings indicate that values congruent living might contribute to a sense of meaning, which might in turn enhance swb. quantitative research is needed to examine causal mechanisms involved in the relationship between 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(2010). the valued living questionnaire: defining and measuring valued action within a behavioral framework. psychological record, 60(2), 249–272. retrieved from http://thepsychologicalrecord.siu. edu/ the physiology of psychotherapy graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university the physiology of psychotherapy: past, present, and future john thomas huber ii university of detroit mercy this paper will first locate the physical science of psychology in its historical context and explore the attempt of past eras to devise medical treatments for the mind. next, present research and clinical applications for the biology of mental disorders will be summarized, with emphasis on the importance of the mirror neuron system. lastly, overall conclusions will be drawn, and their implications for a truly holistic physiology-informed psychotherapy of the future will be discussed. this paper will ultimately suggest that while promising studies have been conducted on the subject, a considerable amount of work remains in order to surpass the soft embryonic stage of research development and to solidify its position in the science of clinical practice. the physiology of psychotherapy is a highly relevant issue today. for countless scientist-practitioners and practitioner-scholars who uphold both sides of their respective boulder and vail training models, the scientific interconnection of the mind and body is still searching for the right outlet of expression in case conceptualization and clinical practice. since psychotherapy is an instrument of self-revelation and health-promotion that is capable of benefiting many facets of human life, it must navigate a delicate balance of movement from unconsciousness to consciousness, from the force of self-constriction to the choice of self-liberation, and from poor bodily conditions to positive physical health. given an assumption of the mind and body as two sides of the same coin, clinicians have often striven in psychotherapy to equally value their clients’ mental and physical lives. however, throughout their training in graduate school and beyond, clinicians frequently accumulate as many new questions pertaining to the function of the physical body in “psychotherapy” designed for the mind as they discover answers. these various questions are often incarnations of just one basic inquiry, “what is palpably happening to the patient in a treatment with tangible results?” in the following paper, the answer will be sought through an examination of the physiology of psychotherapy with respect to; (1) the history of psychology, (2) the evolution of different brain regions, (3) the state of present research, (4) its clinical application to mental disorders, (5) the importance of the mirror neuron system, and (6) unique implications for the future. while most may agree that therapists help their patients cope with or conquer some life problem, it is difficult to explain how without reference to the nebulous process of loose word exchanges in talk therapy. for better or worse, these loose word exchanges comprise a foggy process forever wedged in the illicit border between subjective art and objective science. the physician laurence farmer1 (1950) once denounced the role of clinical therapist as being correspondence: john thomas huber ii, thomashuber_2@yahoo.com an “ill defined psychologist” (p. 175) with poor pseudomedical training. it might, therefore, be meaningful in one’s education to explore the less visible, underlying neurobiology of psychotherapeutic change, given that proper technique can literally alter the patient’s body and correct physiological malfunction. gilbert (1995) once argued that the field of psychology was in a fragile state of disequilibrium from its fragmented uni-dimensional theories opposing body versus mind, and he challenged the field to finally adopt a truly integrative “biopsychosocial” (p. 136) worldview. now almost a decade into the 21st century, gilbert’s plea has gained great ground, and popular opinion in the psychotherapy community is more supportive than ever of a genuinely comprehensive, holistic framework for humanity. historical roots in the past most societies, beginning from the 5th century b.c. and onward, have recognized a primitive anatomical fact: the brain is the biological apparatus of the mind (lewis, 1992). in approximately the 4th century b.c., the greek physician hippocrates proposed his humoral theory of brain functioning that stated bodily fluids, or physiological humors, are responsible for the psychological disorders of the mind (durand & barlow, 2000). by the time of the 17th century, philosopher rené descartes had combined renaissance ideas with scientific revolution notions to form his cartesian dualism, which effectively divorced the mind from the body as a separate entity for study (leahey, 2001). although he was unable to reconcile the seamless interaction of the body and brain with the mind and soul, descartes resorted to speculations about the pineal gland as their intermediary site, and he even wrote one of the first texts on the subject of physiological psychology, l’homme (leahey, 2001). centuries later, the exact relationship between the “brain” and “mind” was still incompletely known, and freud noted that “data do not include any direct relation between these two terminal points of our knowledge” (quoted in 3 huber 4 cappas, andres-hyman, & davidson, 2005, p. 374). incremental advances in the physiological sciences today, however, are beginning to illuminate much of the mysterious brain-mind interaction (lewis, 1992). historically, the revolution in the physiological sciences at the inception of the 20th century occurred in tandem with freud’s revolution in the psychological sciences. freud completed his medical training at the time of the earliest investigations into the neurological configuration of the brain, and his own research on brain physiology is what ultimately narrowed his focus to unconscious phenomenon (mitchell & black, 1995). thereafter, he propounded the first ever psychotherapy to systematically study and mend the mind. with his method wholly unknown to the rest of the world, though, freud felt compelled to justify psychotherapy as a valid science that was important in its own right independent of medical science. as a result, he adamantly opposed the medicalization of psychotherapy and strove to definitively dissociate psychotherapy from his very own training background in neurophysiology (mitchell & black, 1995). even until the last quarter of the 20th century, many psychologists still interpreted freud as having exclusively endorsed the study of behavior over the study of biology (innes, 1971). consequently, these psychologists largely ignored or neglected the neuro-physiological aspects of psychotherapy practice. on the other end of the clinical spectrum were the medical physicians who dismissed psychotherapy as mere pseudo-medical chicanery, which the psychiatrist gabbard (2001) called, “a remnant of persistent cartesian thinking that has led many skeptics to think that psychotherapy may be nothing more than balm for the ‘worried well’” (p. 1). schore (1997) inquired, “a century after freud’s project: is a rapprochement between psychoanalysis and neurobiology at hand?” and reiterated a rare admission by freud himself that “we shall have to find a contact point with biology” (p. 807). indeed, the century subsequent to freud’s era has constructed just such a bridge between biology and psychotherapy and, given the recent trend toward multidisciplinary science, the marriage of physiology and psychotherapy is no doubt one emerging example of the current scientific zeitgeist. evolution of the brain considering humanity to be the culmination of 670 million years of animal evolution on the 5-billion-year-old earth (palmer & palmer, 2002), it is unsurprising that adaptation, or balanced flexibility, is the natural design for improving fitness between an individual specimen and its environment (bernard, mills, swenson, & walsh, 2005). psychotherapy may, in fact, be defined as the installation of balanced adaptation through mediation of the lower default brain circuits, or survival instincts, with the higher cortical supra-system circuits, or centers of introspection (viamontes & beitman, 2006a). in other words, depending on the patient’s problem to be addressed, psychotherapy disentangles the internal conflicts between evolutionembedded id impulses and social herd-imposed superego restraints to promote negotiation and tolerance of these through the self-aware ego, all of which was freud’s tripartite interpretation of and testament to charles darwin’s evolutionary theory (hall, 1961; leahey, 2001). treatment with the animalistic id instincts involves the hypothalamus, limbic system, and cingulate gyrus-nucleus accumbens region of the brain for emotion formation, the pleasure of reward or the fear of punishment, and simplistic stimulusresponse situations (ito, 1998; viamontes & beitman, 2006b). for the societal superego conscience, treatment involves the parietolateral portion of the association cortex and the orbitofrontal-amygdalar region of the brain for sensorimotor processing and socio-emotional self-regulation (ito, 1998; viamontes & beitman, 2006b). and, treatment with the human’s ego self-representation involves the association cortex, sensorimotor cortex, and dorsolateral prefrontal region of the brain for executive control functioning, verbal abstraction, and analytical thinking (ito, 1998; viamontes & beitman, 2006b). the neocortex is one of the most important portions of the human brain which distinguishes it from lower animal brains, and the prefrontal cortex contains 30% of the human neocortex, thereby permitting humans the capacity for goal-directed action, expanded memory, and evaluation of future consequences (viamontes & beitman, 2006b). furthermore, the middle pre-frontal region of the brain is responsible for body regulation of the sympathetic and parasympathetic autonomic nervous systems, fear extinction, impulse inhibition, interpersonal communication, autobiographical knowledge, body awareness, self-reflective insights, empathy or perspective-taking, and pro-social concerns (siegel, 2006). the human’s frontal lobe began to evolve its proportionately greater size over the great apes’ frontal lobe about 20-25 million years ago, but has failed to evolve anymore in the past half-million years (bernard et al., 2005). since the prefrontal cortex is the anterior portion of the frontal lobe, the prefrontal cortex has remained largely the same for 500,000 years, too. there are three premier prefrontal cortex circuits in the brain, including the anterior cingulated circuit, the orbitofrontal circuit, and the dorsolateral circuit (viamontes & beitman, 2006b). while each of these brain circuits regulate specific parts of the patient’s mind during the psychotherapy process, in particular “the dorsolateral circuit is the entry point for verbal psychotherapeutic interventions” (viamontes & beitman, 2006b, p. 241), because of its integral role in executive control functions, higher-level logical reasoning, problem-solving, verbal abstraction, and behavioral modification from linguistic input. for instance, depressed people exhibit imbalanced reductions in blood circulation within the right dorsolateral prefrontal cortex as well as inferior parietal cortex (viamontes & beitman, 2006b) and, therefore, the clinician’s words spoken in psychotherapy directly impact and recalibrate the blood flow imbalances from this pivotal region of the brain. physiology of psychotherapy 5 present research and applications emotional disturbance, such as depression, is one of the most frequent complaints that causes people to seek treatment (barrera, torres, & munoz, 2007), which is thought to assist them in better balancing their maladaptive moods. with magnetic resonance imaging (mri) and single photon emission computed tomography (spect) imaging, psychodynamic psychotherapy for depression has been shown to increase the density of serotonin transporter (sert) binding at the midbrain sites of the raphe nucleus, which then correlated with the alleviation of depressive symptomatology (saarinen et al., 2005). another spect study which included a 1-year-long psychodynamic psychotherapy treatment demonstrated increases and ultimate normalization of serotonin metabolism and uptake in a patient suffering from comorbid major depressive disorder and borderline personality disorder (viinamaki, kuikka, tiihonen, & lehtonen, 1998). cognitive behavior therapy has indicated success in decreasing and normalizing thyroid hormone levels of thyroxine (t4) in depressed patients (joffe, segal, & singer, 1996). in another study with persons affected by negative emotions, it was learned that having the patients rename their emotional circumstances in unemotional words effectively decreased their negative emotional state, which involved stimulation of the lateral and medial prefrontal cortices in conjunction with de-stimulation of the amygdala as well as medial orbitofrontal cortex (viamontes & beitman, 2006b). imaging research has also demonstrated that the amygdala and orbitofrontal circuits, which help control emotional stability, can be successfully altered through the self-awareness thought processes within psychotherapy (viamontes & beitman, 2006b). past research has shown that anxiety relief and decreases in parasympathetic heart measures, like heart rate and variability from electrocardiogram (ekg) recordings, are correlated during therapy with positive self-talk by patients, as well as correlated with simply speaking about the therapy when contrasted with patients’ critical self-evaluations (anderson, 1956). the psychotherapeutic journey from unresolved anger and internal rage to feelings of depression and sadness depends upon sympathetic system activation, such as an increase in temperature of fingers and skin conduction, whereas parasympathetic system arousal, like high consistency of heart rate variation of between-beat intervals, corresponds to sadness elicited before the inducement of anger in therapy (rochman & diamond, 2008). a physiological study of psychotherapy found that clients’ feelings of uncomfortable tension with the therapist were manifested in the client’s increased heart rate, whereas feelings of antagonism against the therapist were manifested in the client’s increased skin temperature (dimascio, boyd, & greenblatt, 1957). as a result, intentionally impacting bodily markers, such as deliberately decreasing clients’ body temperature and reducing their heart rate among other vital signs, may be a relevant auxiliary goal of treatment. the “process of therapy may need to involve working through the anger to reach the pain” (rochman & diamond, 2008, p. 103), such that certain sympathetic system deactivations correlate with the process of arousing buried rage and then gently opening the patient to their associated sorrow. however, the reverse direction does not effectively decrease sympathetic activity, by first shifting from initial sadness to later anger (rochman & diamond, 2008), and should therefore be avoided by psychotherapists. in addition, when research subjects verbally discussed their feelings of rage, their sympathetic activity changes correlated with their self-reports of rage intensity, whereas when patients suffered silently without verbalizing depressive feelings, their parasympathetic system increases corresponded to their self-reports of depression intensity (rochman & diamond, 2008). given the neurological corollaries of emotional verbalization, psychoanalytic authors have declared that defense mechanisms, such as regression and repression, can be neurologically located at the brain sites of neurotransmitters with aversive, noradrenergic, and serotonergic reward stations (heilbrunn, 1979). self-awareness is dependent in psychotherapy upon the right prefrontal cortical region, although transcranial magnetic stimulation of this brain region interrupts selfawareness, which evolved alongside the right hemisphere and its cognitive capacities (guise et al., 2007). it has been noted, however, that disturbances of self-awareness and firsthand perspectives in the right prefrontal cortical region do not impede other-awareness or second-person perspectives (guise et al., 2007). thus, this region is implicated in the ability of patients to understand the therapist’s perspective when he or she empathically interprets to the patient, based upon the therapist’s own right prefrontal cortical region for understanding the patient’s perspective. furthermore, functional imaging research has demonstrated that stimulation of the left prefrontal cortex region is indispensable in the semantic processing of first-person perspectives as well as second-person perspectives, although the medial prefrontal cortex region is connected to selfreference features in the human memory system (heatherton, macrae, & kelley, 2004). the path of memory consolidation resulting in greater adjustment of synaptic plasticity is the main mechanism of information acquisition, retention, and storage for what is learned in psychological treatment (liggan & kay, 1999). therefore, psychotherapy that stimulates left regions as well as medial regions of the prefrontal cortex will be most successful in certain treatment cases, while other situations may demand more activation of the right region of the prefrontal cortex, as in the case of panic and phobias. one physiological study on psychotherapy for arachnophobia determined that linguistic-based cognitive therapy was effective through activation of the prefrontal cortex area, particularly on the right side, during exposure to spiders (johanson, risberg, tucker, & gustafson, 2006). successful post-treatment patients, who earlier had both huber 6 phobias and panic attacks in the presence of spiders, displayed an increase of regional cerebral blood flow in the dorso-lateral frontal cortex and enhancement of neocortical modulation for limbic reactions when in the later presence of spiders (johanson et al., 2006). successful post-treatment patients, who earlier had phobias with no panic attacks in the presence of spiders, displayed a decrease of regional cerebral blood flow in the prefrontal cortex, particularly in the right hemisphere, because they now demanded less strenuous selfmanagement of their reduced emotional response to the noxious stimuli of spiders (johanson et al., 2006). for obsessive-compulsive disorder, behavior therapy engendered comparable reductions in cerebral metabolic rates of glucose in the right caudate nucleus as did pharmacological treatment with fluoxetine (gabbard, 2000). in addition to the treatment of phobias, obsessions, and compulsions, the treatment of impulsive aggression (including violent offenses), the treatment of sexual compulsion, and the treatment of eating disorders may all rely upon activation of the prefrontal cortex (carlson, 2007). specifically, the treatment of impulsive aggression may entail the elevation of serotonergic input as well as serotonin transporters into the medial and ventral prefrontal cortex (carlson, 2007). the treatment of sexual compulsion may entail the stimulation of the right prefrontal cortex, which could inhibit sexual arousal and prevent inappropriate stimulation of the limbic system. lastly, the treatment of eating disorders may entail deactivation of the left medial prefrontal cortex, because this brain region appears over-activated in anorexic and bulimic persons (carlson, 2007). there is research evidence to suggest that prefrontal and frontal region executive dysfunction may be in part responsible for low treatment success among substance abusers, because these patients’ neuro-cognitive capacities such as attention, impulse inhibition, language, novel learning, and goal planning are impaired (weinstein & shaffer, 1993). the neural substrates of the medial prefrontal, the orbitofrontal, and the premotor cortices are believed to be responsible for the sensorimotor regression symptoms known as catatonia, which many psychoanalysts consider a defense mechanism of schizophrenia (northoff, bermpohl, schoeneich, & boeker, 2007). yet certain other difficulties, such as problems with basic attachment and interpersonal relatedness, may lead to the development of personality disorders, most notably borderline personality disorder (bpd). for bpd, psychotherapy must address the mesocorticolimbic dopamine pathways, as well as the anterior hypothalamus vasopressin circuits connected to the nucleus accumbens and ventral tegmental area, in addition to the dorsal cingulate cortex, the middle insula, and the striatum (fonagy & bateman, 2006). these brain regions are wired to the prefrontal cortex, and “the prefrontal cortex may activate the reinforcement system when it detects that the animal’s behavior is resulting in progress toward a goal. but the prefrontal cortex is a target of dopaminergic neurons as well as a source of their control” (carlson, 2007, p. 458). positive attachments, like the therapeutic relationship, are essential to patient improvement (cappas et al., 2005), and these intimate relationships activate the neuropeptide hormones oxytocin and vasopressin for attachment as well as the mesocorticolimbic dopaminergic pathways for positive self-reinforcement (fonagy & bateman, 2006). hence, various psychological disorders require the therapist’s attention be paid to the most relevant brain sites from where dysfunctions arise and from where rewards for positive relationship behaviors accrue, which is typically the prefrontal cortex. while much remains to be learned about how the material “brain” manifests as the immaterial “mind” and, by consequence, what the physiology of psychotherapy is, significant technological advances have nevertheless been made. although some neurobiological psychologists misconstrue contemporary research as a physiological rebuttal against and replacement for the allegedly antiquated notion of the unconscious (grotstein, 1999), it is widely accepted that the brain perceives as well as processes unconscious and non-linguistic data (cappas et al., 2005). it is further recognized that stimulation of the right prefrontal cortex alone provides non-linguistic knowledge of emotion from a patient’s or therapist’s voice intonation, rather than linguistic speech content (carlson, 2007). also, the anterior paracingulate cortex of the prefrontal cortical area is responsible for the comprehension of others’ intentions during social transactions (walter et al., 2004) which, in the context of psychotherapy, are essential for the patient and therapist to mutually understand each other’s motives and the effects of perceived motives. finally, the inferior parietal cortex and right hemisphere prefrontal cortex are instrumentally involved with psychological identification, dis-identification, counter-identification, and projective identification mechanisms (decety & chaminade, 2003), and so must be treated by the clinician with surgical care. mirror neuron system one person’s mere observation of another’s emotional expression activates the same neural pathways in the observer’s brain as in the emotionally expressive person’s brain (viamontes & beitman, 2006a). nerve cells known as “mirror neurons” enable the therapist to empathically experience the patient’s maladaptive emotional states (carlson, 2007), while the therapist simultaneously attempts to balance these states through intentional activation of the patient’s mirror neuron system (mns). harvard biomedical imaging research has documented that cortical thinning of gray matter in the mns region is associated with autism symptomatology and severity (hadjikhani, joseph, snyder, & tager-flusberg, 2006), for which reason autism spectrum disorder (asd) patients often lack the empathy and perspective-taking faculties imparted from the mns (martineau, cochin, magne, & barthelemy, 2008; oberman & ramachandran, 2007). italian neuroscience researchers, rizzolatti and gallese, were the first to haphazardly discover mirror neurons in the physiology of the brain and, http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22martineau%20j%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus physiology of psychotherapy 7 surprisingly, this accident did not occur until the 1990s (rothschild, 2004). the reason is that, although neuroscientists had identified empathy’s effect on the brain, no researcher had thought to search for empathy’s cause in the brain (rothschild, 2004). but with the anatomical root of empathy now known to be the mirror neuron system, the mns possesses the potential, in the opinion of famous neuroscientist v. s. ramachandran, to usher in and welcome the next major copernican-like revolution for psychology, similar to the previous revolutions of darwin’s evolution and freud’s psychoanalysis (rothschild, 2004). the mirror neuron system, located in the fronto-parietal circuit, pre-motor cortex, and superior-temporal sulcus of the brain (carr, iacoboni, dubeau, mazziotta, & lenzi, 2003; martineau et al., 2008; molnar-szakacs, kaplan, greenfield, & iacoboni, 2006), is what scientists depict as the neurological “execution-observation matching system…[of] action recognition” (buccino, binkofski, & riggio, 2004, p. 370). in other words, the mns internally recreates and represents to the same degree of complexity the intricate qualities of the external world, and “the mirror neuron system provides a fairly accurate simulation process of observed actions, mimicking internally the level of motoric complexity” (molnar-szakacs et al., 2006, p. 923). moreover, all behavioral action utilizes the exact same physiological substrates in the inferior parietal lobule as the internal perception of such action (rizzolatti, ferrari, rozzi, & fogassi, 2006), which has myriad ramifications for psychotherapy. for example, mirror neurons may explain the phenomenon of negative therapist experiences known as “compassion fatigue” and “vicarious trauma” when listening to patients’ profoundly abusive and painful life events (rothschild, 2004). psychoanalytic writers have suggested that mirror neurons represent the neurological source of such psychological mechanisms as identification and imitation (olds, 2006). indeed, the fronto-parietal, pre-motor cortical, and superior-temporal mirror neurons contribute an entirely new element of understanding to the psychodynamics of altruism, attachment, displacement, empathy, introjection, projection, reaction formation, transference, and countertransference, among other phenomenon. due to the mirror neuron system and its accordant internal motor simulation, the observation of others’ behavior can disrupt one’s own behavior (shmuelof & zohary, 2007), or can presumably improve one’s behavior if in psychotherapy, because the mns permits humans to learn by action imitation and behavioral understanding (rizzolatti & craighero, 2004). the dysgranular field of the insular lobe has links not only to the main brain regions containing the mns but also to the limbic system, thus interconnecting the compounded action-perception mechanism with the primary emotional processing operation (carr et al., 2003). therapists must rely upon this insular lobe interconnection to produce their empathic resonance and subsequent response to patients in treatment. however, therapists must learn to engage their patients’ amygdalar zone, anterior insular circuit, and superior temporal sulcus, because these regions are more highly activated by the imitation of facial affect than by the mere observation of such emotional expression (carr et al., 2003). the therapist must, therefore, successfully model adaptive stability for emotionally imbalanced patients, who may need to imitate or introject the therapist’s affective behavior. the anterior insular circuit also helps supervise one’s motoric self-control and personal agency (carr et al., 2003), so that empathy might be intimately related to one’s executive sense of self. for example, socially-deficient patients may learn to empathize with others just as their therapist empathizes with them. mcwilliams (1999) has depicted psychotherapy as “the science of subjectivity, in which the analyst’s empathy is the primary tool of investigation” (p. 2). but not only does the therapist employ empathy as a fundamental tool of treatment, empathy also serves as its fundamental goal. yalom (2003) suggested that clinicians must “help patients develop empathy for others” (p. 23) by enabling them to identify with and duplicate the empathy expressed by the therapist for the patient. if empathy is regarded as a form of love, then “therapy is essentially an attempt to help the patient gain or regain his capacity for love” (fromm, 1972, p. 84). this is congruent with freud’s dual claims that therapy both cures the patient through the experience of love and creates love in the patient for others (mcwilliams, 1999; welwood, 2000). given the contingency of psychotherapy on the mns, effective treatment will equip patients’ mirror neuron systems to more appropriately reflect their feelings and empathically respond to other persons. conclusion and future implications hence, physiology-informed psychotherapy might be viewed as a form of socio-linguistic biofeedback, whereby the therapist’s mirror neuronal output constructs a closed feedback loop with the patient’s mirror neuronal input as part of a reciprocal chemical interaction cycle. moreover, this model of treatment would understand the therapeutic relationship as a shared mindfulness meditation, in which both persons’ brain waves and body rhythms would symbiotically adapt and synchronously balance through clinically meaningful verbal or non-verbal exchanges to achieve homeostasis in the patient. the therapeutic atmosphere and environmental output offered by the clinician in the treatment room may also positively change the dormant gene expression of patients, by directing the transcriptional function of their protein manufacturing in relevant genes and guiding their synaptic interconnections (gabbard, 2000). this would further serve to increase the stress threshold of one’s genetic vulnerabilities and help promote protective factors in people predisposed to mental illness (gabbard, 2000), in accordance with the diathesis stress model. both biofeedback, which predominantly engages the analytical and linear functions of the left hemisphere in the brain, and mindfulness meditation, which predominantly engages the contextual and intuitive functions http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22carr%20l%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22iacoboni%20m%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22martineau%20j%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22molnar-szakacs%20i%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22kaplan%20j%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22molnar-szakacs%20i%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22rizzolatti%20g%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22ferrari%20pf%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22carr%20l%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22carr%20l%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22carr%20l%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus huber 8 of the right hemisphere, comprise two different quintessential methods for pursuing neurobiological changes and similar treatment outcomes (shapiro & zifferblatt, 1976). eastern mindfulness “meditation and western [bio]feedback and voluntary control produce the same end results” (p. 96), as noted in the psychiatric research of tomio hirai (1989) from the university of tokyo. mindfulness meditation, which has existed for more than 2 millennia but only in the last century became an object for scientific study outside of eastern religions, may be defined as the sustained purposeful awareness of one’s present mental and physical experience with non-judgmental acceptance (germer, siegel, & fulton, 2005). several authors have designated the construct of mindfulness as among the most fundamental “common factors” of all successful psychotherapies, regardless of theoretical orientation (germer et al., 2005; martin, 1997; 2002), because the mindfulness process involves a deepening awareness of how the brain, body, and mind mutually interact to promote health or restoration at each entry point. meditation techniques have been incorporated with great success into a number of extant treatments, including cognitive-behavioral therapy (hayes, follette, & linehan, 2004; roemer & orsillo, 2002; segal, williams, & teasdale, 2002), dialectical behavior therapy (linehan, 1993; robins, 2002), rational emotive behavior therapy (whitfield, 2006), and psychoanalytic-psychodynamic therapy (fromm, suzuki, & demartino, 1960; molino, 1998; safran, 2003; suler, 1993). the practice of mindfulness by therapists can even increase their empathic attunement with patients (lesh, 1970; shapiro, schwartz, & bonner, 1998) and, as a result, improve the affective performance of the therapist’s mns and its emotional reverberation with the patient’s mns. mindfulness works in large part through the de-automatization of habitually learned responses to particular punishment-reward contingencies, which is the same correctional mechanism operating in biofeedback training that promotes volitional control over preprogrammed, unconscious reactions (bogart, 1991; brown, ryan, & creswell, 2007; shapiro & zifferblatt, 1976). meditation exercise impacts blood pressure, brain waves, heart rate and variability, muscle tension, respiration patterns, skin temperature, and sweat gland activities all in a similar fashion to biofeedback (hirai, 1989; lehrer, 2003; zeier, 1984). since its first experiments a half-century ago, biofeedback training has utilized computer equipment to relay information back in real-time to clients about their autonomic nervous system functions and directions for physiological change (lehrer, 2003). biofeedback may be viewed as the cartesian convergence of clients’ first-person neurobiology and clinicians’ third-party perspective of external phenomena in therapy. as one clinician stated, “bf [biofeedback] modifies the basic client-therapist relationship, introducing a new dimensionthe client’s physiologyas a 3rd component of the important interactive processes” (watral, 1984, p. 11). biofeedback research, thus, becomes an efficient tool for optimizing the therapeutic alliance and behavioral techniques while studying the client's neurobiology during the process of psychological adjustment. the best current example of a professional discipline highlighting the physiology of psychotherapy is applied psychophysiology (ap), which divides its bipartite treatment approach into the complementary methods of biofeedback and meditation (lehrer, 2003). but ap is concerned with preserving the ideological purity of its theory, and it considers traditional talk therapy to be a territory infringement. prominent practitioner m. s. schwartz (1999), for example, claimed that to simply compare applied psychophysiology with conventional psychotherapy would render ap “useless” (p. 8). until empirical evidence demonstrates so, in the words of practitioner j. p. rosenfeld (1999), traditional psychotherapy interventions “are implicitly psycho-physiological interventions, but explicitly non-physiological” (p. 34). they therefore feel comfortable employing techniques from behavior and body-based treatments, yet reject talk therapies because they are apparently not physically conscious enough. although the merits of such reasoning is debatable, it is nevertheless clear impetus for other treatment modalities to more “explicitly” address the neurobiological process supporting their clinical practice, so as to better facilitate the fateful matrimony of physiology with psychotherapy. future research in this area may have influential repercussions for the greater integration of a truly holistic, physiology-informed psychotherapy of tomorrow. this might include concrete biological interventions that therapists can employ exclusively through verbalized words and non-verbal body language, as well as neurological insight into the patient’s transference and the therapist’s countertransference as the treatment process purposefully reinforces rather than blindly explores new mirror neuronal pathways. now that the 20th century has established talktherapy as a credible linguistic technology, the 21st century cultural zeitgeist might be to better integrate the world's multidisciplinary sciences, in terms of the mental health profession, through a mutually enriching relationship between physiology and psychotherapy that produces improved bio-psycho-social benefits to clientele. psychological problems can be addressed concomitantly from physiological perspectives, for instance, therapeutic engagement of the prefrontal cortex and frontal lobe regions are known to be critical for success in most treatments. likewise, therapeutic activation of the neuropeptide hormones oxytocin and vasopressin for social attachment, as well as the mesocorticolimbic and prefrontal cortical dopaminergic pathways for positive reinforcement, also appear critical for treatment success. all of these biological processes constitute part of what is palpably happening to the patient in a treatment with tangible results, if one were to answer the opening question originally posed. this paper has examined the physiology of psychotherapy with respect to; (1) the history of psychology, (2) the evolution of different brain regions, (3) the state of present research, (4) its clinical physiology of psychotherapy 9 application to mental disorders, (5) the importance of the mirror neuron system, (6) and unique implications for the future. an abundance of promising trends can direct the trajectory for scientific progress in this arena, and clinicians can learn therapeutic techniques that impact the physical provinces of the brain and body as part of a genuinely comprehensive, physiology-informed psychotherapy of the new century, whose frontier is waiting to be pioneered. references anderson, r. p. 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(1984). arousal reduction with biofeedbacksupported respiratory meditation. biofeedback and selfregulation, 9(4), 497-508. gsjp volume 16 final 86 graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 86 factors impacting ethnic minority student college adjustment marta i. krajniak, m.a. school of psychology, fairleigh dickinson university college freshmen are faced with a myriad of new challenges and many struggle with the transition into college. a substantial number of individuals who enroll at a university fail to persist through graduation as a result of gliàfxowlhv�wkh\�hqfrxqwhu�gxulqj�wkhlu�àuvw�\hdu���3rru�uhwhqwlrq�udwhv�duh�hvshfldoo\�vwulnlqj�dprqj�plqrulw\�xqdergraduates. understanding the obstacles to adjustment among incoming students of diverse backgrounds is fuxfldo�dv�wkh�àuvw�vwhs�lq�suhyhqwlqj�vwxghqw�gursrxw���7klv�uhylhz�h[dplqhv�olwhudwxuh�rq�wkh�lpsdfw�ri �glyhuvlw\� issues on college adjustment with the hope of informing clinicians providing services to a diverse student popuodwlrq���)dfwruv�lpsdfwlqj�plqrulw\�iuhvkphq�duh�glvfxvvhg�dqg�gliihuhqfhv�ehwzhhq�vshflàf�jurxsv�duh�h[dplqhg�� introduction graduation from college is an important milestone as it improves the prospects of a career and àqdqfldo� vhfxulw\�� �0dq\� lqglylgxdov�zkr�hquroo�dw�d� university, however, do not graduate. research indicates that students who drop out often do so for personal reasons such as social and emotional factors related to poor adjustment to college (bradburn, 2003; kalsner & pistole, 2003; kerr, johnson, gans, & krunmne, 2004). as many as 30-40% of incoming freshmen leave college prior to obtaining a degree, with the majority of these students maklqj� wkh� ghflvlrq� wr� gurs� rxw� zlwklq� wkhlu� àuvw� \hdu� (bradburn & carroll, 2002; consolvo, 2002). an examination of the obstacles that thwart adjustment to college among incoming students is a crufldo� àuvw� vwhs� wr� lpsurylqj� froohjh� uhwhqwlrq� udwhv� college enrollment has increased by over 35% from 2000 to 2010, representing a rise of both majority and minority student matriculation (u.s. department of education, 2012). the growing number of non-white undergraduates is posited to be a response to the changing ethnic and cultural landvfdsh� ri � wkh� 8�6��� dv� zhoo� dv� wr� diàupdwlyh� dfwlrq� policies (santos, ortiz, morales, & rosales, 2007). increased enrollment, however, is not paralleled by graduation rates among minority students. while on average 60% of white students that register at a university graduate with a bachelor’s degree, only 49% of hispanic students (lynch & engle, 2010a) and 40% of black students (lynch & engle, 2010b) earn their degrees. similarly, while undergraduate enrollment has been increasing among native americans, persistence and graduation rates for these students are the lowest of all minority groups (e.g., as low as 15%; guillory & wolverton, 2008; hunt & harrington, 2010; department of education, 2008). despite the breadth of research investigating overall student college adjustment, focus has only recently turned to exploring the unique factors impacting ethnic and/or racial minority freshmen; examination of these obstacles has gained momentum since wkh�sdvvlqj�ri �diàupdwlyh�dfwlrq�srolflhv�wkdw�surylgh� special opportunities for minorities in predominantly white universities. the following review examines the additional burdens to college adjustment faced by students from diverse racial, ethnic, and cultural backgrounds underlying the disproportionate retention rates in this population. although explicit treatment recommendations are beyond the scope of this article, the article highlights adjustment-related problems in the hopes that alleviating these gliàfxowlhv� zlwk� dssursuldwh� vxssruwv� zloo� lpsuryh� retention rates of minority groups. in addition, given the diversity of populations subsumed under the broad racial categories typically used in research (e.g., black, asian) this review notes the particular minority groups that were investigated, when such data were available, to illustrate distinct obstacles confronted by vwxghqwv�iurp�vshflàf�udfldo�ru�hwkqlf�edfnjurxqgv� keywords: college adjustment; minority students; minority stawxv�vwuhvv��vrflrhfrqrplf�vwdwxv��àuvw�jhqhudwlrq�froohjh�vwxghqw� 87 college adjustment adjustment to college is generally used to encompass a variety of factors historically assessed in terms of student academic accomplishment and retention rates, and, more recently, by the use of integrative self-report measures. for example, clark and trow (1966) posited that the student’s identiàfdwlrq�zlwk� wkhlu� froohjh� �l�h���pdwfk� lq�ydoxhv� dqg� beliefs) is pivotal to a successful academic career. tinto (1993), on the other hand, argued that academic and social integration, the level to which the student interacts with peers, faculty, and staff and adheres to the academic requirements, is central to an individual’s persistence through graduation. presently, there has been a movement towards an integrated assessment of college adjustment that takes into account academic, social, personal/emotional, and institutional attachment (baker & siryk, 1989). several integrative self-report questionnaires have been developed to evaluate students’ adjustment to college, which yield an overall adjustment score as zhoo�dv�vfruhv�iru�wkh�vshflàf�idfwruv���$prqj�wkhvh� measures is the college adjustment scales (cas; anton & reed, 1991). the cas was designed to provide a screen for college counselors to distinguish students seeking help related to college adjustment from those with other problems. the college adjustment rating scale (cars; zitzow, 1984) is a questionnaire that assesses four domains of perceived stress in the academic, social, personal, and family realms. the college adjustment test (cat; pennebaker, colder, & sharp, 1990) is a survey that assesses the degree to which students have experienced a variety of thoughts and feelings about being in college. finally, the student adaptation to college questionnaire (sacq; baker & siryk, 1998) is a self-report measure that addresses four aspects of college adjustment including academic, social, personal-emotional, and goal commitment-institutional attachment. the sacq was developed to help identify students at risk for dropping out and is the most widely used measure of college adjustment in research (credé & niehorster, 2012). a substantial body of research has explored factors predicting student college adjustment. studies frqvlvwhqwo\�lghqwlàhg�xqghujudgxdwhv·�dfdghplf�shuformance (credé & kuncel, 2008; wintre & bowers, 2007), institutional attachment (i.e., campus environmental aspects, involvement in campus organizations; hurtado & carter, 1997; wintre & bowers, 2007), social adjustment (e.g., social support from peers, family and professors; friedlander, reid, shupak, & cribbie, 2007; johnson, gans, kerr & lavalle, 2010; martin, swartz-kulstad, & madson, 1999), as well as personal and emotional factors (e.g., stress, depression; beyers & goossens, 2002; brooks & dubois, 1995) as directly and indirectly impacting students’ level of successful adaptation to college. for instance, alvan, belgrave, and zea (1996) demonstrated that among 77 undergraduates, satisfaction with social support zdv�d�vljqlàfdqw�suhglfwru�ri �ryhudoo�froohjh�dgmxvwment above and beyond stress experienced by these individuals. in addition, high school friendships dsshduhg� wr�eh�ri � ylwdo� lpsruwdqfh�gxulqj� wkh�àuvw� few weeks of college, whereas new college acquaintances were more predictive of college adjustment later in the year (swenson, nordstrom, & hiester, 2008). similarly, freshman gpa in 944 undergraduates predicted persistence to graduation (wintre & %rzhuv���������zkloh�odfn�ri �lqyroyhphqw�lq�wkh�àuvw� semester was inversely related to academic integration, institutional commitment, and persistence to graduation (berger & milem, 1999). overall, these àqglqjv�vxjjhvw�wkdw�vwxghqwv�zkr�vwuxjjoh�dfdghpically, experience the campus environment as adyhuvh�� gr� qrw� irup� vxiàflhqw� irupdo� dqg� lqirupdo� social connections, or who experience mental health problems during the transition into college might be at higher risk to leaving college before graduation. minority student college adjustment a smaller body of mostly recent research has begun to demonstrate differences in college adjustment variables among students of diverse backgrounds. for example, anglin and wade (2007) found that dgmxvwphqw� wr� froohjh� zdv� vljqlàfdqwo\� orzhu� iru� 141 black students compared to their white counterparts. similarly, while overall college adjustment for 76 native americans was comparable to other undergraduates, institutional attachment among wkhvh� vwxghqwv�zdv� vljqlàfdqwo\� orzhu� wkdq� wkdw� iru� a large caucasian sample (watson, 2009). african krajniak 88 american, hispanic american, and native american students were also found to have lower social adjustment and instuitional attachment when compared to caucasian students (hutz, martin, & beitel, 2007), while chicano students had poorer social adjustment as compared to other latino/a students (hurtado, carter, & spuler, 1996). despite the clear disparities in college adjustment, especially in the area of social and intuitional attachment realms, between various ethnic minorities and caucasian students, there is still a dearth of ad hoc investigation of the cross-cultural differences with research examining some ethnic and cultural groups, such as arab americans or indian americans, lacking completely. minority students college adjustment factors � &rqvlghulqj� wkh� deryh� àqglqjv�� lw� lv� hylghqw� that poor college adjustment might be underlying the relatively low retention rates among minority students compared to their increased presence on university campuses. the emerging body of literawxuh� lghqwlàhg� vhyhudo� yduldeohv� wkdw�srvh� dgglwlrqdo� challenges to non-white students’ assimilation into the undergraduate milieu including minority status stress, family/cultural factors, socioeconomic stawxv��6(6���dqg�àuvw�jhqhudwlrq�froohjh�vwxghqw�vwdwxv� (fischer, 2007; greer & brown, 2011; walpole, 2003). minority status stress recently, researchers began inquiring whether the distinct characteristics of minority students might confer additional burden to transition into college. the increased matriculation rates of various ethnic and racial student groups imply that many non-white individuals are enrolling in historically white universities. as such, undergraduates of diverse backgrounds might face minority status stress– additional and unique sources of stress associated with their status as a minority and the experience of discrimination and racism, that interferes with college adjustment (greer, 2008; smedley, myers, & harrell, 1993). � 1xphurxv�àqglqjv�vxssruw�wklv�dujxphqw���)ru� instance, among 1,096 minority freshmen of african-american, chicano, latino, american indian, and filipino origin and 300 caucasian matched stughqwv�� plqrulw\� xqghujudgxdwhv� h[shulhqfhg� vljqlàcantly higher rates of covert and overt racism and discrimination than their white counterparts, which frqwulexwhg�vljqlàfdqwo\�wr�sv\fkrorjlfdo�glvwuhvv�dqg� to inferior college performance (i.e., gpa), over and above the effects of gender, ses, race, high-school gpa, and sat (smedley et al., 1993). similarly, among native american students enrolled in a community college, the stress and anxiety associated with the college racial dynamics (i.e., level of discrimination or racial acceptance) were inversely related to students’ academic, social and personal-emotional college adjustment and institutional attachment (watson, 2009). a 1-year longitudinal study also showed that 54 latino/a freshmen experienced the campus udfldo�folpdwh�dv�lqfuhdvlqjo\�krvwloh�ryhu�wkh�àuvw�\hdu� (lopez, 2005). such perceived discrimination, in turn, resulted in the students’ developing an alienated sociocultural orientation (i.e., students become more dyrlgdqw�zkhq�suhvhqwhg�zlwk�glvfxvvlrq�ru�frqálfw� regarding race), decreased assimilation (i.e., associating predominantly with students from same ethnic or cultural background), and turning to their latino/a peers as a source of support. it is, thus, evident that minority undergraduates feel discriminated against on college campuses, and it is likely that such experiences negatively impact their satisfaction with the xqlyhuvlw\��zhdnhq�diàoldwlrq�zlwk�wkh�lqvwlwxwlrq��dqg� discourage social interaction. minority status stress, therefore, directly contributes to poor college adjustment among non-white students and might result in students leaving the institutions prior to graduation. differences across minority groups. while vwxglhv�frqàuphg�wkdw�plqrulw\�vwdwxv�vwuhvv�lpsdfwv� students of various ethnic, racial, and cultural backgrounds (ancis, sedlacek, & mohr, 2000; arbona & jimenez, 2013; awad, 2010), comparative research also revealed differences in the nature, type, and level of this experience between various minority groups. for example, among 111 asian americans, 76 latino/a americans, 50 african americans, reported minority status stress was higher in african american than asian american and latino/a american students (cokley, mcclain, enciso, & martinez, 2013). similarly, among 3,924 students enrolled across 23 u.s. xqlyhuvlwlhv�� eodfn� vwxghqwv� kdg� vljqlàfdqwo\� kljkhu� perceptions of negative racial climate than asian and minority student college adjustment 89 hispanic undergraduates, who had about an equal perfhswlrq�ri �qhjdwlyh�udfldo�folpdwh��exw�vwloo�vljqlàfdqwly higher than whites (fischer, 2007). further, black students are more likely to leave an institution due to the perception of racism than other minority students �)lvfkhu����������7khvh�àqglqjv�lqglfdwh�wkdw�dowkrxjk� minority status stress affects various student groups, these experiences seem to be most prevalent among black undergraduates and profoundly impact their decision to leave the institution prior to graduation. some researchers suggested that perhaps it is not just the magnitude, but also the type, of discrimination perceived by distinct minority groups that differentially impacts their transition into college. in that vein, though some researchers demonstrated that asian american students do not have adaptive problems related to minority stress (e.g., cocchiara & quick, 2004), others indicated that asian americans report higher impostor feelings than black or latino/a american students that are a stronger predictor of psychological distress than minority status stress (chang & demyan, 2007; cokley et al., 2013). imposter feelings– the sense of intellectual phoniness, is believed to stem from the stereotype of asian american students as the model minority who is intelligent, hardworking, high achieving, and academically striving. in contrast, lopez (2005) found that latino/a students experienced feeling that others perceived them as academically inferior and that they were admitted to the university only as a response to diàupdwlyh�dfwlrq�� �)xuwkhu��zkhuhdv�$iulfdq�$phuican students perceived more hostility and less equitable treatment by faculty and staff, latino/a and asian americans experienced discrimination in a less hostile way (i.e., limited respect and inequality; anflv�hw�do���������� �7khuhiruh�� wkh�vshflàf�vwhuhrw\shv� might be associated with the varied level of perceived minority status stress between different groups, their coping strategies, as well as retention rates. although most research on minority status stress addresses individuals with distinct physical characteristics (e.g., skin color), one study explored religious dress as a related factor. rangoonwala, sy, and epinoza (2011) found that among 54 muslim women, muslim identity was inversely associated with college adjustment. surprisingly, though, strict adherence to islamic dress was positively associated with college adjustment. given that over 80% of these students reported perceiving anti-islamic attitude post 9-11, authors posited that an association with that culture resulted in an experience of discrimination and isolation that negatively impacted the student’s college adjustment. the outward expression of acceptance of muslim religion via islamic dress, on the other hand, allowed students to identify each other and form communities that buffer students against minority stress especially in a university with a large muslim population. while skin color is one factor impacting minority status stress, groups exhibiting other visible signs of minority status or adkhulqj�wr�fxowxuh�vshflàf�ehkdylruv��h�j���sud\lqj�ehfore meals) may also experience discrimination that disrupt their social adjustment in college. further, wkhvh� àqglqjv� dovr� ghprqvwudwh� wkdw� zkloh� plqrulty status stress impacts students of various backjurxqgv�� vrph� lqglylgxdov�àqg� wkhlu�xqltxh�fkdudfteristics as a way to aggregate and support each other. college campus factors. as noted above, the racial climate and the number of same-group miqrulw\�vwxghqwv�suhvhqw�dw�wkh�vshflàf�xqlyhuvlw\�dgditionally impact the level of minority status stress. in a study of 160 asian american, african american, and latino/a american students in a predominantly white (90%) university, wei and colleagues found wkdw�xqlyhuvlw\�hqylurqphqw�zdv�d�vljqlàfdqw�phgldtor for the association between minority status stress and college persistence attitudes (i.e., students beliefs regarding the importance of and plans to complete college), beyond general stress, and that this pattern was similar for all ethnic groups (wei, ku, & liao, 2011). among 202 african american undergraduates, those attending a large predominantly white college in the midwest endorsed higher minority status stress than those attending a historically black university in the eastern u.s. (greer & brown, 2011). further, institutional type was the strongest predictor of academic performance in this study. conversely, african american freshmen at a predominantly black university reported better social, academic, and overall college adjustment than either african american or white freshmen at a predominantly white university, and better institutional attachment than afkrajniak 90 rican american freshmen at a predominantly white university (adan & felner, 1995). similarly, rodriguez, morris, myers, and cardoza (2000) examined whether minority-status stresses increases the risk of psychological maladjustment of latino/a students at a university where latinos constitute the largest ethnic group. their results indicated that among 338 latino/a (228 mexican american, 110 central american) undergraduates in a predominantly latiqr�vfkrro��plqrulw\�vwdwxv�vwuhvv�glg�qrw�vljqlàfdqwo\� impact the students psychological adjustment beyond demographic (i.e., gender, socioeconomic status, and ethnicity), sociocultural (i.e., level of acculturation), college role (i.e., generic college stress), and personal �l�h���odfn�ri �dfdghplf�vhoi�frqàghqfh��fkdudfwhulvwlfv��� 7rjhwkhu��wkhvh�àqglqjv�ixuwkhu�vxssruw�wkh�vxssrvltion that the racial climate of an institution has a direct impact on student college adjustment and retention rates, as those attending universities with a large same-group population endorse fewer problems perhaps due to lesser discrimination and/or more available support from other minority peers or faculty. racial identity. since discrimination and racism associated with status stress is more likely to impact minority students in predominantly white universities, on-campus association with students of diverse backgrounds could be an effective coping strategy to buffer against minority status stress. although increasing racial identity– the self-concept that incorporates individual’s knowledge and acceptance of one’s group’s history, values, and practices, has been vkrzq�wr�eh�hiàfdflrxv�lq�exiihulqj�djdlqvw�plqrulty status stress, research on racial socialization has also shown that internalizing racial identity (i.e., embracing only one’s own racial identity) has a negative impact on black students’ college adjustment whereas multicultural racial identity (i.e., embracing one’s own racial identity and feelings of connectedness with other minority groups) positively affects these undergraduates’ adjustment (anglin & wade, 2007). similarly, among native american students the ability to positively embrace one’s own group identity and aspects of the dominant culture’s identity had a positive correlation with academic and social adjustment as well as institutional attachment (watson, 2009). therefore, experience of minority status stress that results in alienation from the majority group and exclusive reliance on in-group support interferes with the development on multiracial identity consequently negatively impacting student college adjustment. moreover, lopez (2005) found that in addition to racial discrimination from other students, latino freshmen also experienced intragroup discrimination �h�j��� ´:k\� duh� \rx� dfwlqj�zklwh"µ��� �$fklhylqj� wkh� edodqfh� ehwzhhq� lqfrusrudwlqj� wkh� hwkqlf�vshflàf� and majority group characteristics to gain both native and dominant group acceptance further complicates the social adjustment among minority freshmen. collectively, the available body of literature implicates minority status stress as negatively impacting college transition among undergraduates from diverse backgrounds, which might at least partially account for the high drop out rates among these students. the preponderance of extant work, however, focuses on black undergraduates and there is a dearth of research investigating minority status stress among arab american, indian american, and native american students. it would be important to investigate whether, and if yes what type of, minority status stress impairs college adjustment for freshmen in these groups. socioeconomic status in addition to minority status stress, non-white students might experience the added burden associated with lower ses, which is often measured in terms of quality and level of education, parent ocfxsdwlrq�� dqg� lqfrph�� � 5hvhdufk� àqglqjv� vxjjhvw� that ethnic and/or racial minority students are more likely to come from households with low ses than white students (terenzini, cabrera, & bernal, 2001). for example, fischer (2007) found that 55-65% of asian and white students come from families that make an income of over $75,000 as compared to only about 42% of hispanic and 37% of black undergraduates. in terms of college adjustment and shuvlvwhqfh�� orz� 6(6� kdv� ehhq� lghqwlàhg� dv� d� ulvn� factor for inferior preparation for college (fischer, 2007; terenzini et al., 2001), poorer college academic achievement among freshmen (smedley et al., 1993), as well as lower graduation rates (mendez, mendoza, & malcolm, 2011; terenzini et al., 2001). it is important to note, however, that classroom particiminority student college adjustment 91 pation and involvement of lower ses students is similar to that of students with higher ses (walpole, 2003), which suggests the need to focus on other reasons related to these students’ drop out rates. several factors associated with low ses can impact students’ adjustment and persistence to graduation. financing college can be an additional stressor for undergraduates as many minority students depend on support from their families in paying school tuitions. parents, family members, or money from personal savings covers about 63-64% of white and asian undergraduates’ college expenses, compared to only 43% of hispanic and 33% of black students’ educational cost (fischer, 2007). in a study of 2,991 college students latino/a (mexican, mexican american, chicano, puerto rican, cuban, or other spanish/hispanic latino) undergraduates were more often confhuqhg�derxw�àqdqflqj�wkhlu�hgxfdwlrqv�dqg�wr�gurs� rxw�ri �vfkrro�iru�àqdqfldo�uhdvrqv�wkdq�qrq�/dwlqr� students (longerbeam, sedlacek, &alatorre, 2004). similarly, a qualitative study by guillory and wolverwrq��������uhyhdohg�wkdw�lqdghtxdwh�àqdqfldo�vxssruw� was one of the major barriers to college graduation among native american students. mendez et al. (2011), on the other hand, demonstrated that availdelolw\�ri �àqdqfldo� dlg�sdfndjhv�srvlwlyho\� lpsdfwhg� college retention rates among native american students, while aguayo and colleagues found increased vhoi�hiàfdf\�lq�0h[lfdq�$phulfdq�vwxghqwv�zkr�kdg� ehwwhu� shufhswlrqv� ri � àqdqfldo� uhvrxufhv� �$jxd\r�� herman, ojeda, & flores, 2011). it is likely that odfn� ri � àqdqfldo� uhvrxufhv� lv� dqrwkhu� idfwru� xqghulying the lower retention rates of minority students. � :kloh� odfn� ri � àqdqfhv� pljkw� gluhfwo\� uhvxow� lq� dropping out, low ses can also indirectly negatively impact minority students’ college adjustment. longerbeam et al. (2004), for example, found that latiqr�dv� zhuh� vljqlàfdqwo\� pruh� olnho\� wr� zrun� dqg� to work longer hours while attending college than non-latino/a students, and attributed needing to have a job to personal and family obligations (i.e., to earn money to support themselves, pay for tuition, and to send money home). further, students from low ses were less likely to live in dormitories (terenzini et al., 2001), with as many as 65% of native american students residing off campus (hunt & harrington, 2010). therefore, it is likely that minority students have less time to study and to participate in on-campus activities due to the extra time devoted to working or commuting, both of which negatively impact college adjustment. lastly, low ses students, especially those of minority status, frequently experience discrimination based on social class espefldoo\� dprqj�zklwh� diáxhqw� xqlyhuvlwlhv� �2vwuryh� � long, 2007), which further impacts their comfort zlwk�mrlqlqj�vrfldo�dfwlylwlhv���5hvhdufk�àqglqjv�jhqerally support this postulation. for example, among 12,400 students from over 200 colleges low ses african american undergraduates had less contact with faculty, spent less time studying, were less involved in extracurricular activities, had lower grades and worked more hours than their high ses peers or all african american students (walpole, 2008). research generally supports the notion that minority undergraduates are more likely to be of low 6(6� dqg� kdyh� pruh� gliàfxow\� àqdqflqj� wkhlu� hgxcation than other college students. consequently, while some drop out of school others either work or reside at home with their families to make colohjh� diirugdeoh�� � 7krvh� vwxghqwv� wkdw� àqg� phdqv� wr�àqdqfh� wkhlu� hgxfdwlrqv�pljkw�gr� vr�e\� vdfulàfing both academic and social college opportunities. family and cultural factors while transition into college provides an opportunity for many students to become more independent of their families, for some enrollment at the university does not afford such freedom. in addiwlrq�wr�uhvlglqj�dw�krph�iru�àqdqfldo�uhdvrqv��fxowxudo� norms, especially values regarding family interdependence and independence, might further complicate the transition into college for some minority groups. for instance, whereas in the white american culture individuality and independence might be stressed, the hispanic culture emphases familismo in which youth are expected to prioritize family needs and spend considerable time with their families and provide hprwlrqdo��àqdqfldo��dqg�shuvrqdo�vxssruw�wr�idplo\� members. similarly, many asian cultures emphasize collectivism, and, although a wide variability exists within the black community, family needs are typically prioritized over other responsibilities. underkrajniak 92 graduates from backgrounds stressing family interdependence might be required to run errands, work, care for siblings, or attend to other family obligations rather than studying or engaging in academic or exwudfxuulfxodu� dfwlylwlhv�� �7kxv�� fxowxuh�vshflàf� idplo\� dynamics can put an additional strain on the transition into college for some minority groups, especially for students for whom cultural norms and family expectations clash with the demands of college life. in line with this supposition, chang, heckhausen, greenberger, and chen (2010) investigated students’ perceptions of family agency among 515 freshman students of east asian american, west asian amerlfdq�� )lolslqr�3dflàf� ,vodqghu� $phulfdq� dqg� (xurpean american descent. while shared agency was ghàqhg�dv�sduhqwdo�vxssruw��frooderudwlrq��ru�dffrpmodation in regards to educational goals, non-shared agency was described as parent un-involvement or diuhfwlrq�frqwuro�ri �wkh�jrdov���7khlu�àqglqjv�lqglfdwed that all asian american students reported higher ohyhov�ri �shufhlyhg�qrq�vkduhg�djhqf\��vshflàfdoo\�ri � parental directing, and lower levels of shared agency, than european american students. furthermore, the study demonstrated that poorer college adjustment among the asian american cohort emerged as a direct result of the students’ perceptions of agency with sduhqwv���6xfk�àqglqjv�vxjjhvw�wkdw�glvfrug�ehwzhhq� the students’ and the families’ college goals might revxow�lq�wkh�xqghujudgxdwhv·�gliàfxowlhv�lq�dgmxvwphqw� and eventual decision to withdraw from a university. further, while all students shared the common goals of attending college as a means for gaining money in the future, obtaining a good job or a career, and for personal growth and learning, asian, latino/a, and african american minority students reported also being motivated to attend college to help their families and to prove one’s self-worth (phinney, dennis, & osorio, 2006). relatedly, tseng (2004) found that among u.s. born children, asian 3dflàf�$phulfdqv�sodfhg�pruh� lpsruwdqfh�rq�idpily interdependence than did european americans with no differences between latino, african/afro-caribbean american and european american students, whereas students with non-american parents valued interdependence more than those with parents born in the u.s. with no differences among the minority groups. the study also demonstrated that those with higher family interdependence spent more time on family obligations, and although attitudes about family obligations contributed to greater academic motivation among youth from immigrant, compared to u.s.-born, families the greater behavioral demands experienced by that group had negative impact on academic achievement and academic adjustment. thus, although initially family factors might contribute to minority students’ reasons to attend college, the added responsibilities or pressure might eventually interfere in college adjustment. although scarce, studies also indicate that native american students struggle to navigate between the demands of college and cultural or tribal expectations (juntunen et al., 2001; hunt & harrington, 2010). for instance, hunt and harrington (2010) described a mismatch between tribal values of independence and the need to form social and institutional attachments while transitioning into college that might result in students’ loneliness and isolation. native american undergraduates reported feeling isolated from their tribal culture and simultaneously alienated from faculty and students on the college campus, which negatively impacts their adjustment and retention rates (thompson, johnson-jennings, & nitzarim, 2013). clearly, cultural factors might not only diuhfwo\� frqálfw� zlwk� wkh� vwxghqwv·� jrdov� dqg� froohjh� responsibilities, but might also guide their decisions regarding seeking assistance or resources on campus. a quantitative study of 132 diverse students by terenzini et al. (1994) nicely demonstrated the complex nature of transition into college for minority students. the content of the study’s focus groups indicated that for many white students going to college is seen as the continuation of a family tradition, whereas minority students experienced going to college as a “break” from tradition. additionally, miqrulw\�vwxghqwv·�dffrxqwv�kljkoljkwhg�wkh�frqálfwlqj� experience of, on the one hand, feeling that their family was supportive of their college career, and on wkh� rwkhu�� h[shulhqflqj� gliàfxow\� pdlqwdlqlqj� idplly responsibilities while meeting academic demands. � 7rjhwkhu�wkhvh�àqglqjv�lqglfdwh�wkdw�fxowxuh�vshflàf� idplo\� idfwruv�� vxfk� dv� sduhqwdo� h[shfwdwlrqv�� goals, and involvement might negatively impact stuminority student college adjustment 93 dents’ ability to perform academically and to assimilate into the college milieu. further, students who tend to place more value on their family obligations pljkw�h[shulhqfh�pruh�vhyhuh�frqálfw�ehwzhhq�wkhlu� college responsibilities and family expectations. future research needs to investigate the additional impact of immigrant status on the relationship between family values and minority students’ college adjustment, as the distinction between immigrant and native-born minority groups is rarely made in studies. first generation college students � )lqdoo\�� plqrulw\� vwxghqwv� duh� riwhq� wkh� àuvw� ones in their family to attend college (terenzini et al., 2001). among almost 4,000 students only 9% ri �zklwh� dqg�����ri �$vldq� vwxghqwv�zhuh� wkh�àuvw� in their family to go to college, compare to 30% of hispanic and black students (fischer, 2007). nawlyh�$phulfdqv� duh� hyhq�pruh� olnho\� wr� eh� wkh� àuvw� in their family to go to college (hunt & harrington, ������� � 0lqrulw\� iuhvkphq� zkr� duh� àuvw� jhqhudtion college students are at a further disadvantage compared to those who can draw from their parents’ or siblings’ college experiences and support. parents who have no college experience are often ill equipped or lack the vital information to assist their children in the transition into higher education. for instance, among 100 minority (84 latino, all mexican or central american; 16 asian, all chinese or chiqhvh�9lhwqdphvh�� àuvw�jhqhudwlrq� vwxghqwv� zkrvh� parents did not complete college, students perceived their peers as better able than their family members to provide the support they needed in order to succeed in college (dennis, phinney, & chuateco, 2005). similarly, friends, not family support moderated the effects of stress on psychological adjustment in mexican and central american latino/a college students (rodriguez, mira, myers, morris, & cardoza, 2003). 7khuhiruh��àuvw�jhqhudwlrq�froohjh�vwxghqwv�pljkw�qrw� be able to count on their parents’ ability to assist them in college-related matters. additionally, these individuals have the additional burden of stress associated with forming interpersonal connections at college as means of support regarding the transition into the university, and might be at an increased risk of dropping out if such social connections are not attained. importantly, many minority students might have foreign-born parents who, although have obtained higher degrees, had different experiences than those of their u.s. born children. for instance, fischer (2007) found that over 60% of asian students have at least one foreign born parent, as compared to 50% of hispanic students, 20% of black students, and 9% of white students. therefore, many minority students with foreign-born parents might share experiences vlplodu�wr�wkrvh�ri �àuvw�jhqhudwlrq�froohjh�vwxghqwv��� � &roohfwlyho\�� wkhvh� uhvxowv� vxjjhvw� wkdw�àuvw�jhqhudwlrq� froohjh� vwxghqwv� dqg� àuvw� jhqhudwlrq�$phuican undergraduates are at a disadvantage regarding college preparation. those who are experiencing academic and adjustment problems and require guidance must rely on other students for support, rather wkdq� wkhlu� sduhqwv�� � )dploldo� frqálfw�� vwuhvv�� ru� uhsentment might also emerge when freshmen seeking help from their parents regarding college-related issues are faced with misguidance or lack of aid. differences across minority groups a comprehensive longitudinal study by fischer ������� lqyhvwljdwhg� qrw� rqo\� wkh� vshflàf� glvdgydqtages minority groups face when compared to their white counterparts, but, more importantly, how these factors differentially impact students’ college adjustment across various ethnic groups. fischer utilized data of 3,924 students from the national longitudinal survey of freshmen who entered 28 us universities in 1999. an equal number of randomly selected white, black, hispanic, and asian freshmen from each institution were selecthg�zkr�zhuh� dvvhvvhg� dw� wkh� ehjlqqlqj�ri � wkh�àuvw� year of college, the spring semester of freshman year, and each following spring through graduation. fischer’s results underline several noteworthy gliihuhqfhv� dprqj� wkhvh� udfldo� jurxsv�� � 6shflàfdoo\�� dqdo\vhv�uhyhdohg�wkdw�ehlqj�d�àuvw�jhqhudwlrq�froohjh� vwxghqw�vljqlàfdqwo\�lpsdfwhg�judghv��h�j���zdv�uhodwed to lower grades) for white and hispanic students but not for black and asian students, and that for the former having at least one foreign-born parent was uhodwhg�wr�kljkhu�judghv���7kh�odwwhu�àqglqj�lv�frqvlvtent with work by tseng (2004) demonstrating that parents’ immigration status is related to increased krajniak 94 motivation to achieve academically. these results may indicate that for some minority students such idploldo�prwlydwlrq�pljkw�exiihu�djdlqvw�wkh�gliàfxowlhv�dvvrfldwhg�zlwk�ehlqj�d�àuvw�jhqhudwlrq�vwxghqw�� overall, for all students, dropping out of college was more strongly related to experiences at college rather than pre-college variables (e.g., number of ap frxuvhv�lq�kljk�vfkrro���exw�wkh�vshflàf�idfwruv�yduied by group. for instance, having friends reduced the risk of leaving college for all students (white and minority). being involved in extracurricular activities decreased chances of dropping out by 83% for all minority students, but not white students, and was stronger for asians and blacks. for white and black students having more social ties outside of the college environment during the freshman year had a negative impact on college grades and increased the chances of drop out, whereas these ties were not related to hispanic and asian students’ grades. as reviewed above, hispanic students seek same group peer support as a result of perceived discrimination as well as guidance in college-related matters and might be an effective coping mechanism for this group. similar dynamics might be responsible for lack of negative impact on grades for asian students with strong social supports outside of the university. for black and white students, however, seeking external support might result in decreased involvement in on-campus social interactions and thus adversely impact college adjustment and institutional attachment, which is consistent with work by swenson et al. (2008). the preponderance of evidence suggests that intervening at the college level, instead of prior to enrollment, lv� qhfhvvdu\� dv� irvwhulqj� froohjh� dgmxvwphqw� vljqlàcantly improves minority students’ retention rates. further, having informal on-campus ties with one’s own ethnic group was negatively associated with hispanic student’s grades but in-group ties were positively related to asian students’ academic performance. this difference, as noted earlier, could be related to within group discrimination among some latino students (lopez, 2005), whereas for asian undergraduates association with same culture students might mitigate the experience of feeling like an imposter. lastly, being involved in more extracurricular activities was positively related to all minority groups’ grades, as compared to whites, supporting the notion that institutional attachment and involvement plays an especially important role in minority students’ college adjustment. in terms of college satisfaction, involvement in on-campus activities was the strongest predictor for black and hispanic students, but only marginally relevant to asian students’ college satisfaction. thus, differences emerge among minority students when addressing offand on-campus social relationships. overall formal on campus involvement with professors, study groups, organizations, athletics, and other activities for minority students might eh�prvw� hiàfdflrxv� lq� lpsurylqj� dfdghplf� shuirumance, satisfaction with college, and retention rates. the necessity and extent of own-group interactions, however, might depend on the particular minority student. increasing socialization with students of other and diverse backgrounds might constitute an important part of improving college adjustment and consequently retention rates of all minority students. clinical implications and future research the scope of research on college adjustment has expanded vigorously over the past two decades, recently including the exploration of obstacles faced by minority undergraduates. the available body of literature on the topic clearly implies that students of diverse ethnic, racial, and cultural backgrounds are more likely to face discrimination, be of low ses, have to navigate cultural and familial expectations that might frqálfw�zlwk�wkhlu�dfdghplf�ghpdqgv��dqg�pruh�riten have parents who did not attend college than white undergraduates, resulting in additional stress with the already challenging transition into college. these additional complexities have been linked with poorer college adjustment among minority students and as potential causes for their higher drop out rates. further, the above-described research demonstrates that various ethnic, racial, and cultural groups are differentially impacted by these variables and effective coping with such obstacles might differ widely. one resource available to students that are struggling with college adjustment is counseling and, thus, clinicians working with minority students should be aware of the particular perceptions and unique expeminority student college adjustment 95 riences of individuals to meet the distinctive needs of each undergraduate. in that vein, clinical programs should integrate into their curricula a throughout exploration of factors impacting college adjustment and train mental health workers in assessing and counsellqj�iuhvkphq�idflqj�vxfk�gliàfxowlhv���5hodwhg�surihvsional organizations should also disseminate emerging research and offer specialized continuing education courses to professionals serving minority college students. therapists should be sensitive to and strive to identify the particular struggles of each student, as well as access to resources, and work on developing coping strategies appropriate for each minority undergraduate. appropriate intervention during the initial stages of transition into college may affect the trajectory of the student’s college career (academic performance, social engagement, and retention rates) dqg� wkxv� kdyh� vljqlàfdqw� olih�orqj� frqvhtxhqfhv�� research on the unique factors adversely impacting minority students’ college adjustment, however, lv� vwloo� lq� lw�qdvfhqfh�� � 6ljqlàfdqw� olplwdwlrqv�ri � wkh� current body of research include the lack of distinction between various sub-cultures subsumed within the broad racial labels of black, asian, and hispanic. future research needs to recognize the uniqueness of the many ethnic and cultural groups that fall under such categories and conduct studies to inform how students from various cultures differ or are alike in their ability to transition into college. this can be achieved by allowing individuals to self-describe their particular ethnic, racial, or cultural group membership instead of forcing them to select one of the few broad categories. additionally, the sample sizes of many of the more discrete minority groups are small and there is a dearth of studies on some cultures, such as the native americans and arab americans. as the presence of these groups on college campuses increases, minority student participation lq�uhvhdufk�vkrxog�dovr�árxulvk�hqdeolqj�uhvhdufkhuv� to access individuals from a greater array of backgrounds. lastly, although the literature includes several qualitative and longitudinal studies, the majority of research exploring minority issues in college adjustment and persistence to graduation entails correlational studies utilizing self-report measures, many of which have not been designed to assess the unique challenges faced by minority undergraduates. future research should focus on developing measures of college adjustment that inquire regardlqj�wkh�h[shulhqfh�ri �plqrulw\�vwdwxv�vwuhvv��vshflàf� idplo\�dqg�fxowxudo�idfwruv��6(6��dqg�gliàfxowlhv�dvvrfldwhg�zlwk�ehlqj�dq�lppljudqw�ru�àuvw�lq�wkh�idplo\� to enroll in a university in addition to the academic, social and personal adjustment and institutional attachment factors assessed by the extant measures. the above-mentioned studies also raised the issue of the potential difference between immigrant and u.s. born minority groups. unfortunately, the available research rarely distinguishes between nativeand foreign-born undergraduates. immigrant vwdwxv��krzhyhu��fdq�kdyh�d�vljqlàfdqw�lpsdfw�rq�frolege adjustment. for instance, aguayo et al. (2011) irxqg� wkdw� àuvw� jhqhudwlrq� 0h[lfdq�$phulfdq� vwxghqwv� kdg� orzhu� ohyhov� ri � shufhlyhg� vhoi�hiàfdf\� than second-generation college students. therefore, future research should bear in mind and distinguish the additional impact acculturation might have on minority students’ college adjustment. there is a plethora of other variables that further impact student college adjustment. this review excluded gender, sexual orientation, substance use, and other relevant factors that interact with the above-mentioned stressors. future research should attempt to lqwhjudwh�wkh�suhvhqw�àqglqjv�dqg�vxfk�dgglwlrqdo�idftors and examine how different variables interact in either posing further challenges or affording unique strengths in the process of transitioning into college. references adan, a. m., & felner, r. d. 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(1984). the college adjustment rating scale (cars) manual. detroit lakes, mn: personal development consultants. krajniak gsjp volume 16 final graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 71 ethical research with people of color: implications for clinical and community applications alicia san miguel, b.s. jennifer moniz, m.s. washington state university department of educational leadership and counseling psychology mental health counseling and research with ethnic minorities and indigenous communities within the united states has evolved; yet cultural consideration should be evaluated in evidence-based research. some of the common errors in research include generalizing cultural groups and using white norms for comparison. the outcome of marginalization of these communities has developed mistrust with healthcare providers. this conceptual paper establishes wkh�uhohydqfh�ri �fxowxudo�gliihuhqfhv�dfurvv�pdq\�grpdlqv�dqg�lghqwlàhv�d�frpprq�fruroodu\�lq�rughu�wr�khos�doohviate past injustices of the ethnic minority population and indigenous communities. given these past injustices, it is vital to discuss avenues that will minimize detrimental effects. and examine possibilities for improving cultural and ethical standards in two regards: in client and therapist relationship and within social psychology research. developing a culturally sensitive environment in psychotherapy research is a growing need, economically and empirically. the current number of ethnic minority individuals in the united states is rising quickly (mindt, byrd, saez, & manly, 2010). according to the u.s. census bureau (2014), it is estimated that ethnic minorities (all diverse populations other than non-hispanic whites) compromise 37% the general population and that number is projected to increase to 57% of the population in 2060. of those ethnic minorities, a percentage are of indigenous origin (cunningham & stanley, 2003). with this increasing diversity, we as social scientists and practitioners are compelled to humbly adapt in therapeutic application and in psychological research. this paper will comprehensively examine culturally appropriate ways to collect data from ethnic minority and/or indigenous communities and culturally hiàflhqw� zd\v� wr� dsso\� hylghqfh�edvhg� wuhdwphqwv�� perspectives on the issue will incorporate culturally competent care from multitudes of frameworks including those from biomedical research, sociopolitical research, healthcare research, and psychological research. in order to reach the expectations of valuing clinical applications with ethnic minorities, we will examine the distinct characteristics that differentiate cultures (interdependence, spirituality, discrimination; hall, 2001), critically assess the common errors found in research, and offer culturally sound practices for therapeutic application and/or research data collection in ethnic minority and/or indigenous communities. there are dissimilar characteristics among cultural groups of ethnic minorities and indigenous communities; these include a group’s sociopolitical context and the historical relationship to their particular geographical region. as authors we chose to vshflàfdoo\�lghqwli\�wkhvh�wzr�pdmru�fkdudfwhulvwlfv�lq� evaluating cultural considerations. although indigenous communities such as aboriginals of australia, american indians (first nations), native hawaiians, and the maori of new zealand fall under the umbrella term indigenous owing to political colonization, we will not discuss sociopolitical implications. rather we favor using the term indigenous (specifically in the united states) through “an attractive ghàqlwlrqµ��6wdqoh\��������s��������,qgljhqrxv�frppxqlwlhv�sodfh�vljqlàfdqw�hpskdvlv�rq�krz�wkh\�uhlate to the natural world, which is strikingly different from other worldviews. three main worldviews include (a) the judeo-christian (western) view in which god is external and heaven is above, (2) the eastern view in which concentration is inward (e.g., in meditation), and (3) the indigenous view in which people have essential relationships with nature including wkh� odqgvfdshv� ri � wkhlu� frppxqlw\³wkhlu� ulyhuv�� mountains, seas, and land (royal, 2003). respectfully, we regard the label of indigenous according to wklv� ghàqlwlrq� udwkhu� wkdq� wkh� ghàqlwlrq� dvvrfldwhg� keywords: indigenous research, indigenous, counseling diversity, culturally diverse, counseling psychology, counseling research, diversity research, counseling competencies. corresponding author: alicia.sanmiguel@wsu.edu 72 san miguel, moniz with the sociopolitical restraints of people affected by colonization (blaser, harvey, & mcrae, 2004). although there are distinctions in experiences among ethnic minorities (e.g., asian americans, mexican americans/latinos(as), african americans) and those in indigenous communities, a comprqdolw\� ri � h[shulhqfh� h[lvwv� lq� lpsurshu� lghqwlàcation, compared with a white norm or standard, issues of microaggression, and mistrust of healthcare providers. we will discuss these themes as well as attempt to offer alternatives for alleviating these issues through culturally appropriate means of collecting research data in these communities and culturally sound ways of applying therapeutic techniques. common errors found in research grouping-mislabeling ethnicity and race are two of the most distinguishable terms used in ethnic minority research, yet they have been used interchangeably. ethnicity denotes shared values, culture, traditions, and sense of identity and group; it is a socially created construct wkdw� lv� xwlol]hg� iru� lghqwlàfdwlrq� �%krsdo� � 6hqlru�� 1994). race is more biologically driven and sociopolitical in context. in the realm of research, the terms ethnicity and race are utilized interchangeably and further complicate the cultural divisions that exist in each origin of race and/or ethnicity. for example, an individual is of one race but can identify from various hwkqlf�diàoldwlrqv��h�j��(wkqlf�lghqwlàfdwlrq�dv�3rolvk� dqg�,ulvk�exw�hvvhqwldoo\�fodvvlàhg�dv�rqh�udfh��zklwh������� � ,q� jhqhudo�� hwkqlflw\� lv� gliàfxow� wr� lghqwli\� lq� and out of research. grouping large cultures withrxw� ghàqlqj� wkh� glvwlqfwlrqv� ehwzhhq� wkhp� dqg� then comparing them may create confounding factors and/or common errors. for example, grouping commonly occurs through the collection of federal data (e.g., u.s. census; miranda, lawson, & (vfredu�� ������� whuplqrorj\� lqfoxghv� wkh� fodvvlàcation of four categories: hispanic, non-hispanic, asian, and caucasian. this terminology is ambigurxv� dqg� odfnv� dq\� vshflàf�phdqlqj� �%krsdo�� ������� let us evaluate the term hispanic for a moment. 7kh�whup�+lvsdqlf�zdv�àuvw�frlqhg�rq�wkh������8qlwhg�6wdwhv�&hqvxv�iru�ghprjudsklf�fodvvlàfdwlrq�sxusrvhv��$owkrxjk� wklv� lqvwdqfh�zdv� wkh�àuvw� wlph� wkh� 8�6�� jryhuqphqw� riàfldoo\� uhfrjql]hg� wklv� fxowxuh�� use of the term aggregated many cultures with spanlvk�ruljlqv�zlwklq� wklv� vlqjoh� fodvvlàfdwlrq� �5hlphuv�� 2005). individuals of spanish origin but from different regions including mexico, cuba, puerto rico, and central and south america were all categorized into one label, one umbrella term, hispanic. however, this term does not differentiate the many cultural differences among geographic regions. the mexican-heritage population alone varies in legal status, time in the united states, race/phenotype, generation status, dqg� odqjxdjh�áxhqf\� �*duftd�� ������/ysh]� �6wdqton-salazar, 2001). the use of the one category of +lvsdqlf�zlwkrxw�ghàqlqj�wkh�xqltxh�fkdudfwhulvwlfv� of any discrete cultures (e.g., mexican american vs. cuban) creates a misrepresentation, and simply speaking, is too broad of a label. there is a very distinctive difference between a mexican american (e.g., chicano(a), latino(a)) who was born in the united states and a puerto rican, who was born and raised in puerto rico but recently immigrated to the united states. in terms of labeling with the term hispanlf�� qrw� doo� lqglylgxdov� djuhh� zlwk� wklv� lghqwlàfdwlrq�� some individuals in the hispanic/latino(a) community associate the term with the negative connowdwlrqv� ri � jdqj� diàoldwlrq�� xqhpsor\phqw�� dqg� orz� degrees of education (austin & johnson, 2012). in some areas of the united states (e.g., los angeles), wklv� vhoi�lghqwlàfdwlrq� lq� wkh� +lvsdqlf�/dwlqr�d�� community has been noted as a development of an “emerging ethnic consciousness” (reimers, 2005, p. 32). so depending on the geographic region of the united states and the relationship one has with his or her identity, an individual of the hispanic/latino community may self-identify differently. hispanic/ latino(a) individuals may identify according to their geographic region (e.g., cuban, chicano(a), latiqr�d���ru�hyhq�0hvwl]r�� vhoi�lghqwlàfdwlrq� lq� uhvshfw� of spanish and amerindian roots; schaefer, 2000). similarly, this transition into more acknowledgedeoh�� uhvshfwixo�� dqg� hpsrzhulqj� vhoi�lghqwlàfdwlrq� has occurred for african americans, asian americans, and american indians. the standard terms have transitioned from “colored” to “negro” to “black” to “african american” and “oriental” to “asian” (dajani, 2001). the common goal in the evolutionary 73 ethical research with people of color changes with labeling is an attempt to socially redeàqh�rqh·v�rzq�jurxs��lqvwloo�jurxs�sulgh��dqg�lpsduw� greater self-esteem (smith & tom, 1992). it is vital in discussion, research, or in the therapeutic realm wr� lqyhvwljdwh� wkh� fxowxudo� ydoxhv� dqg� lghqwlàfdwlrq� of the subgroups rather than focus on an umbrella term that aggregates cultural/ethnic populations into one massive assembly. this descriptive distinction is ehqhàfldo�rxw�ri � uhvshfw� iru� wkh�xqltxh�gliihuhqfhv� each ethnic community or indigenous community has in conjunction with their experiential history. the white standard the comparative approach of using the white population as the norm or standard is concerning to say the least. with the growing interest in health disparities with ethnic minorities and indigenous communities, the normalizing population that was used for comparison shifted to the white (caucasian) population. although this shift was necessary to understand some of the variables that contributed to health disparities in that population, we as social researchers and mental health professionals are now orrnlqj�dw�ydulrxv�rwkhu�gliihuhqfhv��vxfk�dv�hiàfdf\� of treatments (e.g., cognitive-behavioral therapy with american indians). researchers should evaluate the xqghuo\lqj� klvwrulfdo� dqg� vrflrsrolwlfdo� mxvwlàfdwlrq� regarding how and why the white population should be appropriate as the standard control. in the same regards, the outcome of evaluating such health disparities has been translated in the media to be a negative perspective of health in diverse communities. alwkrxjk�lw�lv�gliàfxow�wr�frqwdlq�wkh�shuvshfwlyh�rxwvlgh� the construct of research, it is pertinent that those conducting research with culturally rich communities be aware of the high impact that may result from implications found in studies. furthermore, another possible avenue of alleviating this negative perception of ethnic minority health disparities is through analytical discussion of its social and cultural relevance in peer reviewed journal articles to clarify distinctions (bhopal, 1997). for example, may of the factors that contribute to health disparities (e.g. hispanics and african-american’s are twice as likely as whites to have diabetes mellitus) are due to structural bases of racism such as lack of access, stigma surrounding illness, and lower income rather than direct biological correlations (neville, spanierman & lewis, 2012). mistrust of healthcare providers another barrier that prevents adequate representation of ethnic minorities and indigenous populations includes a prominent mistrust of healthcare providers (miranda et al., 2002). according to the commonwealth fund minority health survey, 43% of african americans, 28% of latinos, and 5% of whites felt mistreated by healthcare providers because of their cultural background (boulware, cooper, ratner, laveist, & powe, 2003). this mistrust may originate from direct experience of the individual due to social cues (e.g., media) or from secondhand experiences (boulware et al., 2003). this frqfhuq� ohdgv� wr� gliàfxowlhv� lq� frqgxfwlqj� vwxglhv� wkdw� dghtxdwho\� uháhfw� wrgd\·v� glyhuvh� frppxqlwlhv�� if there is fear, hesitation, and mistrust on behalf of the participant with a healthcare professiondo��pruh� vshflàfdoo\� d� uhvhdufkhu�� lw� zrxog� eh� gliàcult to ascertain the validity of the data collected. historically, mistrust has arisen due to the ill zloo� wkdw� kdv� ehhq� lqálfwhg� xsrq� hwkqlf� plqrulw\� and indigenous populations. one major instance of major ethical racial bias is known as the tuskegee syphilis study (reverby, 2009). in 1932, united states public health doctors observed the course of syphilis in hundreds of african american men, offering little to no treatment even after the discovery of penicillin in a study called the united states public health service study of untreated syphilis in the male negro at tuskegee. this tainted study lv�lpsulqwhg�rq�rxu�vrflhw\�dqg�uháhfwv�xqhwklfdo�deerrances in medical research. at a later date, it was discovered that the same doctor involved with the syphilis studies had also done a similar unethical study regarding syphilis being introduced into guatemala prison populations with no consent (reverby, 2011). in response to an article published by reverby (2011) on the occurrences of this maltreatment on individuals in guatemala without informed consent, hillary rodham clinton, then secretary of state, and kathleen sebelius, then secretary of the department of health and human services (dhhs), offered a formal apology to the people of guatemala; president barack obama expressed his distress as 74 well to the president of guatemala (reverby, 2011). another such misappropriate handling was the negative perception of african americans during certain political eras in the united states. in the 1850s, psychiatrists labeled african american slaves who were compelled to run away from their white masters with a mental illness called drapetomania; later accounts were also noted in medical journals of a form of madness called dysaesthesia aethiopis when african american slaves disrespected their master’s property (metzl, 2010). although we have progressed into a more culturally sensitive environment, some of the most recent experiences of this negative perception of african americans is as recent as the civil rights movement. in the 1960s, as the political movement of the civil rights uproared, the medical community translated their political reactions into a new diagnosis. in bromberg and simon’s (1968) article “the ‘protest’ psychosis: a special type of reactive psychosis,” they denote a form of schizophrenia that african american men develop with hostility, rage, and delusional anti-whiteness after listening to malcolm x or aligning with any political militant resistance to the social order of whites. the negative perception of african american men and hostility due to the political resistance was dovr�gháhfwhg�lq�dqwlsv\fkrwlf�phglfdwlrq�dgyhuwlvhments such as those for haldol (haloperidol). these advertisements in the 1970s depicted a photo of an $iulfdq� $phulfdq� pdq� zlwk� d� fohqfkhg� àvw� �riwhq� seen in militant groups during the civil rights era), xqghu� d� fdswlrq� $́vvdxowlyh� dqg� ehooljhuhqw"� &rrseration often begins with haldol or haloperidol” (metzl, 2012). although it has been more than four decades since the publication of these campaign dgv�dqg�eodwdqwo\� uháhfwhg� udflvw� vwhuhrw\shv�ri �$irican american men, this skewed perception is still an open wound and continues to lay a foundation of mistrust between patient and medical professional. although not discussed here, other indigenous communities have been subjected to ill care by the phglfdo� àhog�� )ru� h[dpsoh��$phulfdq� ,qgldq�zrpen underwent unethical sterilizations in the 1970s by the indian health services without consent or just medical cause (carpio, 2004). the indescribable shame and fear that arose out of this experience has silenced an already oppressed culture. the sterilization process was due to the belief that native american women were a substantial threat to the colonial structure since they could reproduce another generation of colonial resistance (smith, 2003). the cultivation of many of these negative experiences from various ethnic/cultural backgrounds and indigenous communities still impact everyday inwhudfwlrqv��vshflàfdoo\�zlwk�phglfdo�frppxqlwlhv��,q� order for the medical community to rebuild a foundation with ethnic minority and indigenous communities, we must ethically approach individuals and be sensitive to cultural values in research data collection and in the clinical and therapeutic realm. clinical interaction themes that are more relevant to ethnic minority and indigenous populations include interdependence, spirituality, and discrimination (hall, 2001). implications for therapeutic environment � ,w� lv� gliàfxow� wr� xqghuvwdqg� zklfk� wuhdwphqwv� work with which populations if previous research has not carefully considered the cultural nuances among the various ethnic minority communities and/ or indigenous communities. the american psychological association (apa) has developed objectives to consider this sociocultural framework in psychological assessment, case formulation, therapeutic relationship, and intervention through an integrated approach called the evidence-based practice in psychology (ebpp; la roche & christopher, 2009). the ebpp denotes a more comprehensive approach to evidence-based practices that is more culturally sound and sets the tone for future evidence-based psychotherapy research (apa, 2006). however, although apa has acknowledged the need to be culturally sensitive to the needs of our diverse patients, there still has not been adequate evidence that ethqlf� plqrulw\� srsxodwlrqv� duh� surshuo\� uháhfwhg� lq� uhvhdufk� �0ludqgd� hw� do��� ������� ,q� rughu� wr� àoo� wklv� gap, we will discuss the common themes that are relevant across various ethnic, cultural and/or indigenous communities. these themes include issues of interdependence, spirituality, and discrimination. common ground: interdependence, spirituality, and microaggressions san miguel, moniz 75 � 9dulrxv� wuhdwphqwv� kdyh� ehhq� lghqwlàhg� dv� hyldence-based treatments for certain groups but have qrw� ehhq� dghtxdwho\�prglàhg� iru� fxowxudoo\� glyhuvh� populations. for example, one of the most widely used manualized treatments is cognitive-behavioral therapy (beck, rush, shaw, & emery, 1979). one zd\� wr� dghtxdwho\� uháhfw� d� fxowxudoo\� ulfk� sdwlhqw� lv� to utilize culturally sensitive treatments, which modify clinical interventions to be unique to the indiylgxdo� dqg� wkhlu� frppxqlw\�� 6rph� prglàfdwlrqv� include incorporating cultural components into clinical applications, for example, using racial identity development for african americans (carter, 1995), evaluating empowerment and indigenous problem solving for american indians (lafromboise, trimble & mohatt, 1998), identifying healing and value systems with asian americans (root, 1998), and discussing the family unit with latino americans (szapocznik, kurtines, santisteban, & pantin, 1997). one such example of a culturally sensitive modlàfdwlrq�lqfoxghv�&xhqwr�wkhuds\�iru�/dwlqr�d���+lvpanic populations. cuento therapy is based on bandura’s social learning theory; it utilizes cuentos (spanish language folk stories) in a cognitive and emotional framework to improve outcomes related to role-playlqj�� vrfldo� lqwhudfwlrq�� uháhfwlrq�� dqg� glvfxvvlrq� (ramirez, jain, flores-torrez, perez, carlson, 2009). 7kh�iron�vwrulhv�duh�lghqwlàhg�wr�eh�fxowxudoo\�uhvsrqsive on the various differences between latino(a)/ hispanic cultures. however, this form of culturally adapted therapy is limited such that not many studies have applied this approach across various latino(a)/hispanic populations. otherwise, these forms ri � prglàhg� wkhudslhv� duh� ydoxdeoh� lq� wkh� hiiruwv� of a culturally sound application in psychotherapy. apart from culturally sound treatments, we can evaluate common themes across various ethnic minority and/or indigenous communities. the themes that run through various multicultural applications include interdependence, spirituality, and discrimination as they relate to family and community. these constructs vary across different ethnic minorities but remain focal points of discussion. european americans are less likely to value interdependence and value internal attributes more than other groups such as latino americans and african americans (suro & wesman de mamani, 2013). furthermore, interdependence is emphasized more in collectivist cultures than in individualist cultures. interdependence. although the individualism-collectivism construct varies on a spectrum, vrph�vwxglhv�kdyh�lghqwlàhg�dwwulexwhv�ri �lqglylgxdoism as being higher in the united states, britain, and australia and collectivism attributes as being higher in samples from africa, asia, and latin america (triandis, mccusker, & hui, 1990). culturally sensitive therapy incorporates common values at the community level (e.g. using family therapy for a culture that values the family unit) in order to approach cultural groups with more interpersonal emphasis (hall, 2001). a common mistake in application of family therapy is using the european american middle class model with an individual from a culturally rich family with a dynamically different outlook, one parallel to collectivist values, such as those of asian americans, latinos(as), and the like. similarly, interdependence plays a large role in the matter of intrapsychic forces in the human experience for ethnic minorities and indigenous cultures (yeh, hunter, madan-bahel, chiang, & arora, 2004). in other words, if a mental health professional personally views the distinction of mind and body as separate, that lens of bias will cause a disconnect between the client and mental health professional. according to western psychology, there is a line of separation between spirituality, mental health, physical health, and overall well-being (grills & ajei, 2002; sue & sue, 1999). to clinically treat patients in a culturally and ethically appropriate manner, we should be attentive to such biases. spirituality. the view of approaching spiritual values has evolved within the application of diverse populations. the attention on this issue has grown gxh�wr�wkh�vljqlàfdqfh�ri �lwv�lqwhuzryhq�ihdwxuhv�zlwk� various multicultural dimensions including spiritual traditions, values, and worldview practices (power, 2005). in providing care for an ethnic minority or indigenous patient, spirituality may be an avenue for discussion. such application that is pertinent to therapy through prayer or evaluating spiritual healing experiences may be applicable in some cases where spiritual support is warranted in their family and/or community. the european american perethical research with people of color 76 spective of religiosity is different that other ethnic minority groups; in other various cultures spirituality lv� kljko\� lqáxhqwldo� rq� wkh� vrfldo� dqg� srolwlfdo� frqstruct of the community (hall, 2001). for example, spirituality for chicano/latino individuals shapes the way in which they raise their children in a social environment; the family is viewed as a “protective sanctuary” that honors their ancestors and engrains generational wisdom to the younger generations through prayers of god, angels and saints (koss-chionio & vargas, 1999; cervantes & ramirez, 1992). microaggressions. a pertinent theme that should be acknowledged with a culturally diverse client is the experience of discrimination and/or racial microaggression. these issues could be perceived as a hypervigilant response to the environment; however, it is evident that ethnic minorities experience discrimination much more than european americans (hall, 2001). although discriminatory practices are less common currently than in the period before the civil rights movement and the chicano movement, discrimination still persists (thomson & neville, 1999). discrimination has manifested into what is termed racial microaggression. racial micro-aggressions are “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative, racial slights and insults to the target person or group (sue et al., 2007, p. 273).” in order to competently address ethnic minorities and/or indigenous communities, mental health professionals should develop cultural competency, via cultural humility, to alleviate bias or microaggressions. this also contributes as noted earlier in the paper to issues of mistrust between healthcare providers and ethnic minorities, which leads to discrepancies in care. for example, european americans are more likely than ethnic minorities to obtain mental health care and are less likely to be misdiagnosed with psychotic disorders or depression (alvidrez & areán, 2002). in research alone, mistrust has evolved by earo\�h[sorlwlyh�vrfldo�mxvwlàfdwlrq�ri �hgxfdwlrqdo�vhjuhgation and slavery that is too vast a topic to discuss in this article (e.g., drapetomania: irrational desire of slaves to run away; bhopal, 1997). attitudes and perspectives towards mental health are valid issues worth discussing with an ethnic minority client. this discussion brings to light the generalizing of ethnic minorities through research errors and bias that emphasize health disparities rather than the underlying contribution factors that cause these health disparities. how do we alleviate these errors in the therdshxwlf� hqylurqphqw"� +rz� gr� zh� dfnqrzohgjh� wkh� lqmxvwlfhv� ri � wkh� sdvw� dqg� uhexlog"� :h� fdq� begin to heal the open wounds that the medical community has indirectly caused through the application of cultural competence, cultural huplolw\�� dqg� irfxvlqj� rq� fxowxuh�vshflàf� qhhgv� culturally relevant applications in client-therapist interactions cultural competence multicultural counseling competency. one ri � wkh� sulpdu\� frqfhswxdo� iudphzrunv� wkdw� àuvw� made headway in the multicultural world of counvholqj� sv\fkrorj\� vshflàfdoo\� zdv� wkh�0xowlfxowxudo� counseling competencies (mcc) model by sue et al. (1982). this framework had initiated a call to program accreditation standards (american counseling association, 2005), licensing regulations (council for accreditation of counseling and related educational programs, 2001), and mental health provider standards (apa, 2003). the model can be widely adapted for many cultural, ethnic, and/or indigenous populations. it consists of three areas of emphasis: (a) attitudes and beliefs: being aware of own attitudes, beliefs, biases, assumptions, and values of another culture; (b) knowledge: learning and understanding the worldview of other cultural backgrounds; and (c) skills: learning adequate intervention techniques dqg� vwudwhjlhv� wr�àw� wkh�xqltxh�qhhgv�ri � wkh� folhqw�� in order to have a high quality experience in training, students should seek cultural information and experiences (of self and other cultures), communicate and collaborate with other cultural groups, attend cultural events, and be open to learning about other cultural values/practices (ridley, 2005). cultural humility although cultural humility is minimally discussed within counseling psychology research, we should take into consideration that it is utilized across biosan miguel, moniz 77 medical research and nursing research. cultural humility differs from cultural competency; cultural kxplolw\�grhv�qrw�irfxv�rq�d�àqlwh�hqgsrlqw�ri �vdwisfying cultural competencies but rather on openness to the other (hook, owen, davis, worthington, & utsey, 2013, p. 354). in other words, whereas mcc is viewed as a way of applying and doing, cultural humility is approaching openness and a way of being with culturally diverse clients (hook et al., 2013). cultural humility is an evolving and dynamic process that lqyroyhv�wkh�folhqw·v�fxowxudo�qhhgv�� wkh�uháhfwlrq�ri � the therapist’s worldview, and appreciates that there is no end goal, rather a pursuit for development. encompassing a much deeper process of reáhfwlrq��fxowxudo�kxplolw\�grhv�qrw�irfxv�rq�frpshtence but rather on the recognition that daily exposure to various cultures affects the therapist’s views and brings about the realization of how much is not known about other cultural groups (yeager & bauer-wu, 2013). in a meta-analysis, perceived cultural humility of the therapist (from the client) overlapped with the client ratings of the therapeutic alliance in positive outcomes (owen, imel, adelson, & rodolfa, 2012). so it is believed that with more salient cultural humility on behalf of the therapist, the client may experience positive outcomes through a sense of self, increasing motivation and instilling hope (wampold, 2007). on a smaller scale, counseling psychologists should cater to the unique needs ri �wkhlu�folhqwv��dqg�wkhvh�fxowxuh�vshflàf�qhhgv�fdq� eh� lghqwlàhg�zlwklq�$3$·v�dssurdfk�wkurxjk�(%33�� &xowxuh�6shflàf�1hhgv�7kurxjk�(%33� ebpp has demonstrated the suggestions needed to identify fxowxuh��vshflàf�qhhgv�lq�wkh�wkhudshxwlf�hqylurqphqw��$owkrxjk�(%33�kdv�ehhq�eulhá\�uhylhzhg�lq� this paper, we should demonstrate the emphasis of this framework with culturally diverse populations. one of the objectives clearly emphasized throughout the ebpp guidelines is culturally sensitive psychotherapy. the ebpp guidelines also carefully frqvlghu�wkh�lqáxhqfh�ri �hfrqrplf�idfwruv��vrciocultural factors, and situational factors on the mental/physical health of a client (apa, 2006). although the apa task force of 2006 is a complex and comprehensive approach to evidence-based treatments and considerations for culturally diverse clients, the limitation of this approach consists of the lack of research that encompasses culturally prglàhg�lqwhuyhqwlrqv�dqg�fxowxudo�vhqvlwlylw\�wr� ethnic minority and indigenous communities. healing with indigenous people. in working with individuals who have various worldviews, such as indigenous populations, we need to acknowledge healing from a different perspective. indigenous healing takes a holistic outlook on well-being (singh, 1999; sue & sue, 2002). certain cultures attribute mental illness, deviant behavior, or chronic ailments to spiritual or cultural origins (harner, 1990; sue & sue, 1999; lee & armstrong, 1995). for example, although alternative medicine is viewed as an alternative to natural science and medicine, it is not uncommon for certain cultural groups to view it as primary line of treatment. mestizo communities (indigenous latino(a) origins) utilize plants, herbs, and medicinal teas for the treatment of mental/ physical conditions through a curanderismo (spiritual healer) in their communities (lara, 2008). in this regard, alternative medicinal treatments are not alternative at all to the healers and/or curanderos of a mestizo community (hernandez-wolfe, 2011). some indigenous considerations have been cultivated from work by lee & armstrong (1995), sue & sue (1999) and helms and cook (1999) in yeh et al.’s (2004) review of indigenous perspectives of healing. although the review accounts for various counseling and research considerations, the most pertinent to counseling are as follows: (a) be open and aware to indigenous healers and forms of healing, (b) reach out and connect with healers and incorporate their spiritual/healing beliefs into the therapeutic alliance, (c) understand that indigenous healing is not goal oriented and does not focus on technique ru�txdqwlàfdwlrq��$owkrxjk� wkhvh�duh�rqo\�d� ihz�ri � the listed considerations, they are not exclusive to the therapeutic alliance with indigenous populations. in order to fully encapsulate working with indigenous populations in research we will discuss research suggestions that can be applicable to ethnic minority populations as well, in the research and clinical realm (e.g., latino(a), indigenous populations, mestizo). culturally relevant applications in research ethical research with people of color 78 many of the recommendations that will be provided are similar to community-based participatory research (cbpr); however, cbpr can mostly be found in public health research rather than social science research (flicker, travers, guta, mcdonald, & meagher, 2007). this is not to say that this research method cannot make the transition to a more social science–based practice; however, it is vital to the authors to make a clear distinction of the themes more relevant to indigenous and ethnic minority communities in evidence-based practice research. cbpr “. . . is an orientation to research that focuses on relationships between academic and community partqhuv��zlwk�sulqflsohv�ri �fr�ohduqlqj��pxwxdo�ehqhàw�� and long-term commitment and incorporates community theories, participation, and practices into the research efforts” (wallerstein & duran, 2006, p. 312). some of the major challenges with cbpr include the participation of the community members and the control behind the initiatives of the researchers, and who has the primary control over the research process, data-collection, and data-dissemination. another challenge is based on the community consent and who provides the approval in each community (wallerstein & duran, 2006). cbpr is well established in literature for empowering and improving communities. however, it is important to note that the goals and outcomes of the research should not be solely determined by the researchers and should be a collaborative process with the community. ethnocentric perspectives should not be forced upon the individuals of ethnic minority backgrounds; rather researchers ought to work with the community to ensure that research is meeting the goals of the community and are relative to their worldviews. practice goals should be comparable to the goals of the community. one interesting recommendation provided in the cbpr research is that university-community partnerships should be developed (wallerstein & duran, 2006). however, it is important to mention that this may be a challenge, with the lack of higher educational institutions located in all communities of ethnic minorities. for example, in hawai’i, it is gliàfxow� iru� frppxqlwlhv� wr� ghyhors� uhodwlrqvklsv� with the university system as the main universities are located on the main island and many of the indigenous communities are located on the outer isodqgv���5hodwlrqvklsv�fdq�eh�gliàfxow�wr�ghyhors�edvhg� on travel time and costs, and cultural differences. another limitation is that the literature on cbpr does not show the effect of interventions in communities once researchers/clinicians have left the communities. much of the literature found on cbpr is based on urban health care research (minkler, 2005). with our focus being more on ethnic minorities and indigenous populations; the goals differ. in an urban setting, it is a bit easier to access populations of ethnic minorities, develop university-community relations, and have research meetings. in a more rural and culturally sensitive setting, more challenges arise with the key components of cbpr. relationships take time and effort to develop, with travel time and costs; urban-based research would be more hiàflhqw� wkdq� uxudo�edvhg� uhvhdufk�� 2xu� glvfxvvlrq� will focus on more humble collaborative approaches that are stronger and longer, withstanding the limitations of cbpr in order to establish longer and more salient relationships in the community. research implications for indigenous and/or ethnic minorities developing community relationships. due to previous injustices experienced by ethnic minorities (e.g., discrimination) and previous mistrust of healthcare providers, it is vital that when services are provided they meet the needs of the communities, families, and/or clients. most researchers and practitioners are operating from a western framework; thus, relationship development with ethnic minority patients and the indigenous community is the foundation of ethically sound research and practice. furthermore, building strong communal relationships that are more holistic, universal, and culturally sensitive will ensure more successful implications of clinically competent research (vicary & bishop, 2005). extra care should be taken to be involved in the community in which research and practice is executed. cultivating social relations is vital in building respect within the community (darou, hum, & kurtqhvv�� ������� � 0ruh� vshflàfdoo\�� exloglqj� vwurqj� wlhv� between community members and leaders in the research process helps unite researcher and community san miguel, moniz 79 through at a common framework. since researchers and practitioners can be viewed as outsiders that do not fully understand the culture, this can create a barrier to accurate cultural insight. without a deep xqghuvwdqglqj�ri �wkh�fxowxuh��uhvhdufk�àqglqjv�pd\� qrw� eh� suhvhqwhg� lq� d�pdqqhu� wkdw� lv� � uháhfwlyh� ri � the true nature of minority ethnic or indigenous life. uniting researcher with the community may also alleviate mistrust and help lessen fear associated with the experience of discriminatory and exclusionary history. understanding and respecting these hesitations is necessary in softening the negative perceptions of research in these communities. researchers and practitioners must gain a deeper understanding of the histories of a community and its culture to ensure stronger relationship development (darou et al., 1993). developing advisory boards. developing advisory boards among ethnic minority and indigenous communities to assist oversight of research from initiation to completion can foster trusting working relationships. the objective of these advisory boards would be to protect community values and its members through meaningful culturally relevant research (quinn, 2004). advisory boards would consist of surplqhqw�frppxqlw\�phpehuv�zkr�sod\�vljqlàfdqw� roles in the community, educational leaders, researchers with similar cultural backgrounds, and other relevant advocates. by establishing a community council board, researchers are opening community conversation and considering the input directly from those who duh�lpsdfwhg�e\�wkh�uhvhdufk�surmhfw�dqg�lwv�àqglqjv��� community advisory boards allow for a collaborative research relationship to develop between community members and researchers and continuous community engagement throughout the research process (canadian institutes of health research, 2010). the community board would play an active role in establishing project completion and assist in contributing their perspective on the cultural issues being evaluated. most importantly, the ethical responsibility would rely solely on the researcher regardless of the prominent role the community advisory board plays (darou et al., 1993). so we must keep in mind that researchers must establish this relationship while continuously maintaining ethically sound research in line with ethical review boards (e.g., internal review board). identifying community leaders/advocates. although the strategy of utilizing community leadhuv�lq�wkh�uhvhdufk�surfhvv�lv�ehqhàfldo�iru�dghtxdwh� representation, we must also emphasize the challenges associated with choosing the most appropriate advocate for the community. for example, there is no direct leader or groups of leaders in hawai’i representing native hawaiians. so how would a revhdufkhu� vhhn� rxw� d� frppxqlw\� ohdghu� wkdw� uháhfwv� +dzdl·l� lq�wkhlu�uhvhdufk"�$�srvvleoh�sursrvlwlrq�wr� this challenge is opening discussion with local hiswrulfdo� djhqflhv�� vshdnlqj� zlwk� sxeolf� riàfldov�� dqg� speaking to individuals in the community. although this pursuit is more time consuming and takes a great quality of effort, it contributes to an open and trusting relationship with the people (ball & janyst, 2008; schnarch, 2004). the relationship built between the researchers and community should not be brushed over, as strong bonds are necessary to ensure culturally responsive research that may pave more opportunities for research to be conducted in the community. creating this new trusting relationship may aid some ethnic minority and indigenous communities to combat the injustices faced in history (johnstone, ������� � )xuwkhupruh�� uhvhdufkhuv� frxog� àqg� zd\v� to show appreciation and gratitude to that community for allowing them to enter their cultural space and not impinging on their values in order to conduct research (ball & janyst, 2008). understanding and showing an appreciation of political structures in their communities is important to identify early in the relationship (darou et al., 1993). this may prevent any type of power struggle that may arise. additionally, navigating through this understanding will help minimize the potential for exploitation or the appearance of exploitation (alvidrez & areán, 2002). focusing on trust and communication. according to a core principle of the tri-council policy statement on ethical conduct for research involving humans, it is imperative for researchers to take time to establish relationships with the community in order to promote mutual trust and communication. developing relationships with the community fdq�wdnh�d�vljqlàfdqw�dprxqw�ri � wlph��dq�hvwlpdwhg� timeframe for relationship development should be factored into a prospective research plan. this alethical research with people of color 80 lows the researcher and community to work comsdvvlrqdwho\� lq� wkh� lghqwlàfdwlrq� ri �pxwxdoo\� ehqhàfldo� uhvhdufk� jrdov� �&dqdgldq� ,qvwlwxwhv� ri �+hdowk� research, 2010). once relationships have been established within the community, it is critical for a new researcher to slowly build a similar trusting relationship and not attempt to acclimate too quickly. this process is necessary in order to maintain relationships with the community (schnarch, 2004). sharing data results with the community. throughout the research process and at the end of the project, data-sharing sessions are important for participants, community members, and the advisory boards (darou et al., 1993). these data sharing sessions allow for the community to gain a better undervwdqglqj�ri �àqglqjv�uhodwhg�wr�wkh�surmhfw�dqg�uhodwhg� ehqhàfldo� rxwfrphv�� � ,q� frqgxfwlqj� d� vhvvlrq�� wkh� data should be presented in a general and simplistic procedure. the community should be aware of the systematic approach to research in general and how wkh�àqglqjv�zloo�eh� lqwhusuhwhg��$�fkdoohqjh� wr� wklv� approach includes the authority of who owns the information (schnarch, 2004). during initial establishphqw�ri �wkh�surmhfw��uhvhdufkhuv�vkrxog�fohduo\�ghàqh� wkh�dxwkruvkls�ri �wkh�àqglqjv�dv�zhoo�frppxqlfdwh�� genuine appreciation for the sharing of information by the community. although it is probable that some may suggest ownership belongs to the people and the community and others may believe the researchers and academic institutions hold the rights to the information, the common bond is the sharing of accurate information. another piece of information should be discussed during the initial phases of the research. the community should have an understanding of wkh�srwhqwldo�àqglqjv�dqg�lpsolfdwlrqv�iru�wkh�frppxqlw\��$q�h[dpsoh�ri �wklv�zrxog�eh�li �wkh�àqglqjv� show the community in a negative light by bringing shame to their identity or damaging cultural history. enriching indigenous/ethnic minority cultures. one component of culturally sensitive research is not conducting research for the sake of conducting research but rather it is encompassing the well-being of the participants and their community (darou et al., 1993). research conducted in ethnic minority and indigenous communities should be with aspirations to revitalize and enrich the culture rather than to impose on the culture. revitalization of the culture includes identifying, promoting, and enhancing the strengths of the community rather than emphasizing weaknesses or shortcomings. cultural comparisons and other biases should be carefully considered before initial publications or should be forthcoming in discussion. in other words, including issues in research that are not culturally relevant or congruent for them should be carefully assessed and evaluated. one worldview, such as that of a western perspective, should not be held higher than another worldview (darou et al., 1993). addressing language barriers. in addition to, creating a community advisory board and including members from the community, researchers need to adequately address language barriers, if there are any. individuals from multiple language backgrounds may not understand the research material, test measurements, or even the basic instructions needed to complete a consent form if these materials are not translated accurately in their native language. to ensure maintenance of recruitment and retention, research phpehuv�vkrxog�eh�hlwkhu�suràflhqw�lq�wkh�odqjxdjh� prvw� frpprq� lq� wkh� frppxqlw\� ru� àqg� vrphrqh�� zkr� kdv� suràflhqf\� lq� wkh� frppxqlw\·v� odqjxdjh� and comfortable with working in the community. this critical point is also relevant for clinical practice (lau, chang, & okazaki, 2010). in the effort of translating measures and content used in the research project, researchers should be attentive to cultural differences that may occur in direct language wudqvodwlrqv��)ru�h[dpsoh��vrph�fxowxuhv�pd\�ghàqh� abstract concepts differently from those of a western perspective or an ethnocentric concept, especially in regards to highly technical academic vocabulary. 7khvh�gliàfxowlhv�duh�hvshfldoo\�suhydohqw�zkhq�wu\lqj� to translate research instruments and measures (lau hw�do�����������/dqjxdjh�prglàfdwlrqv�vkrxog�dovr�eh� aligned with treatment protocols. in general, culturalo\�ulfk�folhqwv�pd\�kdyh�gliàfxow\�zlwk�kljk�odqjxdjh� (therapeutic jargon), and this language may be problematic if not translated into laypersons vocabulary (vicary & bishop, 2005). being cognizant of these possible limitations and language barriers is vital. 0ruh� vshflàfdoo\�� xvlqj� dq� dffhvvleoh� xvhu�iulhqgo\� written consent form that only includes relevant insan miguel, moniz 81 formation in conjunction with an oral consent component may lessen possible language barriers (meadows et al., 2003). although these considerations are minuscule in scale, the effect is immeasurable for the ethnic minority and indigenous communities. conclusion although the tasks to approach culturally sound and ethical practices in the application of psychotherapy and in counseling research can be considered a large feat, the discussion of the common threads is fundamental to the practices of researchers and psychologists alike. in looking for answers on ethnic minority clinical treatment, we found a commonality of values within indigenous populawlrqv� wkdw� frxog� ehqhàw� iurp� vlplodu� dssolfdwlrqv�� certain considerations should be evaluated for the xqltxhqhvv� ri � wkh� folhqw� lq� sv\fkrwkhuds\�� vshflàcally evaluating indigenous practices and traditions as a source for mental and physical health. although there is limited support for some conceptual frameworks such as the mcc, it is not a sole framework with which to focus. rather, in order to be culturally sound psychologists, we should have a dynamic framework that encompasses mcc, ebpp, and cultural humility. research is limited in cultural humility within counseling psychology practices, but it would be an interesting focus of research for the future. in regards to working with indigenous communities and ethnic minorities for data collection, it is imperative to focus on long-standing humble relationships. although some frameworks are similar, such as cbpr, which originates in public health, are based primarily on the medical model, as social science researchers, our initiative is based on a more holistic and humanistic approach, commonly named the biopsychosocial model. so it would be interesting to see the applicability of cbpr in the domain of a biopsychosocial framework in social science research on indigenous and/or ethnic minority communities. in appreciation of cultural differences with ethnic minorities and/or indigenous communities, we recognize that as patients or as subjects in uhvhdufk� wkh\� duh� kxpdq� àuvw� dqg� iruhprvw�� $ovr�� building cultural humility is vital in patient/therapist interactions as well as being socially humble with these communities in research. if we keep this in mind, we can further develop and progress as a counseling profession towards ethically sound and culturally relevant clinical and research practices. references alvidrez, j., & areán, p. 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(2004). indigenous and interdependent perspectives of healing: implications for counseling and research. journal of counseling & development, 82(4), 410–419. doi:10.1002/j.1556-6678.2004.tb00328.x ethical research with people of color 78 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university working with transgender clients: considerations for psychological testing and assessment kat lewitzke, psy.d. michigan school of professional psychology psychological assessment is an important component of clinical psychology. it allows for a greater understanding of an individual’s in various ways including socio-emotional functioning, cognitive and neurological processes, and/or adaptive skill, among others. psychologists incorporate and execute a combination of methods to reach a hypothesis about a person. tests can be standardized and norm-referenced for particular age groups, grades, or gender. yet, little has been spoken of regarding protocols to be taken when assessing clients who do not identify with their assigned sex. this article provides a theoretical overview regarding sex, gender, and transgender identity, and moves into applying professional considerations for utilizing gender-normed assessments. in particular, there is a focus on promoting clinical awareness and upholding ethical standards when working with transgender populations. as of present, guidelines and set protocols specifically for psychological testing with this population have not been established. this article attempts to outline procedures and applications which are exclusively intended for working with transgender populations in psychological testing. included are the american psychological ethical standards, the guidelines for psychological practice with transgender and gender nonconforming people, along with the standards of care (soc) for the health of transsexual, transgender, and gender-nonconforming people. the importance of multiculturalism, as well as recognizing issues of diversity, is further discussed. this article also creates a paradigm for future studies to establish norm-referenced testing. there have been continuous attempts to distinguish and understand sex from gender (e.g., money, 1955; prince, 2005). traditionally, whereas sex refers to one’s assigned gender (i.e., based on genitalia and biological characteristics), the perception of gender is a socially constructed concept (money, 1955). however, gender has now been more modernly defined as the collection of mental and behavioral traits that differ in one’s personal identity and expression of masculinity and femininity (levay & baldwin, 2009). this can range in everything from the clothes one wears, to the way a person talks and walks. there are even gender specific names, which can further reinforce the manifestation of one’s identity to his or her sexual category. yet, while gender has traditionally been delineated in binary terms, there has been an increase to conceptualize gender through a feminist, queer, and/or postmodern approach. these theories propose a more fluid approach to gender, and further indicate that gender concepts are influenced through power differentials, social interactions, and group norms (bilodeau & renn, 2005; burdge, 2007; butler, 1990; halberstam, 1998). transgender describes an umbrella term for individuals who identify with and express a gender that is different from their sex assigned at birth (bornstein, 1994; levay & baldwin, 2009; prince, 2005). this may act as in inclusive category for a wide range of identities such as persons classify themselves as gender non-conforming, male-to-female persons (i.e., a person assigned as male at birth who transitions and identifies as female), female-to-male persons (i.e., a person assigned as female at birth who transitions and identifies as male), transsexual, bi-gender, or pangender, among others (bornstein, 1994). gender identity is not easy to define, and even facebook recognizes the complexity of it. since february of 2014, the social media site now offers about 50 custom gender options (griggs, 2014). despite the recognition for gender variably provided by social media, the transgender population has been frequently and habitually underrepresented in the field override (hidden running head text): lewitzke transgender testing keywords: transgender, clinical, testing, assessment, ethics, multiculturalism please address correspondence regarding this article to: katlew.dr@gmail.com 79 transgender testing of psychology. this is especially evident for clinical assessment in regards to the creation and interpretation of norms for various psychological instruments. the purpose of this article is to promote a working model for clinicians in the areas of psychological testing. throughout this article, a brief outline of gender and transgender identity and gender non-conforming identity development will be provided, as well as a review of the literature concerning clinical assessment in an effort to promote ethical testing protocol and interpretation for psychologists working with transgender clients. gender and identity children develop an awareness and understanding of gender and sex differences from an early age. most infants at just 6 months old can already distinguish between male and female voices (miller, 1983); and at 1-year of age can categorize faces by gender, along with sex-typical hair length and clothing styles (leinbach & fagot, 1993). kohlberg (1966) proposed a cognitive developmental model of gender identity to describe how young children learn to understand their gender. his theory progresses in three stages: basic gender identity, gender stability, and gender consistency. it appears that gender identity in children is recognizable in as young as 2 to 3-years old (fagot, 1985; kohlberg, 1966). during this stage, children can identify, discriminate, and apply gender labels. around age 3, children move into the gender stability stage. it is here that physical appearance or gender stereotyped activities become noticeably understood. for instance, if a man is wearing a dress he may be categorized by the child to be a woman; or, a girl may believe she will become a boy if she plays football. however, the perception of gender constancy, which is the realization that sex categories are permanent (i.e., the idea that a man dressing up as a woman is still a man), begins to occur around ages 3½ to 4-years old (bem, 1989). this is referred to as gender consistency, and is the third stage of kohlberg’s (1966) theory. therefore, children apparently go through a oneto twoyear period of being able to recognize and categorize their own sex, prior to developing an awareness of its nature and consistency. when children reach the stage of gender consistency, the idea of gender permanency is developed. kohlberg claimed that children fully understand that gender will remain the same, or constant, throughout the lifespan at around age 6 (kohlberg, 1966). although kohlberg’s model follows a traditional understanding of gender conformity, it may also be applicable to transgender persons as the realization of gender identity follows a similar path. additionally, since gender differences have been noted on psychological assessments (i.e., de goede & postma, 2008; lippa, 2010), some tests have been normed; with similarities and differences in strengths to be interpreted with fairness (willingham & cole, 2013). these concepts will be discussed in greater detail throughout the article. transgender identity gender identity describes an individual’s internal working model and sense of self as male or female on a spectrum of characteristics (wilchins, 2002). cisgender is the word used to refer as any individuals who are not transgender, meaning that they identify with a complimenting balance between their assigned sex and gender expression. this includes the majority of the population, in which a person’s assigned sex and identifying gender align (schilt & westbrook, 2009). a transman refers to a female to male transgender person; wherein a person was assigned as female at birth as male, but gender identifies as a male. a transwoman is a male to female transition, and describes a person who was born male, but identifies as female (levay & baldwin, 2009). in 2013, the dsm-5 (american psychiatric association, 2013) replaced the diagnosis of gender identity disorder to gender dysphoria. this shift highlights that a transgender identity is not a disorder in itself. furthermore, this decision was made as an attempt to ensure clinical care and reduce stigma for individuals who see, feel, and identify themselves as a different gender than their assigned sex (american psychological association, 2013b). furthermore, gender dysphoria is demonstrated in a variety of ways, such as an intense desire to be treated and live one’s life as the opposite of their assigned sex. the incongruence may even create a strong desire to alter or get abate primary and/or secondary sex characteristics (american psychiatric association, 2013). transgender men and women have existed throughout human history, and across all cultures (levay & baldwin, 2009). while there is not precise number of persons identifying as transgender, gates (2011) estimated that there are approximately 700,000 transgender 80 lewitzke individuals living in the united states; which totals about 0.3% of the adult population. a true count remains a challenge for various reasons. many individuals continue to struggle with finding self-acceptance, and fear the process of ‘coming out’ due to social acceptance (grant et al., 2010). additionally, while there are well-regarded surveys, such as the u.s. census bureau and center for disease control, which collect data on one’s biologically assigned sex, these fail to capture a person’s identifying gender (chalabi, 2014). feminist, postmodern, and queer theories discuss gender identity as a function of a fluid, rather than rigid or binary, existence (bilodeau & renn, 2005; burdge, 2007; butler, 1990; halberstam, 1998). gender schema theory, developed by bem (1981), emphasizes the sociocultural experiences that influence masculine and feminine schemas in the development of gender roles. it has also become an increasingly more accepted hypothesis that gender identity is programmed at birth (bao & swaab, 2011), and is influenced by social interactions and power inequalities (bem, 1981; butler, 1990; halberstam, 1998). feelings of a lack of alignment, or mind-body discord, between one’s assigned sex and gender generally begin in early childhood; often as young as ages 2 or 3 (kennedy & hellen, 2010). this is also the time at which children begin to conceptualize gender (fagot, 1985; kohlberg, 1966; pardo, 2008). while kohlberg (1966) discussed the understanding of one’s gender to begin at this young age, it appears that a realization of transgender identity develops for persons at this same time (kennedy & hellen, 2010). the majority of transgender individuals report becoming aware of their identity by age 8 (kennedy, 2008; kennedy & hellen, 2010). some may report this recognition as transpiring later, around ages 12 or 13 at the onset of puberty when there are changes in physical body appearance (pardo, 2008). a heart-rending example is the story of david reimer, otherwise known as the john-joan-john case. david was born a boy but tragically lost his penis at 8 months during a botched circumcision. he was then surgically reassigned as female, forced to take estrogen medications, and socially raised as a girl. despite these efforts, as well as not initially knowing his assigned sex at birth, david struggled to identify as female and eventually transitioned back to male at the age of 15 (colapinto, 2000). various models of transgender identity development often begin with an initial awareness, anxiety, and distress of feeling different from a person’s assigned sex. this creates confusion, and there may be a period denial or attempt to repress the experienced internal tension. yet, a process is followed by educating one’s self and establishing support. when acceptance for the desired identity has been formulated, the individual can then begin to integrate one’s self into society (e.g., devor, 2004; lev, 2004). it has been suggested that applying traditional human development models, such as erikson (1968) and marcia (1966), may be not be entirely appropriate for transgender populations because these constructs are based on traditional gender role constructs (mallon, 1999). there are models that exist to specifically address developmental issues, yet these rather reflect a social process of personal experience in the understanding one’s self (e.g., devor, 2004; lev, 2004; mallon, 1999; bilodeau & renn, 2005). one example is lev’s (2004) transgender emergence model; which includes six stages that examines how transgender individuals come to conceptualize and appreciate their identity. this model further integrates the responsibility of the counselor, such as normalizing and exploring the process with the individual. however, while research and awareness for transgender populations has increased (e.g., denny, 1998; devor, 1997; glicksman, 2013; lev, 2004), there is still a need to understand and establish non-stigmatizing practices of transgender identity development (american psychological association, 2015; bockting, 2014; mallon, 1999; morgan & stevens, 2008). additionally, there is even a greater need to understand and established standard and ethical psychological testing protocols with transgender clients. history of transgender testing and assessment for several decades, society, along with the psychological community, pathologized and stigmatized transgender clients (glicksman, 2013). there has been a heavy emphasis on cisgender lifestyles, with a view of binary gender versus gender fluidity. individuals have been expected to conform to an identity that aligned with their assigned sex (american psychological association, 2015). until the 1970s, psychotherapy as a means to reestablish a gender that reflects a person’s assigned sex was the primary treatment for gender 81 transgender testing identity disorder. this treatment has shown to be ineffective; and instead, psychologists are now advised to maintain a supportive role, create a non-stigmatizing environment, and promote acceptance (glicksman, 2013). however, despite these strides to establish awareness and understanding, it was reported in a study as recent as 2013 that transgender populations more often face rejection and negatively from society than lesbian, gay and bisexual individuals (norton & herek, 2013). additionally, practitioners need to be educated on proper term usage, and be aware of the harsh social impacts which transgender individuals continuously face (american psychological association, 2015; glicksman, 2013). lothstein (1984) completed an extensive review of 41 studies spanning over 30 years, from 1953 to 1983, regarding psychological testing with trans-persons. findings suggested that lower stability and greater psychological disturbance appeared more often in male to female transgender than female-male transgender. there was also evidence which reported that pre-operative transgender individuals still living in the male gender role had higher psychological problems than persons living as female. this may be reflective of social stigma. furthermore, there have been suggestions to propose an increase of psychological stability and adjustment in male to female transgender persons following the initiation of sex-reassignment surgery. while this study occurred over 30 years ago, the information is still critical for interpretation of testing results. psychologists should be mindful of this when conducting assessments, and how existing discomfort may increase symptoms of anxiety and/or depression; which may then affect other scores, such as processing speed (tsourtos &thompson, 2002) or inattention (darke, 1988). it has been consistently emphasized in the research that psychopathology is not a requirement of transgender development. specifically, maintaining a transgender is not rooted in psychopathology, but should be conceptualized as a manifestation of physical, social, and psychological conflict with which the client is enduring (fleming & feinbloom, 1984). closer examination with an adolescent population reported that youth identifying as transgender did not significantly differ from cisgender individuals in regards to thinking disturbances and negative self-image. however, adolescents seeking psychiatric care conveyed higher levels of pathology symptoms than both transgender persons and non-transgender not in treatment (cohen, ruiter, ringelberg, & cohen-kettenis, 1997). furthermore, while an absence of pathology in transgender populations have been reported in studies utilizing various versions of the mmpi, elevations in scale 5 (masculinity-femininity) have been noted (cole, o’boyle, emory, & meyer, 1997; miach, berah, butcher, & rouse, 2000; tsushima & wedding, 1979). this elevation was reported to be most prevalent and significant in transwomen populations (cole et al., 1997). findings from this are suggestive that applying a person’s identifying gender verses assigned sex will reduce the tendency to pathologize, and would act as a more congruent and clinically appropriate method. considerations for carrying out testing with transgender clients differences between genders have been noted, but research remains narrow in the area of transgender identity. this further leads professionals limited in their ability to treat and interpret clinical data from this particular population. there are currently no set protocols on how to ethical administer, score, and infer psychological assessment among transgender clients. the question remains: are professionals to interpret data in accordance with one’s assigned sex or identifying gender? in this section, concepts have been included from the american psychological ethics code, along with the guidelines for psychological practice with transgender and gender nonconforming people, and attempted to assimilate components from standards of care (soc) for the health of transsexual, transgender, and gender-nonconforming people to be used for psychological testing use with transgender clients. the american psychological association established the ethics code for working psychologists to use professional guidance when making decisions as part of their clinical, academic, or scientific roles. instruments chosen for evaluations must have established validity and reliability. this entails that the psychometrics are sound for the instrument, as well as for the population of interest. some tests, such as the caars (conners, erhardt, & sparrow, 1999) and mmpi (butcher, graham, williams, & ben-porath, 1990), are gender-normed, 82 lewitzke meaning that there are different scores and interoperations for gender. however, as of present, there are no tests, protocols, or studies which specifically normed for transgender populations. differences in a variety of cognitive and personality traits have been found between men and women (levay & baldwin, 2009); including aspects of visualspatial perception, reasoning, judgments, and memory tasks. specifically, research has found that men generally display higher developed visuospatial skills than women, as well as greater skills in target accuracy and navigation (goldstein, haldane, & mitchell, 1990; levy & baldwin 2009; peters, manning, & reimers, 2007; moffat, hampson, & hatzipantelis. 1998; watson & kimura, 1991). however, women reportedly outperform men in areas involving fine motor manipulation (peters, servos, & day, 1990), recalling object location (de goede & postma, 2008), and verbal memory and fluency (weiss et al., 2006). variations in personality traits across genders, such as behaviors, feelings, attitudes, interests, and values, have also been examined. men and women tend to display different interests; with women being more interested in people or socially related activities, while men prefer thing-oriented pursuits (lippa, 2010). gorski (1998) proposed that these differences in malefemale performances on visual-spatial and verbal tasks are the result of early hormonal exposure on specific regions of the brain during neural development. while the understanding of binary cisgender regarding cognitive and personality traits has been established, we could further our clinical knowledge by researching transgender performance on such tasks. studies on brain activity have also revealed that one’s brain activity is more concurrent with his or her identifying gender (rather than assigned sex) (rametti et al., 2011a; rametti et al., 2011b). therefore, it appears important to assess possible parallels between the performance of cisgender men with transmen, and cisgender women with transwomen. furthermore, differences in cognitive and personality traits across cisgender populations (levay & baldwin, 2009) need to be taken into consideration when assessing and interpreting data for transgender populations. according to results from a meta-analytic review by archer (2004), men also score higher on written tests of aggressiveness. this was noted on both self and peer reporting. additionally, across most cultures, men reportedly show more verbal and physical aggression, and have greater incidences of committing crimes (archer, 2004); whereas women generally tend to express aggression through indirect or non-physical means, such as malicious gossip (hess & hagen, 2006). current available research (although limited) appears to suggest the use of gender identity congruent norms use for interpretation (i.e., lippa, 2010; micah, 2000; rametti et al., 2011a; rametti et al., 2011b). there appears to be some evidence to support that applying gender identity congruent mmpi/-2 norms (in place of assigned sex norms) resulted in transgender profiles to be reported within normal limits on a majority, if not all, scales (micah, 2000). in 2015, the american psychological association established guidelines for psychological practice with transgender and gender nonconforming people (tgnc; hereafter guidelines) as in introductory resource to “assist psychologists in the provision of culturally competent, developmentally appropriate, and transaffirmative psychological practice with tgnc people” (american psychological association, 2015, p. 2). transaffirmative practice entails the practice of marinating awareness, consideration, and supportive care for the identities and personal experiences of tgnc individuals (korell & lorah, 2007). the intent is to recognize the importance of clients of minority and culturally diverse backgrounds, and created guidelines “intended to enlighten all areas of service delivery, not simply clinical or counseling endeavors” (american psychological association, 2015). guidelines are aspirational and aim to promote respect of the client’s culture, as well as maintaining knowledge on current and relevant research. psychologists should also be aware of how their own attitudes, ethnicity, and cultural background may influence interpretation of data surrounding the client’s psychological processes (american psychological association, 2015). in following with these guidelines, psychologists should attempt to understand where clients are in their transition process. yet, even with an aspirational outline, it would be more ethically sound to engage in research that addresses the interpretation and procedures of transgender identity in psychological assessment. i propose that it is important for psychologists to be fully competent in their education and training to deal with the various ethical concerns that deal with 83 transgender testing transgender clients. perhaps an awareness and understanding of qualitative analysis should be integrated into the interpretation, rather than solely basing practices on quantitative reports. transgender clients experience an elevated risk of becoming victims of various violent and traumatic acts (mizock & lewis, 2008). therefore, it is important for working professionals to maintain knowledge on feminist and multi-cultural theory and techniques to minimize distress of the client (richmond, burnes, & carroll, 2012). maintaining a fluid verses binary approach to gender identity will expand the clinician’s own cultural awareness, and reduce pathology of the client (american psychological association, 2015). it is also advisable that psychologists take reasonable steps in explaining the assessment results. this could imply that during the feedback session, the examinee is aware of why certain scales were elevated over others; or how a particular gender norm was chosen for interpretation. additionally, an understanding of the impact brought on by minority stress theory, which emphasizes the effects of how social situations cause stress and poor health for minority individuals (meyer, schwartz, and frost, 2008), is important. this concept describes the health risks of sexual minorities, such as transgender individuals, which is increased and a result of conflict with the dominant social environment. the transgender population faces higher rates of psychopathology and discrimination compared to their cisgender peers. for instance, across the lifespan, it has been reported that they are at an increased risk of substance abuse, suicidal attempts, anxiety, and depression (cochran, keenan, schober, & mays, 2000). despite these conflicts and the negative impacts, clinicians are faced with challenges due to the lack of appropriate interventions. any professional working with persons from transgender populations can follow the core principles outlined in the standards of care (soc) for the health of transsexual, transgender, and gender-nonconforming people (coleman et al., 2012). the soc were developed by the world professional association for transgender health; an international advocacy association with multidisciplinary goals that aims to promote evidence-based treatments, policy, research, healthcare, and education for the transgender population. these standards were created to assist healthcare professionals when working with transgender individuals. due to the prior establishment of these guidelines, core components of soc, as outlined by coleman (et al., 2012), will be integrated in attempted to be specifically applied for psychological testing and assessment with clients from transgender populations: • exhibit respect for patients with nonconforming gender identities: psychologists should aim to exhibit humanistic principles of unconditional positive regard and empathy to build rapport (cain, 2002). psychologists need to consider differences in cognitive and personality traits between genders (levay & baldwin, 2009), and how these factors may be reflected in individuals’ identifying with transgender populations. psychologists must also be knowledgeable in current biological and social research regarding this specific population in the consideration of test report interpretation. • provide care (or refer to knowledgeable colleagues) that affirms patients’ gender identities and reduces the distress of gender dysphoria: client’s should not be pathologized for their differences in gender identity or expression. thus, using gender-based norms that converge with identifying gender may promote a more sound interpretation of results. psychologists should also emphasize and interpret qualitative data (i.e., behavioral observations) just as importantly as quantitative results. • become knowledgeable about the health care needs of transsexual, transgender, and gender nonconforming people, including the benefits and risks of treatment options for gender dysphoria: psychologists need to assess all clients in accordance to the referral question, and be cautious and sensitive when making interpretations, as well as recommendations; especially when working with clients from transgender populations. when appropriate, psychologists may recommend goals that allow for relief from negative self-concept and psychological distress. • be prepared to support and advocate for clients within their families and communities (i.e., schools, workplaces, and other settings): it is possible that a testing report be required and sent to such settings. psychologists need to be prepared to explain testing results and interpretations to the involved parties, while supporting clients with best intentions. 84 lewitzke future directions there are numerous resources specifically targeted for transgender clients. protocols have been created that outline procedures for conducting psychotherapy for both individual and group settings (adler, hirsch, & mordaunt, 2012; bockting, knudson, & goldberg, 2006; mizock, & lewis, 2008). transgender clients may struggle to connect with professionals who lack competence and compassion for working with this population (sanchez, sanchez, & danoff, 2009). to guarantee that a working alliance will be established and maintained, psychologists and persons from related professions need to become familiar with the gender identity research. transgender terminology and language is continually changing. to facilitate better communication, working professionals should remain aware of and sensitive to the client’s language (american psychological association, 2015; bockting, knudson, & goldberg, 2006). clinicians can turn to the guidelines for psychological practice with transgender and gender nonconforming people for direction and inspiration. additionally, this article provided an attempt to outline ethical practices when applying psychological assessments by integrating parts of the soc for the health of transsexual, transgender, and gender-nonconforming people (coleman et al., 2012). my efforts are mere recommendations and based on ethical principles. yet, this outline barely constitutes a foundation to work from, and it is not nearly enough. our practice with this particular population greatly lacks empiricism in the area of psychological testing and assessment. although the notion of gender has increasingly replaced sex in research settings (haig, 2004), there is extensive investigation needed to further understand transgender populations. this is especially true due to the lack of professional guidelines for utilizing transgender norms for psychological assessment. we are missing an important piece to the puzzle, and these issues should no longer be neglected. if this problem persists, providing inadequate (and possibly unethical) care is at risk. it is imperative that psychologists address these concerns to move away from culturally encapsulated practices and improve awareness on the impact of culture in clinically work (wrenn, 1962). in order to better address the clinical concerns of individuals identifying as transgender, valid measures need to be addressed. there has been an ongoing cisgender privilege in the area of psychological assessment; 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(1962). the culturally encapsulated counselor. harvard educational review, 32, 444–449. graduate student journal of psychology graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university navigating the “unhappy constellation” of dissociative identity disorder, infant trauma, and type d attachment cameron kiely-froude the catholic university of america rebecca fuller the catholic university of america patients with a current diagnosis of dissociative identity disorder and a history of infant abuse may present for therapy with a constellation of neurobiological and socioemotional issues. during the initial stages of therapy, clinicians’ primary goal is to stabilize the patient and reduce acute symptoms. understanding the most effective way to achieve this baseline goal requires the clinician to appreciate the chronic neurobiological effects of trauma for a patient abused during infancy. through an attachment theory lens, this paper will discuss the effects of infant trauma on the brain, review traditional methods used to stabilize the patient, postulate complementary strategies discussed in the literature, and recommend directions for future research. modern day psychologists define dissociation as a condition when thoughts, feelings, and experiences fail to integrate into the consciousness and become fragmented (bernstein & putnam, 1986; spiegel & cardena, 1991). dissociative experiences exist on a continuum, ranging from common (i.e., daydreaming and déjà-vu) to pathological (i.e., failure to integrate thought, feelings, and emotions) (mulder, beautrais, joyce, & ferguson, 1998). normal dissociative experiences are highly prevalent in the general population. ross, joshi, and currie (1990) conducted one of the first studies on dissociation in a normal sample. from an initial population of 650,000 people, they selected 1055 individuals using a stratified random sampling method. they reported that dissociative experiences were common in at least a quarter of the sample. the american psychiatric association (american psychiatric association, 2000b) categorizes four clinically significant dissociative disorders: depersonalization disorder (american psychiatric association, 2000a), dissociative amnesia (american psychiatric association, 2000c), dissociative fugue (american psychiatric association, 2000d), and dissociative identity disorder (american psychiatric association, 2000e). specifically, dissociative identity disorder (did), previously referred to as multiple personality disorder, is the alternation of two or more distinct personality states with impaired recall of important information (american psychiatric association, 2000b). the prevalence of did in the u.s. population is between 6% and 10% (foote, smolin, kaplan, legatt, & lipschitz, 2006). however, since this disorder often goes unrecognized, it is difficult to accurately estimate the prevalence.1                                                              correspondence: cameron kiely-froude, kielycam@gmail.com this review will discuss a) the history and definition of dissociation, b) the criteria for diagnosis of dissociative disorders, c) the relationship of dissociation to infant trauma, d) the neurobiology of infant trauma and attachment, e) the various theories of infant attachment, and f) the phases of treatment for dissociative identity disorder. lastly, with special attention to the first phase of treatment, a history of both infant trauma and type d attachment, the authors propose complementary strategies to address stabilization and symptom reduction for adult patients with a history of infant trauma and a diagnosis of did. defining dissociation and dissociative disorders the concept of dissociative disorders stems from janet’s (1886) psychological experiments with his patient lucie, who displayed spells of hypnosis where she neither remembered events nor felt physical pain. eventually, janet trained lucie to enter a hypnotic state by asking her to concentrate on a conversation that he held with a third party. as she concentrated, janet whispered questions to her and she wrote the answers on a sheet of paper. lucie signed these pieces of paper as “adriene.” janet reported that lucie’s consciousness had three states, which included lucie 1, lucie 2, and lucie 3 (i.e., “adriene”). shortly after janet hypnotized “lucie 1,” this state was quickly interrupted by “lucie 2.” “lucie 2” retained memory for every episode for which she was present and also had the uncanny ability to remember events during which “lucie 1” was present. “lucie 3,” also known as “adriene,” could remember every experience from “luci 1” and “luci 2” and she recalled events that occurred in early childhood. janet argued that “adriene” represented total consciousness as lucie displayed conscious actions and felt physical pain when she became “adriene” (van der hart & horst, 1989). janet asserted that lucie displayed dissociative phenomena as a 59 kiely-froude & fuller   60 result of a trauma that occurred when she was 7 years old (van der hart & horst, 1989). research today challenges whether lucie had a true case of did or whether she is simply an illustration of a therapist’s influence over a patient (piper & merskey, 2004). the current diagnostic criteria in the dsm-iv for dissociative disorders are as follows (american psychiatric association, 2000b): 1. the presence of two or more distinct identity or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. 2. at least two of these identities or personality states recurrently take control of the person's behavior. 3. inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. 4. the disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). 5. in children, the symptoms are not attributable to imaginary playmates or other fantasy play. a patient’s history, xrays, blood tests, and other procedures can be used to eliminate the possibility that symptoms are due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of did. before diagnosing a client with did, differential medical and psychological diagnoses should be carefully considered. for example, therapists must clarify whether a patient’s symptoms are not a physiological response to substance abuse or a general medical condition (e.g., complex partial seizures). a client’s medical history, blood tests, and x-rays will rule out symptoms from substance abuse, sleep deprivation, and other issues that produce symptoms which mimic those of did. differential psychological diagnoses for did include, but are not limited to, psychotic disorders, anxiety disorders, somatization disorders, and personality disorders. clinicians may utilize the dissociative disorders interview schedule to discriminate between various dsm-iv diagnoses (american psychiatric association, 2000b; ross & ellason, 2005). after the therapist addresses the differential diagnoses, the therapist may use the structured clinical interview for dsm-iv dissociative disorders to diagnose dissociative disorders. the next step is to create a plan to treat the patient in light of the did diagnosis. often categorized as a population with limited social capacity, poor boundaries, and manipulative character traits, patients with did certainly pose a significant challenge to therapists (issd, 2005; mcallister et al., 2001). dissociation and infant trauma studies speculate a link between dissociation and the experience of trauma (ferguson & dacey, 1997; mulder et al., 1998; sanders & moore, 1999), especially when trauma occurred in childhood (zlotnick et al., 1996). children, namely infants, may resort to dissociation to cope with trauma because of their limited range of coping strategies (schore, 2001). there is a growing recognition that consequences of infant victimization include: (a) psychological maladjustment (yehuda, halligan, & grossman, 2001), (b) altered brain development (keverne, 2004; schore, 2001, 2002), and (c) delayed socioemotional growth (main & hesse, 1990). relationships are also seen between dissociation and posttraumatic stress disorder-like symptoms (farley & keaney, 1997), bulimic symptoms (reto, dalenberg, & coe, 1993), and self-mutilation (briere & gil, 1998). while dissociation protects the infant psyche from trauma, it ultimately becomes a maladaptive coping strategy in adulthood (schore, 2001). while research continues to point to an association between trauma and dissociation, frankel (1996) and piper and merskey (2004) warn against claiming causation between two variables when research points only to association. nevertheless, dissociation presents in many survivors of childhood abuse who may seek assistance from a trained psychologist. therefore, therapists must be prepared to treat patients with a diagnosis of did who report a history of childhood abuse. moreover, due to the tenuous causal relationship between childhood abuse and did, therapists should not assume that the patient’s history of childhood abuse caused did in adulthood (piper & merskey, 2004). infant attachment infant attachment is assessed through a standardized laboratory procedure when the infant is between 12 and 18 months old (ainsworth, 1982). clinicians observe the infant during two brief episodes of separation and reunion with the primary caregiver. the infants’ response in the scenario is meant to reflect the relationship that the infant and caregiver maintain in the home (ainsworth, blehar, waters, & wall, 1978). initially, there were three classes of attachment: secure (type b: infant cries at separation and is easily comforted at reunion), insecure-avoidant (type a: infant cries at separation and avoids caregiver at reunion), and insecure-ambivalent (type c: infant cries at separation and is not easily comforted at reunion). several years later, main and solomon (1986) created a disorganized (type d) attachment type for children whose behaviors did not reflect a coherent pattern. the creation of this fourth category emerged when researchers reported that a portion of infants demonstrated an absence of an organized emotional regulation strategy during stressful periods (carlson, cicchetti, barnett, & braunwald, 1989; main & solomon, 1990). behaviors fell on a continuum, ranging from abstract (observer’s expectation of infant patterns) to obvious (freezing of movement and dazed expression for 30 seconds or longer). infant trauma and did 61 infants categorized as having a type d attachments display one of the following: disordering of expected temporal sequences, simultaneous display of contradictory behavior patterns, incomplete or undirected movements and expressions, direct indices of confusion and apprehension, and behavioral stilling (main & solomon, 1990). research on the disorganized attachment bond report four findings that distinguish d attachments from the others: (1) attachment status is independent across caregivers (main & solomon, 1986), (2) caregivers reported unresolved attachment-related trauma issues (main, 1983; main & cassidy, 1988; main, kaplan, & cassidy, 1985), (3) a majority of infants with abusive parents display type d attachment as compared with a minority of control infants (egeland & stroufe, 1981; main & hesse, 1990), and (4) 5 years later a majority of children displayed controlling and parental behaviors toward their parents (main & cassidy, 1988). at a 5-year follow-up, researchers found that when children displayed a type d attachment with one caregiver and a different classification with another caregiver during infancy, attachment status remained the same with the former caregiver and changed to either type b or c with the other caregiver (main & hesse, 1990). when interviewers asked mothers about their children’s separation, mothers’ responses remained fearful and disorganized (main & hesse, 1990). research also points to the relationship between disorganized attachment behavior and dissociation, which will be discussed in greater depths in this paper (hesse & main, 2000). neurobiology of attachment and trauma animal models provide researchers with a solid foundation on which to understand the long-term neurological consequences of child abuse (gutman & nemeroff, 2002). stemming from classical articles that report the effects of maternal separation on the squirrel monkey (coe, lulbach, & schneider, 2002), current research demonstrates the long-term neurobiological changes in animals that are subjected to prenatal and post-natal stressors (nemeroff, 2004). generally, studies show that periods of maternal separation may cause neurobiological issues that resemble mood and anxiety disorders (nemeroff, 2004). research on non-human primate models also supports the notion of a sensitive period of neurobiological development and attachment with the mother. hubel and wiesel (1979) sought to test the importance of sensitive periods of development in cats by blocking the visual input to one eye of a cat during a sensitive period. results showed that the cat suffered permanent impairment in that eye. when researchers tested this theory on children (taylor & taylor, 1979), they found that children have irreversible reduction in visual acuity if they have cataracts or squint beyond the age of 8 to 10 years old. these findings suggest that external influences during sensitive periods have major consequences on healthy development. is it safe to extend these findings to other areas of the human brain where stunted development may not display as readily as it may in certain human brain regions or in animal brains? the literature has only recently begun to explore the qualities of trauma at the infant stage of development (perry, pollard, blakley, baker, & vigilante, 1995). beginning in pregnancy and continuing through age 2 years old, the infant brain is the most plastic and requires an immense amount of energy to develop (perry et al., 1995). reflective of the animal studies described earlier, infants also have sensitive periods of development (perry et al., 1995) when their brains are receptive to novel information but also highly susceptible to the effects of abuse (schore, 2001). although the sequence of brain development is not influenced by the infant's environment, the quality of brain development relies upon the external stimuli provided by the caregiver (schore, 1994). the infant brain expects certain experiences to occur during infancy. for example, the infant expects for the mother to regulate her emotional states (schore, 1994), minimizing the negative and maximizing the positive (schore, 1997). the infant expects this type of warmth from the mother since she is the only person that the infant knows, and it depends upon the mother to care for its basic survival needs. this includes all executive functioning tasks, arguably one of the most important of which is the infant's reliance on the mother to modulate its emotional and physical response to external stimuli (streeck-fisher & van der kolk, 2000). the immature infant brain lacks the sophistication to cope with trauma in the ways used by healthy adults (perry et al., 1995; schore, 2001). when the mother fails to regulate the infant's response to stimuli by soothing and calming the baby, the infant must rely on its primitive coping mechanisms. primarily, the infant brain responds to trauma in two ways: hyperarousal and dissociation (perry et al., 1995). when an infant feels distressed, its autonomic nervous system is activated and it screams and cries (schore, 2001). when the primary caretaker fails to comfort the child, it becomes increasingly agitated and its sympathetic nervous system (sns) becomes hyperaroused (perry et al., 1995), a phenomenon that gellhorn (1967) labeled egotropic arousal. during egotropic arousal, high levels of corticopin releasing factor (crf) and noradrenaline are released into the bloodstream (brown et al., 1982). when crf and noradrenaline are secreted, a rush of adrenaline surges through the body. this chemical reaction causes the brain to enter a hypermetabolic state (schore, 2001). at this stage in the stress response, the processes that are essential to the infant’s survival become hyperaroused and secondary processes are inhibited (perry et al., 1995). the infant’s heart rate increases, eyes dilate, and breathing quickens (schore, 2001). the baby is fully alert and hypersensitive to its dangerous environment. to preserve energy for survival needs, the infant’s digestion and reproductive urges are inhibited (schore, 2001). although infant and adult reactions to stress hold some similarities, kiely-froude & fuller   62 there is one critical difference that places infants at a higher risk for developing maladaptive coping strategies in later years; infants cannot choose how they react to stress in the same manner as adults. cannon (1929) called his stress response theory “fight or flight” because the person who experiences the stress prepares to either fight the danger or to flee from it. infants do not have the luxury to decide whether to fight or flight (perry et al., 1995). they can do neither. the irony for infants with abusive parents is that the person to whom they literally cry for help is the one who harms them. after many failed attempts at crying for its mother's attention, the infant will abandon this help-seeking behavior (perry, 1995). at this point, the infant has moved through the "fight or flight" continuum and enters the dissociative continuum (schore, 2001). instead of seeking help and attention from the mother in the form of crying, infants who dissociate retreat inward and cease to interact with their external or internal environments (schore et al., 1994). when infants experience a helpless and desperate situation, their parasympathetic regulatory system begins inhibiting certain brain processes in order to protect them from the dangerous situation. instead of expending energy on processes to prepare for a fight mentality (i.e., quick heart rate, dilated pupils), the body enters a state of conservation withdrawal (kaufman & rosenblum, 1967). unlike the overarousal experienced in the primary stages of trauma, dissociation involves numbing, avoidance, compliance, and restricted affect (putnam & loewenstein, 1993). the infant brain responds to stress in this manner to numb the physical pain of abuse and to remain virtually invisible as a strategy for protecting itself against further harm (perry et al., 1995; schore, 1994). instead of utilizing complex systems in the cortical-limbic region to modulate stress, the infant who dissociates relies on primitive autoregulatory systems found in subcortical-limbic brain regions (schore, 2001). in an effort to maintain homeostasis during egotrophic hyperarousal, parasympathetic trophotropic arousal (gellhorn, 1967) occurs for the infant. simultaneous activation of the sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal (hpa) axes typically occurs during acute stress, but eventually they operate independently (schore, 2001). when an infant experiences chronic trauma, both the sympathetic energy-expending and parasympathetic energy-conserving components of the infant’s developing autonomic nervous system are hyperactivated (perry et al., 1995). despite the rush of adrenaline surging throughout the infant’s body during the acute response to stress (sns activation), the infant’s brain begins secreting opioids, which decrease blood pressure and heart rate and inhibit processes like crying (pns activation). schore (2001) describes this paradox as the infant's body and brain "riding the brake and the gas at the same time" (p. 231). the simultaneous arousal of these two systems (putnam, 1997) may explain why infants classified as having a type d attachment rapidly shift into primitive sympathetic states. among other criteria, main and solomon (1990) characterized type d infants as displaying undirected expressions and contradictory behavior. a chronically abused infant who rapidly shifts between sympathetic hyperarousal and hyperparasympathetic dissociation will meet these criteria. the infant may display distress in the form of crying and shrieking (sympathetic hyperarousal) followed immediately by emotional withdrawal and blunted affect (hyperparasympathetic dissociation). since abused infants’ brains are in a perpetual state of survival mode, they lack the limbic formation and organization displayed by infants reared in healthier households (schore, 1994). an infant with an underdeveloped limbic system may display difficulty adapting to changing environments and organizing novel information (mesulam, 1998). an infant’s stress response sets the pattern for later stress responses (van ijzendoorn, schuengel, & bakermans-kranenburg, 1999). therefore, an infant who chronically hyperarouses and dissociates in response to a traumatic situation will likely classify as having a type d attachment and may utilize dissociative behaviors later in life (van ijzendoorn, et al., 1999). individuals prone to entering dissociative states may utilize this primitive defense not only during acute stress but also moderate and mild stress (schore, 2001). when dissociation becomes an instinctual reaction to trauma, the infant's emotional intelligence is stunted (schore, 2001). research suggests that chronic childhood abuse may severely impact the orbitofrontal cortex (balbernie, 2001; schore, 1994, 2001, 2002), an area of the limbic system involved in cognitive processes like emotional regulation and positive affect (anderson, bechara, damasio, tranel, & damasio, 1990). development of this part of the brain depends on interpersonal relationships during infancy, which include but are not limited to attachment bonds with the mother (balbernie, 2001; schore, 2000). the orbitofrontal cortex assesses the infant's internal state and regulates its emotional reactivity (balbernie, 2001). well-adjusted children react appropriately to aversive stimuli in their environments, whereas maladjusted children may overreact to external stimuli or dissociate entirely (schore, 1994). an underdeveloped orbitofrontal cortex may result in a lack of flexibility to cope with aversive stimuli and a limited array of cognitive coping strategies like self-soothing (morgan, romanski, & ledoux, 1993). patients with a history of infant trauma and a current did diagnosis likely suffer from many of the neurobiological issues discussed above. intense psychotherapy may affect not only the socioemotional wellbeing of the patient, but also the patient’s neurobiological reactions to stress. a landmark study by paquette et al., (2003) found that cognitive and behavioral changes achieved during psychotherapy lead to regional brain alterations in patients diagnosed with major depression or obsessive compulsive disorder. researchers chose subjects suffering from spider phobia (n = 12) and measured their regional infant trauma and did 63 brain activity before and after cognitive behavioral therapy (cbt) using fmri. before completion of cbt, fmri scans taken during fear states showed a significant activation of the right dorsolateral prefrontal cortex, the parahippocampal gyrus, and the associative cortical areas, bilaterally. after completion of cbt, significant activation was not shown in the dorsolateral prefrontal cortex or the parahippocampal gyrus. this study, the first to measure the effects of therapy on brain states, shows that therapy has the potential to change patients’ reaction to stressful stimuli. as noted earlier, an underdeveloped limbic system greatly impedes the patient’s ability to cope with stressful situations beyond primitive responses. therapists may work with patients to change their maladaptive responses to stress, which were systematically created during infancy. working with the patient to develop more sophisticated responses to stressful situations can be addressed during phase one of treatment. this is a vital step that will provide the patient with the necessary tools to combat intense issues in later treatment phases (i.e., traumatic memories and “alter” reintegration). treating dissociative identity disorder the international society for study of dissociation (issd) recognized the complexities in treating patients with did and created a set of guidelines for therapists to follow (issd, 2005). the issd recognizes that patients with a complicated trauma related disorder, such as did, are most appropriately treated with a phase or stage oriented approach. typically, treatment includes three stages: (a) enacting safety, stabilization, and symptom reduction, (b) working directly and in depth with traumatic memories, and (c) utilizing identity integration and rehabilitation (issd, 2005). each phase of treatment is important to the patient’s mental health and physical safety (issd, 2005). yet, the literature is imbalanced in the amount of research dedicated to each phase. the number of studies that discuss traumatic memories and identity integration outweigh those that address safety, stabilization, and symptom reduction. aside from the growing body of research studying the efficacy of using pharmacological modalities to stabilize patients with did (issd, 2005; putnam & loewenstein, 1993), the stabilization phase of treatment for did has only recently begun to receive attention. considering phase one is the groundwork upon which the therapeutic relationship is built, it is surprising that more research is not dedicated to studying the initial stages of the patient-therapist relationship. to fill the gap in the literature on the first phase of treatment, this paper will focus solely on safety, stabilization, and symptom reduction. many patients with did focus primarily on establishing a trusting relationship with the service provider, often for a substantial amount of their time in treatment (mcallister et al., 2001; issd, 2005). this finding may illustrate the difficulty for patients to reduce symptoms and remain stable. patients with a long abuse history, reaching as far back as infancy, may demand a longer and more in depth focus on the safety and trust issues that are discussed in phase one (issd, 2005) to ensure a healthy dependency on the therapist (steele, van der hart, & nijenhuis, 2001). when patient and therapist explore how to increase the patient’s feelings of internal and external safety and learn strategies that reduce her symptoms, the patient may become more functional in therapy and in her daily activities (issd, 2005). while this is an ideal scenario, it is not easily achieved. the early phase of treatment: setting biopsychosocially competent boundaries a healthy therapeutic relationship is a delicate balance among sympathetic listening skills, re-parenting tactics, and boundary setting (peternelj-taylor, 2002). while maintaining appropriate boundaries with every patient is important to the therapeutic relationship (atkins & stein, 1993), it is especially important when working with childhood abuse survivors (briere & elliot, 1994). the power dynamic presented in therapy mimics the relationship that survivors had with their caregiver(s): the patient (or, child) seeks help and nurturance from the therapist (or, caregiver) (peternelj-taylor, 2002). the therapist and caregiver hold the power in the relationship, while the patient and child are the vulnerable counterparts seeking guidance. one of the goals in therapy is to guide and nurture the patient without re-traumatizing or abusing her (mcallister et al., 2001). when a therapist treats a patient without violating her boundaries, the patient’s inherent belief that caretakers will compromise ethics and morals for their own personal gain is challenged (boyrs, 1994). when the creation of boundaries stems from the therapists deep understanding of the patient’s issues surrounding trust and intimacy, they are a healthy and essential part of the therapeutic process. therapists who blindly and defensively follow rules solely to protect themselves from malpractice claims are usually inefficient and negligent to the unique needs of their patients (boyrs, 1994; lazarus, 1994). lazarus illustrates this point with an example when he disregarded traditional boundaries with a “difficult” patient by inviting the patient to share a meal with him. ultimately, the boundary violation was a “turning point” in therapy and served to dramatically reduce the patient’s hostility. while many therapists may take offense to this example, it is used to illustrate why boundaries exist in therapy, when clinicians may appropriately disregard certain boundaries, and how boundary negotiation occurs between therapist and client. for instance, lazarus reports that a traditional boundary violation resulted in improved patient functioning. while many therapists may assert that sharing a meal with a patient is unethical, lazarus’s unconventional relationship with the patient serves to remind us that patients are human beings that thrive on warmth and compassion. does this mean that therapists who set boundaries with patients are treating them in a detached manner? boyrs kiely-froude & fuller   64 (1994) asserts that adherence to boundaries does not equate to depersonalized and cold therapy. rather, strict boundaries during therapy may serve to model for the patient how she can create boundaries within herself to reduce the sense of fragmentation experienced by many patients with did. the opposing viewpoints in the literature on boundaries serve to create a continuum for which therapists can personally decide the end on which they will practice. although boyrs (1994) and lazarus (1994) disagree on a number of tenets regarding clinical boundaries, they both agree on at least one overarching concept: therapists who engage in "rote, mindless rule following" are performing a disservice to their clients (boyrs, 1994, p. 273). trauma-induced neurobiological changes and their influence on treatment challenging “mindless rule following” may not always include walking the fine line of boundary infraction with the patient. it may include assessing parts of the patient’s internal systems that are not traditionally part of psychotherapy. analyzing and discussing the patient’s neurobiology is a way that therapists can understand the patient in a fresh and innovative light that defies tradition. neurobiological changes in brain structure may have significant effects on the therapeutic process. studies report that parahippocampal gyrus, hippocampus, and amygdala volumes were smaller in participants with did than healthy control groups (ehling, nijenhuis, & krikke, 2008). as described earlier, schore (2001) reports that corticolimbic areas of the abused infant brain do not develop appropriately, which results in compromised intraand interpersonal interactions. although psychologists are still in the preliminary stages of understanding exactly how certain neuroanatomical brain changes affect daily functioning, researchers have a sound grasp on the functions of certain parts of the brain. immature functioning in certain brain regions may impact the fluidity of the therapeutic process. research demonstrates that the hippocampus is an integral component to learning and memory (vargha-khadem et al., 1997) and is particularly sensitive to stress (sapolsky, 1996). specifically, the hippocampus is responsible for placing a memory in the appropriate time, place, and context, as well as integrating memories as they occur (holscher, 2003). patients with a history of infant abuse will likely have a hippocampus that is dramatically reduced in volume in comparison to patients who have not experienced severe trauma (stein, koverola, hanna, torchia, & mcclarty, 1997). although the literature has yet to directly address how brain abnormalities affect the therapeutic process, studies have analyzed this phenomenon in other contexts. for example, saigh, mroueh, and bremner (1997) studied academic performance in traumatized adolescents in beirut. compared with a non-traumatized group and a traumatized group without ptsd, the participants with past trauma and confounding ptsd had greater deficits in academic performance. since therapy is a place where patients learn about themselves and their diagnoses, similar issues may extend to the therapy office. when setting boundaries with a traumatized population, the therapist may present information using a number of different modalities throughout treatment. this may include verbal, physical, and pictorial representations presented consistently during therapy. since a primary function of the corticolimbic system is to regulate appropriate interactions with others and moderate emotional reaction, patients may have difficulty accepting the boundaries and verbally communicating why they are resistant. in this case, the therapist may include non-verbal activities like art (chapman, morabito, ladakakos, schreier, & knudson, 2001), dance (gray, 2001), and sandplay (daniels & mcguire, 1998) into the session. research on these types of alternative therapy is scarce and needs further investigation to support their efficacy as independent modalities. the limited literature on these therapy models indicate their effectiveness in reducing ptsd symptoms in children (chapman et al., 2001), rebuilding adults’ sense of self after torture (gray, 2001), and communicating recurrent nightmares in adult war survivors (daniels & mcguire, 1998). reduced hippocampal volume and immature corticolimbic system in traumatized populations are only two examples of the several brain structures affected by chronic abuse and stress. therapists can manage patient care by understanding the neuropsychological literature and modifying treatment plans to account for the unique neural functioning of each patient. patients who consistently violate boundaries may have difficulty accepting those limitations into their neural networks and respecting them in therapy. patients with a history of abuse starting in infancy have learned to dissociate in order to protect themselves from a caretaker chronically violating physical, emotion, and mental boundaries. therefore, the transition into therapy will likely reflect that history. literally, trauma has reshaped patients’ brains. since the patient experienced abuse at the hands of a caretaker during infancy, the therapist should consider assessing the patients’ psychopathology and neurobiology under an attachment lens. traditional strategies for treating dissociative identity disorder talk therapy and alternative interventions. talking is a major part of most therapy sessions. when treating survivors of trauma who dissociate, a multidisciplinary approach to treatment may prove effective since the patient may not have the words to express her emotions verbally. schore (2001) offers persuasive evidence that right brain development is severely impeded in chronically abused children. the areas that respond to the traumatic event are those located primarily in the right hemisphere, for example the right infant trauma and did 65 amygdala. given the underdevelopment of those areas during infancy, neural networks connecting experiences with emotions in certain brain centers may not have formed. perhaps this is a reason why infants store memories of abuse in their limbic system, which is considered a major network for emotions (schore, 2001). what effect does this abnormal storing of events have in later years? van der hart, bolt, and van der kolk (2005) explain that when a person remembers a traumatic event the primary language and speech areas shut down. therefore, when patients arrive at therapy years after the abuse occurred, they may present with overwhelming emotions and limited verbal capacity. clinicians may use alternative ways of understanding the patient’s physical and emotional state aside from verbal communication, like utilizing grounding and containment strategies as a means to assist clients in achieving stability during and after therapy (issd, 2005). these strategies may be used during phase one of treatment to teach the patient a series of healthy coping mechanisms that she may employ throughout the therapeutic process. the following section includes a brief outline on the traditional therapeutic techniques of grounding and containment as well as a review of the sparse literature on complementary forms of treatment such as exercise and meditation. these techniques will be reviewed in light of the attachment issues and neurobiological functioning in adults abused as infants. self-soothing techniques like grounding and containment may be especially useful for adults with an infant abuse history since they do not require that the patient express herself verbally. instead, they ask the patient to connect her mind and body in novel ways. these are likely invaluable additions to therapy sessions with trauma survivors since they are tools that the patient may adopt as coping techniques in her everyday life. these techniques empower the patient to regulate her own emotional responses to stress, which she may lack as a result of an underdeveloped corticolimbic system. grounding and containment. when a patient enters a dissociative state during therapy, clinicians may use that moment as an opportunity to work with the client on grounding and containment techniques. getler (2005) describes grounding techniques as “tools to help the patient stay in the here and now” (p. 69). therapists can remind the patient where she is, the date and month, and other facts that will help her remain in reality. therapist may encourage patient to feel her own body and touch physical objects in the room (getler, 2005). the therapist may use grounding techniques at various points during the session to meter the patient’s disclosure, as well as to help her remain emotionally and physically present. diaphramatic breathing is another strategy that provides patients with a means to center the self and modulate overwhelming feelings. aside from providing the patient with a technique to collect her thoughts and feelings, deep breathing also grounds the patient in the moment and reminds her that she is physically present. therapists may also discuss ways to temper an oncoming dissociative state by identifying behaviors that occur just before the patient dissociates. brown, russell, thorton, and dunn (1999) report that discussing patients’ visual responses to dissociation like field constriction, fogginess, and difficulty concentrating on stimuli, are effective for connecting mind and body for patients who have eating disorders. therapist may consider teaching these techniques during initial sessions of treatment to provide the patient with healthy coping mechanisms that she may use during more intense parts of treatment. to date, research in the area of grounding and containment needs randomized controlled studies that assess the efficacy of these techniques for trauma survivors. research endeavors may include an analysis of how therapists teach these techniques and the manner in which patients receive the instruction. understanding the effects of these techniques on patients during therapy and in their daily lives will allow for a more standardized approach to treating patients with a history of infant trauma and a did diagnosis. complementary treatment strategies exercise. since morgan and goldston’s (1987) observation that psychiatric patients who were unfit were more depressed than their physically fit counterparts, researchers continue to study the relationship between physical fitness and mental health. a review paper by byrne and byrne (1993) tentatively reports that exercise programs decrease depression and anxiety while enhancing positive mood. similarly, steptoe and butler (1996) showed that rigorous exercise was related to a decrease in emotional distress. in a very recent study, moor, stubbe, boomsma, and geus (2006) collected data on a sample (n = 19,288) of twins who exercised a minimum of 60 minutes weekly at 4 mets (metabolic energy expenditure index). exercisers were less anxious (-.18 sd), depressed (-.29 sd), and neurotic (-.14) than non-exercisers. exercisers were also more extraverted (+ .32 sd) and achieved higher scores in areas of sensation seeking (+.25 sd, + .47 sd) than nonexercisers. while studies have shown that exercise is effective in reducing mild to moderate anxiety symptoms, research does not adequately identify the specific components of exercise that may alleviate anxiety symptoms (jorm et al., 2004). further research is needed to understand how exercise affects psychopathology in patients that report infant trauma. meditation. four out of five randomized controlled studies that examined the effects of meditation on anxiety report that meditation produced equivalent effects to other forms of relaxation (i.e., muscular relaxation, biofeedback) (jorm et al., 2004). a recent study (simpson et al., 2007) evaluated whether a 10-day vipassana meditation course offered in a minimum security prison was associated with participants (n = 302) substance use and psychological distress outcomes at 3-months. results indicate that there was no significant difference in ptsd symptom severity between patients who completed the meditation and those kiely-froude & fuller   66 who did not. the meditation course was associated with improvements in drug use and drinking outcomes for those with and without ptsd symptoms. in his descriptions of kundalini yoga meditation techniques, shannahoff-khalsa (2004) discusses how mentally ill patients, specifically those with depression and sleep disorders, may use these techniques to battle their condition(s). “tuning in,” a technique used before the practice of any kundalini practice, gives the experience of “being in a womb of healing energy” (p. 93). the practice leads the patient into a meditative trance through a combination of chanting and deep breathing exercises. further research is needed to understand how specific meditation techniques affect individual symptomatology in patients with did. conclusion bridging the research gap between the fields of neurology and psychology is the next logical step in the study of infant trauma and did. the authors assert that the overall goal is to develop a holistic view of the neurobiological and psychological effects of infant abuse on the adult survivor and to effectively treat them. future research endeavors should focus on reporting the relationship between neurobiology and psychology in patients with did and a history of infant abuse. academic neurological literature clearly outlines the devastating effects of chronic emotional and physical trauma to the anatomy and physiology of the developing infant brain. academic psychological literature illustrates the attachment and boundary issues that manifest in therapy with adults survivors of childhood abuse. first, the authors encourage researchers to build on these studies in addition to the work of schore (1994, 1996, 2001) and perry et al. (1995) to develop a comprehensive understanding of how infant trauma impacts and disrupts child and adult socioemotional adjustment. secondly, more longitudinal studies are needed to understand how the brain changes along the developmental continuum, and which specific types of infant abuse (i.e., shaken baby syndrome, sexual abuse) produce effects that alter development. understanding the interaction between a patient’s neurobiological systems and their development can greatly improve clinical care and guide treatment. in recent years, infant research on relational trauma has been growing steadily. as this knowledge base develops, new clinical tools will provide therapists with better assessment measures for evaluating trauma survivors and their families presenting for treatment. lastly, future research endeavors should also study how infants removed from abusive households and placed in protective care may or may not develop secure attachments to other caregivers (i.e., foster parents). clinically, this will provide therapists with information regarding the creation of attachment bonds with foster parents. with this information therapists may develop attachment techniques to teach protective caretakers as they learn how to develop secure attachment bonds with their infant. this may have great public health implications since healthy development of cortical regions is associated with appropriate intraand interpersonal communication and emotional regulation in adulthood. in closing, understanding physicians’ and therapists’ experiences working with abusive families and treating neglected infants is an essential component to the existing literature on infant abuse. when neurologists and psychologists collaborate on understanding how abuse affects the patients across the lifespan, the literature may move closer to identifying a causal relationship between childhood abuse and dissociation. identifying the relationship among infant attachment to caregiver, neurobiological changes after infant trauma, and adult psychopathology will allow for comprehensive, multidisciplinary treatment of patients with did and a history of infant abuse. references ainsworth, m. d. s. 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(1996). the relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse and self-mutilation. comprehensive psychiatry, 37, 12-16.   running head: graduate student journal of psychology copyright 2009 by the department of counseling & clinical psychology 2009, vol. 11 teachers college, columbia university hiv/aids-related ethical dilemma of confidentiality cristnei aquino american school of professional psychology at argosy university/schaumburg martha j. secker american school of professional psychology at argosy university/schaumburg nicolejoanne wood american school of professional psychology at argosy university/schaumburg the centers for disease control and prevention (2006) estimates over 1 million people are living with hiv/aids in the u.s. with 40,000 new infections reported yearly. given the pervasiveness of hiv/aids, it has become almost inevitable that mental health professionals will come into contact with affected patients. as a result, mental health professionals often face ethical dilemmas specific to this population, such as the knowledge of one’s hiv/aids status and unsafe sexual practices. this dilemma is raised when a clinician becomes privy to one’s hiv-positive status, but the partner is not yet informed. treatment poses complex legal issues as mental health professionals are faced with the uncertainty of reporting potential danger, while facing the ethical issue of confidentiality that is central to the field. in addition, an overview of the screening, progression, and treatment of hiv/aids is included. human1immunodeficiency virus (hiv) was first identified in the united states in the 1980s and has since affected millions of people worldwide. in the united states, people of color seem to contract the disease in disproportionate rates. while several advances have been made that have aided in a better understanding of the disease, a cure has not yet been reached. mental health professionals serve a crucial purpose in the treatment of those with hiv/aids, but at the same time, face certain ethical dilemmas in this context. as such, this paper outlines the ethical dilemma of confidentiality when working with individuals with hiv/aids. because of the gravity of hiv, mental health professionals seem to be in a predicament if, and when, they gain knowledge of their client’s unsafe sexual behavior, as this could potentially put others in danger. a review of the literature suggests there is no clear solution to this dilemma, and often mental health professionals are subject to abiding by ambiguous or contradicting state laws and ethical codes. this paper highlights some of these laws and ethical codes to demonstrate the problem and discusses some of the related clinical implications. what is hiv/aids? hiv is an incurable disease that attacks one’s immune system, thereby making it difficult to fight off infections. if the immune system becomes exceedingly compromised, correspondence: cristnei aquino american school of professional psychology at argosy university/schaumburg, 999 n. plaza drive, suite 111, schaumburg, il 60173-5403 or cristneiaquino@comcast.net acquired immune deficiency syndrome (aids) can occur and an opportunistic infection can prove fatal. not every individual who is diagnosed with hiv develops aids. however, research evidence supports that all persons who develop aids initially had hiv (anderson & rowe, 2006). aids occurs when a person’s t cell count drops below 200 per cubic millimeter and when an opportunistic infection results (kukoleck, 2008). in order to become infected with hiv, one needs to be exposed to an infected other’s bodily fluids, including blood, semen, vaginal fluid, and saliva. the most common ways for hiv to be spread among people is through risky behavior, including unprotected sex or sharing needles during intravenous drug use. unprotected sex can include anal, oral, or vaginal intercourse. the centers for disease control and prevention (2008) reports that male-to-male sexual contact is the transmission category resulting in the highest number of aids cases in 2007 alone and through 2007 from the beginning of the epidemic. this is likely the reason hiv/aids has been stigmatized as a “gay person disease.” however, the high-risk heterosexual contact transmission category elicited the second highest number of estimated aids cases in 2007 (center for disease control and prevention, 2008). therefore, it is fair to say that hiv/aids is a disease that can affect anyone. upon contraction of hiv, the symptoms of hiv can initially be elusive. soon after infection has occurred, one can experience flu-like symptoms and easily dismiss them as such. after this, much time can pass where the infected individual does not exhibit any symptoms but his or her body is rapidly producing antibodies to combat the virus that is quickly spreading throughout the body (klimas, o’brien koneru, & fletcher, 2008). in order to confirm that one has 52 hiv/aids-related ethical dilemma of confidentiality 53 hiv, one must be tested for the presence of antibodies to hiv in the bloodstream. the caveat in this, however, is that antibodies can take awhile to develop. the cdc reports that detectable antibodies, on average, take two to eight weeks to develop from time of initial exposure. if one is tested for hiv shortly after exposure, they may not test positive for hiv antibodies because his or her body is still in the phase of creating those specific antibodies. this type of test would not be indicative of hiv in this situation, producing a false negative result. in most cases, hiv antibodies can be detected within three months of exposure. however, there have been rare cases noted where it took six months for hiv antibodies to be developed (cdc, 2009a). also, it is important to note that when one is tested for hiv, multiple tests are done to ensure accuracy of the findings (anderson & rowe, 2006). if hiv is diagnosed, appropriate treatment is critical. hiv is now treated with medications known as highly active antiretroviral treatment (haart). haart medications are actually combinations of different classes of antiretroviral medications which act on the virus at various stages of its life cycle (klimas et al., 2008). these combinations of medications have markedly slowed the progression of hiv to aids for many. up until this, the average time span for hiv to develop into aids was seven to ten years (anderson & rowe, 2006). haart medications have increased life expectancy and overall quality of life for those infected with hiv/aids (liu et al., 2006). in spite of this, people of color, specifically african americans, have a disproportionately higher incidence rate of contracting hiv and aids (klimas et al., 2008). some of this appears to be due to educational level and socioeconomic status, and hence, a lack of resources. a 2004 study by ebrahim and colleagues, found that these disparities may be due to a significantly lower level of knowledge about hiv among african americans and latinos than whites, even though these ethnic groups were tested for hiv at a significantly higher rate. moreover, people of color have been shown to develop aids as a result of hiv at a significantly higher rate than whites, even when matched for education and ses (anderson & rowe, 2006). ultimately, hiv and aids can have major impacts on one’s interpersonal and intrapersonal relationships; therefore one’s sociological and psychological well-being can be affected. hiv infection is highly correlated with depression. because of this, an interdisciplinary approach to treating someone with hiv is paramount. mental health professionals can play a major role in the functioning and well-being of those infected with hiv/aids. who is affected by hiv/aids? according to the cdc (2006), 49% of those living with hiv are african americans, 30% caucasians, 18% hispanics, 1% asian/pacific islander, and <1% american indian/alaska native (see table 1). more specifically, males account for 73% of those living with hiv whereas women account for 26% (cdc, 2006). the cdc (2008) recently reported the estimated new hiv/aids infections by transmission category in 2006. fifty-three percent of new hiv infections were transmitted by male-to-male sexual contact; 31% from high-risk heterosexual contact; 12% from injection drug use (idu); and 4% from male-to-male sexual contact and idu. the cdc (2008) also broke down estimated new infections by age in 2006: 34% ages 13-29; 31% ages 30-39; 25% ages 40-49; and 10% ages 50 and over. table 1 hiv/aids in the united states (2006) gender race/ethnicity age male 73% african americans 49% <13 <1% female 26% caucasian 30% 13-24 15% hispanic/latinos 18% 25-34 26% asian/pacific islander 1% 35-44 32% american indian/alaska native <1% 45-54 20% 55-64 6% > 65 2% note. data obtained from: center for disease control and prevention (2006). retrieved from: http://www.cdc.gov/hiv/resources/factsheets/us.htm according to the american psychological association’s (apa) standard 2.01, boundaries of competence, mental health professionals have an ethical obligation to ensure that they are competent in the area in which they provide services. this includes and is not limited to culture, ethnicity, gender, and sexual orientation (apa ethics code, 2002). since research indicates that african americans and gay and bisexual men of all races continue to be most severely affected by hiv/aids, it is important for mental health professionals to be aware of the cultural, familial, and community norms and values pertinent to their patients (cdc, 2006). one example of how this can be accomplished is by attending seminars or conferences regarding cultural diversity. a 2002 study by low-beer and colleagues examined prevalence rates of hiv/aids in relation to sexual orientation, socioeconomic status, and education among a large sample of men from the west end of vancouver, canada. the study surveyed a total of 1,176 men; 300 men identified as being either gay or bisexual. about 16% of those men, who identified as gay or bisexual, reported being positive for hiv. the results of the study indicated that, in general, gay or bisexual men who were hiv-negative had more education, higher rates of full-time employment, and aquino, secker & wood 54 higher incomes than the hiv-positive participants. the data collected from this study is presented in table 2 (low-beer et al., 2002). table 2 comparison of sociodemographic characteristics between gay and bisexual hiv-positive (n = 47) and hiv-negative men (n = 237) in vancouver’s west end characteristics hiv-positive [n (%)] hiv-negative [n (%)] age median 38 37 education > 12 years 44 (94) 228 (97) < 12 years 3 (6) 8 (3) full-time employment yes 19 (40) 187 (79) no 28 (60) 50 (21) income > 20,000 31 (66) 198 (85) < 20,000 16 (34) 36 (15) the cdc (2009b) reported a study that showed a 15% increase in hiv/aids diagnoses from 2004-2007 in 34 states. these 34 states all have long-term hiv/aids reporting. the cdc suggests four possible reasons for this increase: (1) the increase may be the result of changes in state reporting regulations. some states have now included reporting all viral loads and cd4s during laboratory tests. (2) more people are getting tested for hiv/aids due to increased emphasis on the benefits of early testing. the cdc reports that the testing rates are higher for pregnant women, people who engage in behaviors that are known hiv risks, young people (ages 18-34), and african americans. (3) there may be instability in the data. (4) there may be an actual increase in hiv/aids infections. the cdc has identified specific subgroups that have shown the greatest increase in hiv/aids diagnosis. there has been a 26% increase in hiv/aids diagnoses among men who have sex with men (msm). the centers for disease control and prevention states that “although it is difficult to determine whether the increase in diagnoses represents a true increase in incidence, a recent cdc analysis indicated that hiv incidence among gay and bisexual men has been increasing since the early 1990s” (cdc, 2009). along with increases among all racial/ethnic groups, there has been a 9% increase seen among high-risk male heterosexuals, and a 14% increase among females. increases in hiv/aids diagnoses were seen in 28 out of the 34 states included in this study. although increases were seen the most in the southern states, estimates per region were not included (cdc, 2009b). a recent cdc (2008) report used an extended backcalculation model to show the estimated number of new hiv infections. figure 1 is taken directly from the august 2008 cdc report “estimates of new hiv infections in the united states.” as can be observed from the figure, the estimated number of new hiv infections have drastically decreased since the mid-to-late 1980s, but have slowly risen from the early 1990s and have since began to level off. note: estimates are for 2-year intervals during 1980–1987, 3-year intervals during 1977–1979 and 1988 –2002, and a 4-year interval for 2003–2006. figure 1. estimated number of new hiv infections, extended back-calculation model, 1977–2006 ethical and legal issues the ethical principles of psychologists and code of conduct (apa ethics code, 2002) serve as the mental health professionals’ reference for professional standard of care. the hiv/aids-related ethical dilemma of confidentiality involve ethical principle a: beneficence and nonmalficience, and apa standard 4.01: maintaining confidentiality. principle a: beneficence and nonmaleficence the ethical principle of beneficence refers to being kind and doing good for others. furthermore, the principle involves “respecting the dignity and worth of the individual” (hughes & friedman, 1994, p.2). under this principle, mental health care professionals are required to provide compassion for their patients infected with hiv/aids (hughes & friedman, 1994). regardless of the clinician’s theoretical orientation, mental care professionals strive to provide quality care while maintaining and valuing the person, content, and therapeutic relationship. the principle of nonmalficience means “do no harm” and requires mental health care professionals to “attempt to hiv/aids-related ethical dilemma of confidentiality 55 prevent harm to clients and third parties as long as doing so does not present the professional with significant risks or costs, and the benefits that clients or others would receive are not outweighed by the risks or costs incurred by the professional” (melchert & patterson, 1999, p.180). if a treating clinician shares the commonly held view that avoiding harm to others is a more compelling responsibility than the responsibility of benefiting patients, then they are likely to breach confidentiality when faced with the hiv/aids-related ethical dilemma of confidentiality (melchert & patterson, 1999). however, there are mental health professionals who err on the side of confidentiality and will not, unless mandated by state law, break mental health professional-patient confidentiality. it is argued that those mental health professionals who break confidentiality to protect and avoid harm to third parties are causing more harm than good as there is a possibility that breaking confidentiality “could result in harm to the client, who may experience extreme distress at the violation of trust, and, possibly, rejection by the threatened partner” (hughes & friedman, 1994, p.3). here lies the core of the ethical dilemma: should mental health care professionals maintain confidentiality or should they risk confidentiality and possibly cause harm to their patients to protect unsuspecting sexual partner(s)? to some mental health professionals, resolving this ethical dilemma is rather simple, but to others it is a complicated and often times, an unclear and painstaking process. resources for mental health professionals in this circumstance appear to be limited to the apa ethics code and state laws. both literature and the ethical principles of psychologists and code of conduct (apa ethics code, 2002) maintain that legal mandates supersede ethical guidelines. however, not every state has a law surrounding the issue. therefore, it is the clinician’s responsibility to resolve this ethical dilemma. maintaining confidentiality (apa standard 4.01) the ethical principles of psychologists and code of conduct (apa ethics code, 2002) address confidentiality in standard 4.01: psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. the apa has specified their position on breaching confidentiality with an hiv/aids patient. they state that “no legal duty to warn should be imposed, and if such legislation is imposed, disclosure by the therapist should occur only after (a) a known partner is identified to be at risk, (b) the partner is not himself/herself aware of the risk, and (c) the patient has not been willing to tell that individual directly” (huprich, fuller, & schneider, 2003).2 the tarasoff ruling states that “when psychotherapist determines, or pursuant to the standard of his profession should determine, that his patient presents a serious danger of violence to another he incurs the obligation to use reasonable care to protect the intended victim against such danger” (dimarco & zoline, 2004, p.69). the tarasoff ruling in 1976 is a major legal aspect that demands attention when addressing the hiv/aids-related ethical dilemma of confidentiality. although some situations may meet the tarasoff requirement for duty to warn, some argue that the issue of hiv/aids is simply not applicable. however, as important as the tarasoff ruling is, many states have not adopted tarasoff, thus placing professional responsibility on the treating mental health professionals to resolve the dilemma (corey, corey, & callanan, 2007). those advocating for the maintenance of confidentiality argue that clinical mental health professionals are nonmedical professionals, and therefore, “cannot legitimately be held responsible for making an assessment of dangerousness, since the diagnosis is a medical one” (dimarco & zoline, 2004, p.69). this view is in stark contrast to mental health professionals who maintain that it is their responsibility to breach confidentiality and reveal the danger that results from some patients that may not honestly disclose their hiv/aids status. these mental health professionals actively advocate breaching confidentiality in such situations to protect others from potential harm (dimarco & zoline, 2004). the best course of action on ethical dilemmas is often achieved after a careful evaluation of personal and professional values and review of the ethical guidelines and legal mandates. confidentiality is viewed as an essential component in therapeutic relationships. mental health professionals often reassure patients that the therapeutic relationship and the therapeutic environment is safe, open, and most importantly, confidential. the literature states that “without assurance of confidentiality, patients may be hesitant to seek treatment because of fear of stigmatization” (chenneville, 2000, p.661). as previously stated, breaches of confidentiality may cause harm to patients. research shows that the “ultimate question is not whether to breach confidentiality but rather how to protect third parties without destroying the therapeutic alliance between clinician and client” (chenneville, 2000, p.661). in terms of the hiv/aidsrelated ethical dilemma of confidentiality, the literature encourages mental health professionals to consider less intrusive means of dealing with the hiv/aids-related ethical dilemma of confidentiality, such as persuading the patient to self-disclose to their sexual or needle sharing partner(s) (corey et al., 2007). 2 although this article was written before the publication of the apa’s 2002 ethics code, the authors indicate that their analysis “have not been substantially altered by the 2002 ethics code revisions” (huprich et al., 2003). aquino, secker & wood 56 generally, confidentiality (apa standard 4.01 “maintaining confidentiality, apa 2002) should be maintained except in circumstances in which a patient’s behavior poses physical danger to others or one’s self. since mental health professionals have a legal duty to protect and warn, it is imperative that mental health professionals are familiar with the ethical guidelines and legal mandates. mental health professionals’ duty to warn and protect is “especially difficult because counselors face not only ethical and legal issues surrounding confidentiality of client communications but also specific statutory prohibitions against disclosures of hiv information” (corey et al., 2007, p.252). each state differs in their statutory prohibitions. for instance, pennsylvania law mandates that mental health professionals “may not break confidentiality to warn that a client poses a threat to others through hiv/aids” (corey et al., 2007, p. 252). on the other hand, some states (e.g. montana and texas) provide legal protection for mental health professionals who break confidentiality to warn third parties of possible harm (corey et al., 2007). there is no apparent consensus on what most states legally mandate regarding disclosure of hiv/aids to a monogamous partner. a recent study by pabian, welfel, and beebe (2009) showed that an average of 76.4% of surveyed mental health professionals were incorrect when asked to select the one statement that most accurately described their state’s law regarding duty-to-warn. the study also found that the mental health professionals had inaccurate interpretations of situations involving duty to warn. it is important that mental health professionals continue to educate themselves regarding ethical and legal dilemmas. while the “duty to warn” concept is generally accepted in the mental health care field in the areas of homicidal and suicidal intent, and child and elder abuse, some mental health care professionals argue that “the risk that hivpositive clients pose to others is fundamentally different” and consequently, “hiv-positive clients’ rights to confidentiality outweighs the benefits of breaking their confidentiality to warn third parties of their possibility of contracting hiv” (melchert & patterson, 1999, p.180). similar to principle a: beneficence and nonmaleficence, the ethical dilemma becomes whether to maintain confidentiality or break it to protect third parties from possibly contracting hiv/aids. in fact, a person is at risk for contracting hiv when engaging in unsafe sexual behavior, it is not certain that the person will indeed contract hiv. therefore, it is hard to conclude that imminent physical injury will occur (huprich, fuller, & schneider, 2003). the literature suggests that mental health care professionals should advise and actively work with their patients to either terminate their risky sexual and needle sharing practices or inform the potential victim(s) (melchert & patterson, 1999). the american psychiatric association ad hoc committee of aids policy (1988) further specified that is it ethically permissible to notify an identifiable person if the patient refuses to self-disclose to a partner(s) in which unsafe sex practices are being employed (melchert & patterson, 1999). mental health professionals need to make various decisions when assessing risky behaviors among their hiv/aids patients, including breaching confidentiality to reveal the hiv/aids status to a partner and how to discuss the importance of safer sex practices. to aid mental health professionals in making these decisions, knapp and vandecreek (1990) suggest three levels of risky behavior. ‘low-risk behavior’ is casual contact where breaching confidentiality may not be an issue. these behaviors include kissing, human bites, and tattoos. ‘intermediate-risk behavior’ is engaging in safe sex, but without informing the partner of the risks involved. ‘high-risk behavior’ is unsafe sexual contacts and sharing needles (knapp & vandecreek, 1990). this rating system can be used to help mental health professionals make decisions about breaching confidentiality by helping them decide which situations are the most serious and perhaps more likely to necessitate a breach in confidentiality. current beliefs of mental health professionals burkemper (2002) found that, in regards to maintaining confidentiality with an hiv/aids patient, professional ethics (as opposed to legal considerations) were most important to mental health professionals. palma and iannelli (2002) studied if biases held by mental health professional trainees affect their therapeutic reactivity to confidentiality with hiv/aids patients. they found that trainees held the highest level of therapeutic reactivity towards heterosexual male patients and the lowest level of therapeutic reactivity towards heterosexual female patients. the authors describe therapeutic reactivity or one’s willingness to breach confidentiality as a shift in willingness to maintain confidentiality. their research also found that trainees emphasized the patient’s safe or unsafe sexual behaviors, as well as the gender and sexual orientation of the patient, when making their decisions regarding confidentiality. the study gave evidence of a bias in regards to therapeutic reactivity when the patient is gay or lesbian. although the data shows that trainees were the most reactive towards male heterosexual patients and least reactive towards female heterosexual patients, a bias appears evident when considering reactivity towards gay male and lesbian female patients (palma & iannelli, 2002). the information gathered in palma and iannelli’s 2002 study indicated that work needs to be done to lessen the biases of mental health professionals. although no nationwide study was found, a 2001 study by simone and fulero looked at a group of ohio mental health professionals to determine if they would breach confidentiality with their hiv/aids patients and found that their sample was strongly split on the issue. these mental health professionals “tended to stigmatize patients who became infected through iv drug use and homosexual contact more than they stigmatized patients who became infected through heterosexual contact and blood transfusions” (simone & fulero, 2001, p.433). as hiv/aids-related ethical dilemma of confidentiality 57 knowledge of aids increased, the level of stigma towards aids patients decreased, which in turn decreased the likelihood of breaching confidentiality. although the mental health professionals did well on the aids risk knowledge (ark) scale, they received a lower score on tests regarding the legal and ethical knowledge related to “duty to protect.” a lower score regarding legal and ethical knowledge regarding liability concerns was found to correspond with increased likelihood of breaching confidentiality. however, it is important to note that only 17% of respondents reported having experience with hiv/aids-infected patients (mcguire, nieri, abbott, sheridan, & fisher, 1995; simone & fulero, 2001). clinical implications there are several steps a mental health professional can take before breaching confidentiality to ensure the safety of their patient and others. an important therapeutic tool when working with hiv/aids patients is psychoeducation (huprich et al., 2003). the mental health professional can recommend that the patient inform their partner about their hiv status or encourage them to refrain from engaging in sexual activity with their partner. if the patient refuses to do either of these steps, the mental health professional can then advocate for practicing safe sex. gray and harding (1988) suggest a “process of helping the patient take responsibility for informing a sexual partner(s).” this process includes educating the patient about the specific transmission processes and current medical advice, consulting with the patient’s primary care physician, and actively supporting the patient when they rehearse difficult communication situations (gray & harding, 1988). whereas the ethical principles of psychologists and code of conduct (apa ethics code, 2002) attempts to provide psychologists with clear guidelines by which to abide, mental health professionals are often faced with uncertainty as a result of the contradictions that arise between legal mandates and ethical codes. given that the hiv/aids-related ethical dilemma of confidentiality is of concern in clinical practice, the following are recommendations for mental health professionals treating hiv/aids infected patients (corey et al., 2007): 1. discuss limits to confidentiality at the onset of treatment. 2. possess awareness of state laws in regard to disclosure. 3. possess awareness of ethical guidelines. 4. possess sufficient self-awareness in regard to one’s attitude, biases, and prejudices. 5. mental health professionals should speak openly about their concerns over their patient’s behavioral practices. 6. utilize consultation and supervision. 7. if the clinician decides to break confidentiality to protect identified and unsuspecting third parties of their risk in contracting hiv/aids, the clinician should advise their patient prior to disclosure both the purposes of maintaining rapport and to attempt to obtain the patient’s permission. 8. always follow statutory guidelines. before breaching confidentiality, the following is suggested for consideration (hook & cleveland, 1999): 1. maintain current knowledge of the medical dimension of hiv/aids, including transmission. 2. encourage patients to be retested to ensure an accurate diagnosis. 3. maintain current knowledge of relevant existing state laws. conclusion although confidentiality in therapeutic relationships is valued and protected, there are situations in which a breach in confidentiality may be necessary and/or mandated by law. confidentiality with a patient who has hiv/aids has been debated for years. when breaching confidentiality, it is important for mental health professionals to take reasonable precautions, seek consultation and supervision, and refer to and review state laws and professional ethical guidelines. these are some of the 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(2001). psychologists’ perceptions of their duty to protect uninformed sex partners of hiv-positive clients. behavioral sciences and the law, 19, 423-436. graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 102 differences among ethnic groups in trauma type and ptsd symptom severity emily trepasso-grullon california school of professional psychology, alliant international university psychologists are interested in individual characteristics associated with posttraumatic stress disorder (ptsd) to better understand stress and stress responses. the current literature is mixed about differences among ethnic groups for trauma and ptsd symptom endorsement and severity. culture-specific perspectives lend different interpretations of potentially traumatic events, suggesting that members from different ethnic groups experience stressors differently and may consequently endorse different symptoms. although some studies have examined differences among ethnic groups with respect to mental illness, research on the relationship between ethnicity and endorsement of trauma or ptsd symptoms is limited. further, few studies have explored explanations for such differences. group differences in symptom endorsement between individuals from african american, hispanic, and non-hispanic caucasian ethnic groups will be examined. additionally, hypothesized reasons for these differences (such as response bias and methodological issues) will be explored. this review highlights the importance of considering ethnicity-specific as well as methodological factors that influence endorsement of traumatic events and ptsd symptoms in response to traumatic stressors. this review will guide treatment providers in understanding and appropriately assessing ptsd symptoms by enhancing their understanding of the role of culture. posttraumatic stress disorder (ptsd) has been a topic of interest for more than 30 years.  ptsd affects people from all ethnic groups; however, cultural dynamics complicate understanding ptsd across ethnic groups. for example, some studies suggest that unique cultural factors increase ethnic minorities’ risk for ptsd (breslau et al., 1998; marsella, friedman, & spain, 1996; pole, gone, & kulkarni, 2008). cultural experiences, values, and beliefs influence the interpretation of and reaction to traumatic stressors, expression of ptsd symptoms, symptom severity, coping skills for dealing with symptoms, likelihood of seeking and completing treatment programs, and response style on selfreport instruments (brewin, andrews, & valentine, 2000; elhai & ford, 2007; jobson & o’kearney, 2008; matlow & deprince, 2012; stephens et al., 2011). additionally, type of trauma exposure, perceived severity, and level of engagement in treatment affect development of ptsd differently across ethnic groups (brewin et al., 2000). ptsd is characterized by a response of intense helplessness, fear, or horror, to actual or threatened death, serious injury, or threat to the physical integrity of oneself, or learning about a traumatic event that occurred to a close friend or relative. several traumatic events recognized by the american psychiatric association (2000) include: military combat; assault (e.g., sexual assault, non-sexual attack, torture, robbery, mugging); natural or manmade disasters; emily trepasso-grullon, m.s., california school of professional psychology, alliant international university, san diego, ca. correspondence concerning this article should be addressed to emily trepasso-grullon, 10455 pomerado road, san diego, ca 92131. email: emilygrullon@gmail.com incarceration; being in an accident, kidnapped or taken hostage; or diagnosed with life-threatening illness. in addition to responding with intense helplessness, fear, or horror, individuals must also experience at least one reexperiencing symptom (e.g., nightmares, intrusive or unwanted thoughts, flashbacks), three avoidance symptoms (e.g., avoiding stimuli associated with the event, conversations, people, or places that remind the individual about the event, difficulty remembering important parts about the event, decreased interest in activities that used to be enjoyable, feeling emotionally numb, guilty, or depressed), and two hyper-arousal symptoms (e.g., difficulty sleeping, being easily startled, “on edge,” or tense). additionally, symptoms must cause impaired functioning in social, occupational, or other areas for a period of one month or more. duration of symptoms determines whether an acute (one to three months), chronic (three or more months), or delayed onset (symptoms begin six months after the event) specifier is used (american psychiatric association, 2000). diagnostic criteria for ptsd have changed over the years, indicating that clinicians’ understanding of ptsd is constantly evolving. the diagnostic and statistical manual, third edition (dsm-iii) required an individual to experience a catastrophic event outside the normal human range of experience. in contrast, the dsm fourth edition, text revision (dsm-iv-tr) requires an individual to be exposed to a traumatic event and respond with intense helpless, fear, and horror (american psychiatric association, 2000). criteria for ptsd for the dsm, fifth edition (dsm-5) are currently under review. the goal of this revision is to make diagnostic criteria more specific to ptsd and to increase validity of the diagnosis across samples (friedman, resick, bryant, & brewin, 2011). trepasso-grullon 103 despite the addition of ptsd to the dsm-iii in 1980 by the american psychiatric association (2000), relatively few studies have explored the experience of members of noncaucasian ethnic groups who have lived through a traumatic stressor (triffleman & pole, 2010). therefore, these groups are greatly underrepresented in current research (kramer, ross, & davidson, 2001). some meta-analyses and major epidemiologic studies (e.g., brewin et al., 2000; kessler et al., 2005) explored ptsd but omitted ethnicity from their analyses entirely, grouped all minorities into broad groups, or grouped all minorities into one ‘supergroup’ to compare to non-hispanic caucasian adults as a reference group (e.g., breslau et al., 1998; brewin et al., 2000). moreover, studies that have examined ethnicity present mixed conclusions about the relationship between ethnic groups, trauma type, and ptsd symptom endorsement (roberts, gilman, breslau, breslau, & koenen, 2011). these differences may be attributed to a number of factors, such as protective and risk factors. many people do not develop symptoms that warrant a diagnosis of ptsd after exposure to a traumatic event (u.s. department of health and human services, 2009). lifetime prevalence for ptsd among american adults is between 3.5% and 6.8% (kessler et al., 2005). however, a more recent study suggests that lifetime prevalence of ptsd is on the rise. according to roberts and colleagues (2011), african american adults have a higher lifetime prevalence (8.7%) than hispanic adults and caucasian adults (7.0% and 7.4%, respectively). also, african american individuals are more likely to meet criteria for ptsd than hispanic individuals or non-hispanic caucasian individuals (asnaani, richey, dimaite, hinton, & hofmann, 2010). the rates of ptsd are lower than rates of other mental illnesses (roberts et al., 2011). low rates of ptsd in comparison to other mental illnesses may be due to various protective factors such as social support, religion, reframing the traumatic event as a learning experience and catalyst for positive change, accepting one’s actions during the event, or the perception that one responded effectively during the stressor despite being afraid (charney, 2004; kleim & ehlers, 2009). nevertheless, such coping mechanisms for trauma differ across ethnic groups. for example, some studies have suggested that african american adults and hispanic adults identify religion as a coping skill. however, in these studies, african american adults were more likely than caucasian adults (bradley, schwartz, & kaslow, 2005; greenawalt et al., 2011; weist et al., 2007) and hispanic adults (ford, 2012) to identify religion as a primary coping mechanism. coping skills may also mediate ptsd symptoms and substance use, such that individuals with coping skills for ptsd symptoms are less likely to use substances and consequently are less likely to experience severe ptsd symptoms (yeater, austin, green, & smith, 2010). several risk factors are associated with the development of ptsd. these include low socioeconomic status (ses), low education, low intelligence, pre-existing psychiatric disorders such as depression or anxiety (kessler, sonnega, bromet, hughes, & nelson, 1995; shalev et al., 1998), family history of mental illness (brady, killeen, brewerton, & lucerini, 2000; breslau, 2002; brewin et al., 2000; ozer, best, lipsey, & weiss, 2008; ullman & filipas, 2001), childhood trauma (andrews, brewin, rose, & kirk, 2000; breslau, 2002; brewin et al., 2000; wu, schairer, dellor, & grella, 2010), re-exposure to traumatic events in adulthood (khoury, tang, bradley, cubells, & ressler, 2010), and repeated exposure to the same or multiple traumas (al-saffar, borgå, edman, & hällström, 2003; green et al., 2000; matlow & deprince, 2012). socio-demographic variables, such as geographic location, social status, acculturation, and perceived discrimination, may also affect the type of trauma experienced, ptsd endorsement, and symptom severity (koenen, goodwin, struening, hellman, & guardino, 2003). for example, individuals who are members of a minority group may be more likely to live in lower income communities, be less acculturated to the dominant group, experience hardships such as discrimination, and are consequently more likely to be exposed to potentially traumatic events such as dangerous shootings or other threats to the physical integrity of oneself or others (brewin et al., 2000; breslau, 2002; chipman, palmieri, & hobfoll, 2011; turner & lloyd, 2004). although the trend is changing, current research suggests that individuals of minority groups are also less likely than caucasian adults to pursue higher education (orfield & lee, 2005). regardless of magnitude of exposure to traumatic stressors, individuals who are less educated are more likely to develop ptsd than are individuals who are more educated (breslau, peterson, poisson, schultz, & lucia, 2004). independent of ses and education level, comorbidity of ptsd with other diagnoses is the norm rather than the exception. about 80% of individuals diagnosed with ptsd are diagnosed with at least one other disorder (grinage, 2003; kilpatrick et al., 2003; najavitis, schmitz, gotthardt, & weiss, 2005) such as depression (kessler et al., 1995; shalev et al., 1998) or substance use (najavitis et al., 2005; yeater et al., 2010; wolff et al., 2010). substance use may be a method of avoiding distressing intrusive thoughts and other ptsdrelated symptoms; however, substance users may not recognize the relationship between behavior and avoidance (wolff et al., 2010). co-occurring disorders make understanding unique ptsd characteristics more difficult because they compound impairment in social, occupational, or other areas of functioning (breslau, 2002; brunello et al., 2001; hein, cohen, & campbell, 2005; najavits, norman, kivlahan, & kosten, 2010; najavitis et al., 2005). ethnicity may also affect the likelihood of seeking and completing treatment. individuals from ethnic minority groups are less likely than caucasian individuals to seek treatment for ptsd unless they know where to obtain treatment, have resources to pay for treatment, and have symptoms that significantly disrupt one or more areas of functioning (roberts et al., 2011; wang et al., 2005). in comparison to caucasian and african american adults, ethnicity, trauma, and ptsd symptom severity 104 hispanic adults are more likely to wait longer to seek mental health services due to concern of stigmatization. likewise, lester, resick, young-xu, and artz (2010) found that african american respondents were significantly more likely to drop out of or not begin therapy, even when age, income, education, treatment expectations, and trauma exposure variables were taken into account. it is questionable whether differences in trauma exposure among ethnic groups are due to actual differences or due to other factors such as ses. controlling for ses and exposure to traumatic events removed differences between african american and caucasian subjects in some studies (kulka et al., 1990; monnier, elhai, frueh, sauvageot, & magruder, 2002) but not others (alim, charney, & mellman, 2006; lester et al., 2010). for example, african american veterans reported higher rates of ptsd and greater symptom severity than caucasian veterans; however, these differences ceased to exist when controlling for ses and type of exposure to trauma (kulka et al., 1990; green et al., 1990). counselor or researcher ethnicity may also influence individuals’ likelihood of being open and honest when reporting symptoms (sue, rivera, capodilupo, lin, & torino, 2010). for example, patients from ethnic minority groups who are paired with a counselor from a non-minority ethnic group (i.e., an african american patient with a caucasian counselor) are more likely to drop out of treatment prematurely than those paired with an ethnically-matched counselor (rosenheck, fontana, & cottrol, 1995). such factors may result in underreporting of symptoms and symptom severity until they are unable to cope with symptoms (macdonald & calhou, 2010). since minorities tend to wait to seek services until symptoms are unbearable, severity of symptoms and willingness to endorse symptoms may be significantly higher for african american or hispanic individuals than for caucasian individuals seeking counseling to ensure that they receive psychotherapeutic treatment when necessary. in addition, they may be more likely to seek more inexpensive services from mental health providers with less training, to feel disrespected and misunderstood by providers, and to drop out of treatment prematurely (roberts et al., 2011; lester et al., 2010; ruef, litz, & schlenger, 2000). this underscores the importance of reducing stigmatization, building rapport and trust, as well as other factors that may influence patient disclosure to minimize omission of valuable information. understanding the expression of ptsd symptoms among ethnic groups has significant clinical implications. such understanding will enhance providers’ cultural competence in delivery of treatment interventions aimed at addressing and alleviating ptsd symptoms. this review will first examine the differences in type of trauma experienced as well as the impact of trauma on persons of different ethnic groups in terms of self-reported symptom severity. then, response style and measurement bias will be explored as proposed explanatory factors for discrepancies among prior studies. finally, recommendations for future research will be provided. trauma type and symptom severity certain traumas are reported as being more distressing than others. the development of ptsd and the type of traumatic stressor may influence disclosure of experience (bedard-gilligan, jaeger, echiverri-cohen, & zoellner, 2012). in general, individuals who develop ptsd after exposure to a traumatic stressor report greater difficulty in disclosing their traumatic event and details of the event than those who did not develop ptsd. individuals who reported sexual and childhood trauma reported greater difficulty disclosing their trauma than individuals who reported other traumas (bedard-gilligan et al., 2012). ethnicity may also impact comfort with disclosure. african american adults were less likely than caucasian adults to disclose incidence of sexual trauma; and reported regret at disclosing their experience due to negative reactions of their confidant (jacques-tiura, tkatch, abbey, & wegner, 2010). this may be due to social factors such as guilt, shame, mistrust of the interviewer, and fear of the consequences of disclosure (jacques-tiura et al., 2010). although a few studies (e.g., breslau, 1998; mainous, smith, acierno, & geesey, 2005) suggest that ethnicity is unrelated to trauma type, other studies (i.e., alim et al., 2006; breslau et al., 2006; marshall, schell, & miles, 2009; norris, 1992; roberts et al., 2011) suggest that differences do exist. for example, caucasian individuals are more likely than african american individuals to experience robbery or disaster (norris, 1992) and to learn about a traumatic event to someone they are close to (roberts et al., 2011), whereas african american individuals are more likely than caucasian individuals to be exposed to assaultive violence, such as physical assault, homicide, and rape (alim et al., 2006; breslau et al., 1998). in addition, african american and hispanic adults are more likely than caucasian adults to report childhood maltreatment, witnessing domestic violence, and war-related events as traumatic events (roberts et al., 2011; alim et al., 2006). controlling for demographic differences does not eliminate differences between groups (alim et al., 2006; spoont, hodges, murdoch, & nugent, 2009). that is, alim and colleagues (2006) found that controlling for demographic variables decreased exposure to traumatic events but did not eliminate differences between ethnic groups and type of trauma reported. therefore, type of trauma is important to consider because different traumas elicit symptoms differently across ethnic groups. ‘symptom severity’ is a term frequently used to describe the magnitude of distress experienced by an individual in response to particular traumatic events (brewin et al., 2000). although some studies suggest that there are no differences between individuals from african american, hispanic, and caucasian ethnic groups with respect to symptom severity (adams & boscarino, 2011; mainous et al., 2005; montoya, covarrubias, patek, & graves, 2003; ozer et al., 2008), other studies suggest that there are differences (breslau et al., 2006; marshall et al., 2009; pole et al., 2008; pole, best, metzler, & marmar, 2005; pole et al., 2008; rosenheck & ortega, 2000; trepasso-grullon 105 stephens et al., 2010). for example, mainous et al. (2005) initially found no significant differences in symptom severity or rates of ptsd diagnosis between caucasian and african american individuals. however, when trauma type was included as a control variable, caucasian subjects reported significantly more distress than did african american subjects stemming from hyper-arousal, re-experiencing, and avoidance symptom clusters in response to a nonphysical trauma. this suggests that studies which do not account for trauma type in analyses may neglect rich information about differences among ethnic groups in response to trauma. marshall and colleagues (2009) found significant differences between hispanic and caucasian, but not between hispanic and african american, individuals for symptom endorsement and severity. alternatively, other studies suggest that hispanic adults report greater overall symptom severity than african american and caucasian adults (e.g., breslau et al., 2006; pole et al., 2008; pole et al., 2005; rosenheck & ortega, 2000). hispanic adults may also experience symptoms differently, such that they are significantly more likely to experience hyper-vigilance and more severe physiologically-based symptoms than african americans (marshall et al., 2009). alternatively, african american adults who reported emotional abuse reported greater symptom severity than hispanic adults. african american adults who reported emotional abuse reported greater symptom severity from adult victimization than hispanic or caucasian adults, even when amount of victimization is similar across the groups (ford, 2012). alternatively, hispanic adults who suffered physical abuse and african american adults who suffered emotional abuse were more likely to report greater overall symptom severity (balsam, lehavot, beadnall, & circo, 2010). however, greater overall symptom severity does not necessarily equate to greater impairment. rosenheck and ortega (2000) posit that the differences in reported symptom severity among individuals from hispanics, african americans, and caucasian ethic groups are influenced by expressed emotion. these authors attribute hispanic adults’ significantly higher levels on symptom severity to their expressive style. however, both hispanic and african american adults who reported child abuse reported greater ptsd severity than caucasian adults, even when ses was taken into consideration (marshall et al., 2009). this suggests that there are unique within-group cultural features irrespective of certain variables (e.g., ses, comfort with disclosure, expressed emotion) that may influence individuals’ experience of trauma. some researchers have examined clusters of symptoms rather than individual symptoms (e.g., green et al., 2000; khoury et al., 2010). cluster analysis can be problematic because it overlooks potentially significant between-group differences with respect to individual symptoms. although some studies have examined differences between groups with respect to clusters of symptoms, few studies have examined differences in individual symptoms across ethnic groups. one study conducted by marshall and colleagues (2009) suggests that hispanic adults endorse similar individual symptoms as caucasian adults, but the study did not find a clear pattern of differences among ptsd clusters. however, the authors did find that hispanic individuals reported more positive symptoms (hyper-vigilance, intrusive thoughts, flashbacks, emotional reactivation) than negative symptoms (emotional detachment, restricted affect, difficulty sleeping, impaired concentration). matlow and deprince (2012) did not find significant differences among ethnic groups and total ptsd symptom endorsement; however, african american respondents were more likely to endorse item 14 of the postttraumatic diagnostic scale (pds)―i.e., feeling irritable or having angry outbursts (foa, 1995). since differences in individual symptom endorsement emerge even when differences in clusters do not emerge, theories that rely solely on an overall increase in ptsd symptoms or cluster-analysis are helpful but insufficient. this suggests that varied results about whether there are significant differences between ethnicity and ptsd may be due to lack of item-level analyses. that is, there may be significant differences among ethnic groups’ endorsement of items, despite non-significant differences among ethnic groups in total ptsd symptoms (matlow & deprince, 2012). this suggests that there are factors associated with certain ethnic groups that affect their experience of trauma and trauma-related symptoms. in addition to influencing the likelihood of developing ptsd, ethnic identity, ses, level of education, acculturation, and perceived discrimination also influence the experience and severity of trauma (khaylis, waelde, & bruce, 2007; kulka et al., 1990; green et al., 1990; matlow & deprince, 2012). more specifically, lower ses, limited access to resources, minimal or no social support after a traumatic event, and experience of additional stressors such as job loss and financial hardship after the event increase symptom severity. additionally, repeated exposure to multiple traumatic events and surviving dangerous events when others did not survive increased risk for development of ptsd and symptom severity (brewin et al., 2000; matlow & deprince, 2012). symptom severity may also be influenced by acculturation and perceived discrimination. in particular, minorities who strongly identify only with their ethnic group and not the dominant group may perceive greater stigma and discrimination are more likely to report greater ptsd symptom severity (breslau, 2002; galea et al., 2004; khaylis et al., 2007; loo et al., 2001). discrimination is multidimensional in that it can occur within subgroups, between minority groups, and between minority and majority groups (ruef et al., 2000). perceived discrimination accounts for greater differences in mental health than does ses. individuals who are members of the african american ethnic group are more likely to perceive discrimination than are individuals who are members of hispanic or caucasian ethnic groups (hausmann, jeong, bost, & ibrahim, 2008). minorities who perceive that they have been discriminated against report greater symptom severity than individuals who identify with the majority group ethnicity, trauma, and ptsd symptom severity 106 (bogart et al., 2011; wagner, bogart, galvan, banks, & klein, 2012). for example, african american and hispanic adults who reported that they were discriminated against reported greater symptom severity than caucasian adults who did not perceive discrimination (ruef et al., 2000). they also report worse mental health care (hausmann et al., 2008). thus, differences in response to trauma are influenced by a variety of factors and may be explained by one’s experiences and worldview. this suggests that differences between ethnic groups may be due to factors associated with particular ethnic groups rather than the ethnic group itself. future studies should consider socio-demographic variables in analyses to determine whether differences in trauma type and symptom severity between ethnic groups are due to ethnicity itself rather than factors associated with all ethnic groups. in a similar vein, differences in response style should be considered to rule out between-group differences in response styles. response style and measurement bias response styles are defined as a person’s way of responding to questions such as those in psychological assessment inventories (franklin & thompson, 2008). several response styles cited in the literature include socially desirable responding, acquiescence, and extreme responding (johnson et al., 2011; marshall et al., 2009). response styles are important to consider when assessing ptsd because selfreport measures are frequently used to assess symptoms (elhai, gray, kashdan, & franklin, 2005). differences in response style make it difficult to identify exaggeration in patients who may receive secondary gain from a ptsd diagnosis. response styles may artificially magnify or conceal differences in endorsement of trauma and symptom severity. that is, an observed difference may be due to the construct of ptsd rather than actual differences between groups. alternatively, if no differences are found, there may be problems with measurement methods that suppress differences (drasgow & probst, 2004). most studies on ptsd do not explore response style, despite bias in self-reported symptoms (franklin & thompson, 2008). in such studies, it is unknown whether differences are due to differential response styles or actual differences between ethnic groups. for example, hispanic culture may be more accepting of and open to discussing anxiety-related symptoms. if this is the case, endorsement of such items is attributable to differences in cultural norms about appropriate sincerity and modesty in social interactions (rosenheck & ortega, 2000). another explanation for between-group differences may be due to differences in interpretation. for example, ethnic differences may be due to measurement artifacts such as differential item functioning (dif) or problems associated with translation (lewis-fernandez et al., 2008; miles et al., 2008) and sensitivity and severity when assessment instruments are used in different populations (mcdonald & calhou, 2010). it is also important that measures are translated correctly. for example, the posttraumatic stress disorder checklist (pcl; weathers, litz, herman, huska, & keane, 1993) is a frequently used self-report instrument used to measure ptsd symptoms and severity (blanchard et al., 1996). marshall et al. (2009) did not find disparities between responses on spanish and english versions of the pcl. however, these authors only included individuals who experienced a physical injury that was severe enough to warrant hospitalization. since prior studies suggest that there are group differences in type of trauma experienced, future research should evaluate differential item functioning of spanish and english versions of the pcl in groups which experienced different types of trauma (clarke, 2000; miles et al., 2008; weathers et al., 1993). therefore, it is necessary to ensure the items in ptsd instruments do not pull for certain answers (miles, marshall, & schell, 2008). social desirability may also affect responses. socially desirable responding is defined as reporting information that portrays oneself in a more favorable light (johnson et al., 2011). individuals who are from ethnic groups which value harmony and conformity are more likely to demonstrate socially desirable responding than are individuals from ethnic groups which value independence and autonomy (johnson et al., 2011). for example, individuals from african american and hispanic ethnic groups were more likely to respond to ptsd questionnaires in a socially desirable manner when compared to individuals from the caucasian ethnic group (pole et al., 2005). similarly, acquiescence bias, defined as agreeing or disagreeing with the majority of statements, may account for differences between ethnic groups such that individuals who identify with certain ethnic groups may also be more likely to overor under-endorse certain items (macintosh & strickland, 2010; marshall et al., 2009; pole et al., 2005). specifically, african american adults are more likely than caucasian adults to demonstrate acquiescence and extreme responding in their endorsement of items at the extreme ends of response scales, regardless of content (bachman & o’malley, 1984; clarke, 2000). hispanic individuals are also more likely than caucasian individuals to acquiesce and demonstrate extreme responding (ortega & rosenheck, 2000). in contrast to african american adults, hispanic adults are more likely to agree with items indicating a directional bias, which may influence conclusions drawn from the data (bachman & o’malley, 1984; clarke, 2000). given these findings, it may appear that hispanic individuals tend to report more symptoms and endorse unusual items that consequently lead to inflated scores even when not more severely impaired than individuals who are members of nonhispanic ethnic groups (pole et al., 2005). instruments used to compare response styles among clinical samples are increasing in popularity (franklin & thompson, 2008). the trauma symptom inventory (tsi; briere, 1995) is cited as a useful instrument for measuring response style as well as post-traumatic psychopathology. this 100-item structured self-report instrument has three validity scales (response level, inconsistency, and atypical trepasso-grullon 107 response). however, most research conducted with this instrument uses college students and may not generalize to ethnically diverse or clinical samples. the minnesota multiphasic personality inventory 2 (mmpi-2; hathaway & mckinley, 1940) and structured interview of reported symptoms (sirs; rogers et al., 1992) may also be used to assess response styles. it is important to select instruments that have been validated using samples that reflect the population of interest. that is, instruments selected to assess ptsd in african american adults should be normed using a similar sample of individuals to minimize measurement bias. measurement bias inflates measurement error and complicates interpretation of findings. since ptsd is assessed using various instruments and methods, is also important to minimize contamination from measurement bias. sources of measurement bias include problems with translation, comprehension, cognition, memory, experimenter expectancy (the susceptibility of researchers to find what they expect to find), experimenter reactivity (the susceptibility of researchers to influence the behavior of subjects either intentionally or unintentionally), and social desirability (johnson et al., 2011). in addition to measurement bias from characteristics of extraneous variables, the assessor’s, or instruments’, administration method may also influence self-report. individuals are more likely to report greater symptom severity in response to a traumatic event when interviewed by an interviewer than when given a self-report questionnaire (breslau et al., 2006). therefore, utilizing both structured interviews and questionnaires is recommended to cross validate responses. self-report and clinician-assessed symptoms are comparable across ethnic groups (macdonald, greene, torres, frueh, & morland, 2012). however, method of administration (e.g., computerized or paper-and-pencil) may influence results. although computer-administered or paperand-pencil measures do not always result in differences between ethnic groups (booth-kewley, edwards, & rosenfeld, 1992), paper-and-pencil and intervieweradministration has more of an impact on social desirability than does computer administration, especially when questions are highly personal, disturbing, intrusive, or sensitive, and when the interviewer is of a different ethnicity than the respondent (wood, nosko, desmarais, ross, & irvine, 2006). in such cases, computer administration is beneficial since it reduces social desirability and scoring time, while increasing accuracy of scoring. however, computerized assessments can introduce user error if participants are not comfortable with using computers. if comfort level with computers is not assessed, methodology may impact accuracy such that individuals with less computer experience may make more errors and thus provide less accurate information about their experience with traumatic events (montoya et al., 2003). this may lead clinicians to misdiagnosis individuals (alim et al., 2006). response bias and measurement bias may explain discrepancies among research studies aiming to clarify whether differences among ethnic groups actually exist or are measurement artifacts. future studies should carefully and comprehensively evaluate the influence of response style and measurement bias among ethnic groups to avoid drawing incorrect conclusions about ptsd symptom severity and type of trauma. instruments such as the greenleaf extreme response measure (greenleaf, 1992) , an instrument with 16 items that are cross-culturally applicable, and an instrument to measure social desirability, such as the social desirability scale (stoeber, 2001) may be helpful to determine whether participant responses fit a pattern rather than the construct of interest (clarke, 2000). statistical analyses will clarify the source of differences between ethnic groups due to unique characteristics of members that comprise the groups, rather than the instruments used to elicit information about traumatic experiences. statistically significant differences in response style and socially desirable responses would necessitate controlling one or both of these variables. furthermore, most studies have examined ethnic minority groups as broad categories. some studies (e.g., breslau et al., 2006; brewin et al., 2000) cluster all ethnic minority groups into one ‘supergroup’ to compensate for insufficient sample size. comparing this ‘supergroup’ of all non-caucasian adults to caucasian adults as a reference group reduces generalizability because important differences in the manifestation and experience of symptoms between ethnic groups may be overlooked (roberts et al., 2011). grouping all hispanic individuals into one categorical group neglects the heterogeneity of groups and, consequently, loses important information unique to subgroups. for example, hispanic adults from different regions (e.g., mexico, puerto rico, dominican republic, and cuba) have unique aspects of their culture that impact manifestation of symptoms as well as reporting of symptoms on ptsd instruments. future studies should include ethnic sub-groups to determine if group differences may be accounted for by one sub-group. multimodal assessment is also recommended for assessing ptsd symptoms because response style may lead to faulty conclusions about ethnic group differences. clinicianadministered and self-report measures allow researchers to evaluate discrepancies or similarities among individuals’ response styles. conclusion the purpose of this review was to highlight differences in response to traumatic events. differences among ethnic groups underscore the importance of cultural competency when assessing ptsd. possible explanatory factors for these differences were examined to enhance understanding about the differences in trauma and ptsd symptoms experienced by members of different ethnic groups. previous research shows that there are qualitative differences between individuals from caucasian, african american, and hispanic groups in terms of interpretations of traumatic events and self-reported ptsd symptoms. response style and measurement bias may help to explain these findings. future ethnicity, trauma, and ptsd symptom severity 108 studies should include measures of acculturation to explore the impact of level of acculturation on self-reported ptsd symptoms, since treatment practices that were normed on caucasian-dominant populations may need to be revised to better address issues relevant to ethnic minority groups. furthermore, in many cases, sub-groups are combined into largely generalized groups. by doing so, researchers are neglecting within-group differences and increasing the possibility of drawing incorrect conclusions about betweengroup differences. existing literature about ethnic differences and ptsd is also limited by global groupings of participants into minority and majority groups, as well as by failure to consider differences in trauma type, symptom severity, and the impact of response and measurement bias on participant responding. although the examination of ethnic differences is becoming more popular in contemporary research, many studies do not consider the impact of acculturation and perceived discrimination, nor do they take into account the heterogeneity of ethnic groups. therefore, future researchers should examine differences among ethnic sub-groups rather than combining minorities into general groups (e.g., african americans, hispanics, and caucasian adults) or combining them into one large supergroup. future studies should also allow subjects to indicate the sub-group with which they identify. this would allow researchers to build a more precise picture of differences and similarities among ethnic groups with respect to trauma and ptsd symptom severity. recruiting a sample of trauma survivors that is large enough to be representative of the larger group inclusive of subgroups would provide a closer examination of differences in symptom manifestation, expression, and appropriate attention to differences in response style. although a few researchers (e.g., adams & boscarino, 2011; kessler et al., 1995; mainous et al., 2005; montoya et al., 2003; ozer et al., 2008; spoont et al., 2009) maintain that there are no differences among ethnic groups for type of trauma experienced and ptsd symptom severity, other researchers (e.g., khaylis et al., 2007; kulka et al., 1990; green et al., 2000) provide evidence for between-group differences among ethnic groups. this review highlights the importance of considering multiple factors when drawing conclusions about individuals from different ethnicities with ptsd. several explanations have been offered to explain differences among trauma type and symptom severity reporting among ethnic groups in the literature. socioeconomic status, acculturation, perceived discrimination, response style, and measurement bias may differentially contribute to differences among ethnic groups. additionally, differences in individual life experiences can influence interpretation of trauma and, consequently, manifestation of ptsd symptoms. a multimethod approach including selfreports and clinician-administered, qualitative instruments may be helpful for understanding culturally specific factors related to ptsd. researchers and therapists would benefit from increasing their awareness about differences among ethnic groups in terms of the types of trauma they are more likely to experience, as well as the perceived severity of trauma-related symptoms when working with ptsd. in particular, awareness of between-group ethnic differences would avoid prescribing a blanket solution to assessing and treating patients with ptsd symptoms. addressing the aforementioned concerns will enhance researchers’ and mental health providers’ understanding and conceptualization of ptsd and may consequently improve the quality of future research studies and treatment interventions. references adams, r. e., & boscarino, j. a. 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(2010). coping mediates the relationship between posttraumatic stress disorder (ptsd) symptoms and alcohol use in homeless, ethnically diverse women: a preliminary study. psychological trauma: theory, research, practice, and policy, 2, 307-310. doi:10.1037/a0021 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 13 effects of auditory stimuli on empathic emotion faylin musson-moyer teachers college, columbia university individuals are exposed to a variety of stimuli that elicit empathy. however, it is unclear whether the sensory mode (i.e., auditory or visual) through which a stimulus is perceived influences empathic responses. the present study experimentally examined the differences between audiovisual communication channels in their ability to elicit empathic reactions from undergraduate students. participants completed the balanced emotional empathy scale (bees: mehrabian, 2000) in order to determine one’s emotional empathy trait prior to visually, aurally, or audiovisually viewing a short video clip of an infant child in a state of distress. subsequently, the participants rated their emotional reactions to the video clip based on subjective level of distress, how upset participants felt, and participants’ desire to help the infant. there were no statistically significant effects of the presentation style of the video on participants’ upset reactions or participants’ desire to help. however, the effect of the stimuli presentation on participants’ level of distress was statistically significant, particularly among participants with “very below average” or “below average” empathy traits. the findings of the present study suggest that empathic responses are greatest when an individual can see and hear another individual in distress, as he or she cannot misinterpret the incoming information. empathy is an affective state that mirrors another person's affective state. in other words, empathic responses are induced through the observation (imaginarily or in vivo) of the other person's affective state (de vigemont & singer, 2006). a last crucial part of the definition of empathy is that the person is aware that the other person is functioning as the source of his or her own affective state (batson & shaw, 2001; de vigemont & singer, 2006; van lange, 2008; westbury & neumann, 2008). though the neuropsychological processes of observation and imagination differ, both processes are capable of independently activating an empathic state (han, fan, & mao, 2008; staub & vollhardt, 2008; van lange, 2008; westbury & neumann, 2008) researchers have long wondered why people empathize. some researchers, for instance, have proposed that empathy functions as an intermediary between one’s cognitive and social domains during role-taking processes (iannotti, 1978; knafo, van hulle, zahn-waxler, & robinson, 2008). the suggested association between empathy and role-taking does not, however, connote inclusive similarities; rather, empathy drastically differs from role-taking (or emotional contagion) as it is capable of holding aspects of both cognition and emotion, resulting in a multidimensional construct (massilindsey, yun, & hill, 2007; seitz, nickel, & azari, 2006). the cognitive aspect of empathy brings about the capability to comprehend a distressing situation, distinguish another person’s emotions, and assume his or her perspective. the  faylin musson-moyer, m.a., department of counseling and clincial psychology, teachers college, columbia university. correspondence regarding this article should be addressed to faylin musson-moyer, 85 south main st., manchester, ny 14504. email: fmussonmoyer@gmail.com. affective aspect, on the other hand, requires an individual to “experience an indirect emotional response to others’ expressed emotions” (knafo et al., 2008, p. 737). recent evidence has emerged which suggests that during the observation of another person’s actions, specific regions within one’s own brain are affected (seitz et al., 2006). given that these specific regions have been shown to be involved in the preparation of one’s own actions, one can conclude that observing another’s pain involves brain activity similar to experiencing his or her own pain (jackson, brunet, meltzoff, & decety, 2005; seitz et al., 2006; staub & vollhardt, 2008; van lange, 2008). it is believed that the neurological activity is due to a “large-scale cortical network of nodes of convergence” (seitz et al., 2006, p. 743), linking information from various regions of the brain. through the use of fmri, jackson et al. (2005) confirmed this statement, demonstrating that the activation of the same pain-related neural network is indeed brought about when imagining oneself in a painful situation and when imagining another person in a painful situation. specific regions that are involved in this process include the temporal lobe (which provides knowledge of past experiences), superior temporal sulcus (which provides information about observed behavior), and medial prefrontal cortex (which links cognitive information to basic emotions). also, there is speculation related to the prefrontal cortex’s role in linking one’s actions with the emotional contexts associated with empathy because of the region’s condensed “spatially distinct activation clusters” (seitz et al., 2006, p. 745) which are related to thoughts and emotions (jackson et al., 2005; seitz et al., 2006). clusters similar to those found in the previously mentioned regions of the brain were also present in the superior frontal gyrus and on the border of the cingulate gyrus. this finding suggests that one’s ability to generate musson-moyer 14 mental concepts and physical actions is integrally related to the prosocial behaviors that are associated with empathic emotion (jackson et al., 2005; seitz et al., 2006). the interconnected regions within the brain emphasize the various effects that empathy can have on the individual. empathy-related emotional responses affect the activity within the nervous system as well as the cognitive accuracy and emotional intensity particular to one’s overt behavior (jackson et al., 2005; seitz et al., 2006; westbury & neumann, 2008). for instance, empathy and prosociality are considered essential components in the expression of compassion (batson et al., 1995; shaw, batson, & todd, 1994; knafo et al., 2008), which can be defined as a “dimension of morality that emphasizes concern for the wellbeing of others in distress, as well as an important aspect of interpersonal responsibility and ethical behavior” (knafo et al., 2008, p. 737). the tendency to help one individual over another, which is often generalized across species, has been found to lead to an increased helping behavior towards those who have a closer genetic relatedness or share more similarities with the individual (allen et al., 2002; batson, 1990; bierhoff & rohmann, 2004; westbury & neumann, 2008). though prosocial acts result from empathic emotion, the manifestation of such acts as altruistic or egoistic behaviors remains in question (batson, 1990; batson & shaw, 1991; jackson et al., 2005; van lange, 2008). we present here several constructs which are closely related to empathy and which may be viewed as behavioral manifestations of empathy. altruism altruism is viewed as devotion to the welfare of others or an act in which an individual wants to help others at a significant cost to him or herself (batson & shaw, 1991; van lange, 2008). the activation of empathy―a point at which the individual becomes less self-interested―leads to an increase in altruistic motivation, which ultimately leads to helping behavior (staub & vollhardt, 2008; van lange, 2008). van lange (2008) explained the occurrence of this phenomenon in terms of over-exposure. when another person is in distress or in need, the primary attention of an individual is diverted from the self and captured by the distressed person. therefore, through repeated experiences, empathy can become associated with not only benefiting others but also with specific costs to the self. with this in mind, it is important to note that empathy activates an increase in altruistic motivation, but does not significantly affect one’s selfishness/selflessness or egalitarian motives (batson et al., 1995; van lange, 2008). empathy, therefore, is an emotional state that results in a unique desire to help others at a cost to the self but without necessarily affecting personal motives. egoism humans are social creatures in thought and in action. however, when motivated by internal or external desires, we can become capable of caring only for ourselves (batson, 1990). in essence, the egoist theory assumes that humans are motivated by an ultimate goal of either maintaining or enhancing self-image, and are not interested in the welfare of others (batson, 1990; staub & vollhardt, 2008). therefore, according to the theory, an individual’s ultimate goal is always a subtle form of self-benefit (batson & shaw, 1991). maner and gailliot (2007) explained that circumstances leading an onlooker to experience empathic concern for another also elicit emotional states that remain focused on the self. after all, pain-processing areas within the brain have been found to be more widespread when an individual imagines himself or herself in a painful situation versus another person in the same painful situation. this denotes a shift of focus away from another person’s needs and onto one’s own feelings of stress and discomfort, concentrating on reducing aversive empathic arousal (batson, 1990; jackson et al., 2005). also, a sense of perceived similarity could account for actions that appear to be driven by empathic concern. the theory behind the idea of perceived similarity is that a self-focused emotional state arises from a feeling of shared-self with the individual in need. nevertheless, according to the egoist theory, one cannot be viewed as acting entirely selflessly (i.e., altruistically) when helping the individual because they would, in a psychological sense, also be helping themselves―therefore, acting egoistically (batson, lishner, cook, & sawyer, 2005; maner & gailliot, 2007). overall, a person’s prosocial acts consist of definitive objectives that concern only the self and consequently are manifested through egotistic motives. the empathy-altruism hypothesis the empathy-altruism hypothesis views empathic concern as a situation-specific response in which an affective focus remains on the person in distress instead of on oneself. therefore, in contrast to the egoist theory, the desire to assist an individual through an attempt to diminish their suffering is viewed as a truly selfless motive as it increases or strengthens one’s drive to alleviate the other person’s need (batson et al., 1995; bierhoff & rohmann, 2004; maner & gailliot, 2007). however, an individual can also deduce the value of another person’s wellbeing and respond accordingly (batson et al., 1995). much like any other hypothesis, the empathy-altruism hypothesis has been disputed on the grounds of its origins and motivational foundation. first, there remains a possibility that prosocial actions may be motivated by more egoistic/selfcentered concerns rather than altruistic intentions (maner & gailliot, 2007). as previously mentioned, researchers have argued that a sense of shared-self can, in fact, account for actions that are outwardly driven by an empathic concern through the unconscious perception that another person is part of one’s own self (batson et al., 1995; maner & gailliot, 2007). according to batson (1990), the presence of helping behaviors when empathy is low indicates the presence of underlying egoistic motives. bierhoff and rohmann (2004) predicted that prosocial behavior would most likely occur within conditions where empathic concern overrode all other auditory stimuli and empathy 15 variables (free of situational constraints) or where personal distress predominated with difficulty to psychologically escape the condition. when situational constraints were present and an opportunity to psychologically escape was deemed complex, an inclusive helping behavior was positively correlated with empathy, and a sense of accountability and fluctuating self-esteem were primarily dominated by one’s egoistic motivations (bierhoff & rohmann, 2004; staub & vollhardt, 2008). bierhoff and rohmann (2004) had also predicted that those who experienced a great deal of personal distress but who had the opportunity to exit the situation would exert a minor degree of help because the ease of dismissing the situation from the mind would allow for one’s own distress to be alleviated. nevertheless, if an individual is altruistically motivated, then the helping behavior would not decrease, signifying that empathy is a good indicator of altruistic motives (bierhoff & rohmann, 2004). the primary concept behind the empathyaltruism hypothesis is based upon situation-specific responses. it is within these conditions that an observer who witnesses another person’s troubles may become motivated to behave in an altruistic manner with the sole intention of reducing the other person’s suffering (bierhoff & rohmann, 2004). the significance of the empathy-altruism hypothesis tends to coincide with various theoretical explanations of helping behavior as well, including shared genetics (allen et al., 2002; batson, 1990; thibodeau, jorgensen, & jonovich, 2008; westbury & neumann, 2008), relationship status (allen et al., 2002; maner & gailliot, 2007; staub & vollhardt, 2008; westbury & neumann, 2008), and preferential biases. however, there is still uncertainty as to why people are empathic. the answer to this may not be directly related to earlier renowned notions of human behavior, but rather, in one’s ability to interact and communicate with others. whom we choose to help and why relationships and closeness. in comparison to distant social relationships, relationships that are generally close are commonly characterized by elevated levels of empathic concern and sincere affection for another’s wellbeing. these characterizations are evident in everyday conversations as people choose what type of personal information to discuss dependent on who they are talking to. a conversation between two strangers, for example, will consist of fairly selfish objectives in order to maximize one’s benefits to their costs (maner & gailliot, 2007). however, when an observer witnesses a person in distress who is similar to himself or herself, increased signs of physiological arousal and distress are displayed (allen et al., 2002; westbury & neumann, 2008). there are implications that helping in close personal relationships may possibly be stimulated by empathic concern and an actual desire to improve the welfare of another person, though these motives seem to dissipate as the relationship becomes more distant (maner & gailliot, 2007; o’gorman, wilson, & miller, 2005). an empirical study conducted by maner and gailliot (2007) assessed the relation between empathy and willingness to help a family member and a stranger; their findings revealed that the strength of the empathy-helping link was dependent on relationship context. though, these findings can also be used to clarify the differences in egoistic and altruistic factors. by showing that meaningful forms of prosocial acts are more likely to be directed by empathic concern when taking place within a close relationship―despite the lack of evidence regarding empathic concern as a predictor to the willingness to aid a stranger―it can be concluded that only egoistic factors can predict an individual’s inclination to help. in other words, prosocial acts among strangers may look as if they are altruistically driven but they are in actuality driven by more self-centered concerns, while prosocial acts within a close relationship appear to be driven by genuine empathic regard (maner & gailliot, 2007; staub & vollhardt, 2008). empathy/prosocial behaviors and genetic closeness. empathic responding is extended from human to human, often varying in intensity, and can be generalized towards other species as well (westbury & neumann, 2008). however, individuals who have a lower empathy trait may not experience stimuli in the same manner as individuals who contain a moderate or high empathy trait (westbury & neumann, 2008). this response is reflected in the empathyaltruism hypothesis, in which behavior serves as a function of emotional responsiveness (batson et al., 1995). in this sense, the more empathy that an individual feels for another will largely predict the degree of altruistic motivation present within the given prosocial act. however, it is important to note that one’s empathic concern does not denote a ‘help’ vs. ‘not-help’ state of mind, but rather refers to the extent to which motivation is considered altruistic or egoistic (bierhoff & rohmann, 2004). movement of the corrugator supercilii, a small muscle located near the middle of the eyebrow, is often regarded as the principal muscle in the expression of suffering and can be equated to one’s level of empathic emotion (westbury & neumann, 2008). a distinguishing feature of this muscle is to lead observers to detect a direct relationship between acknowledgement of distress and genetic relatedness, such that we can correctly interpret the expressions of others who appear more similar to ourselves―solely based on another’s movement of their corrugator supercilii muscle (maner & gailliot, 2007; o’gorman et al., 2005). evolutionarily speaking, it is likely that species have either evolved to react empathically to distress calls or have evolved the distress calls that are effective at eliciting an empathetic response from others (allen et al., 2002; batson, 1990; westbury & neumann, 2008). of all the communication channels that can be used to elicit an empathetic response, it would seem as if visual and auditory cues would be the most likely to be effective at a distance (batson et al., 2005). however, if the latter were more accurate, an evolutionary push to develop auditory distress musson-moyer 16 calls over visual cues would exist. after all, those who are most likely to help and are in proximity of the individual in need would be more likely to hear a distress call than to see the distress cues. yet, most research regarding empathy has been based on still pictures or silent video. if an individual does experience an empathic response to non-verbal vocal communication with no corresponding visual stimuli, an indication toward one’s capacity to interpret signals that help is needed overrides the genetic variable. in other words, the ability to interpret empathic emotion may be primarily due to another’s ability to effectively communicate their distress to other individuals. it is hypothesized that the highest amount of empathy will be elicited when an individual can see and hear another individual in distress. however, when an individual can only hear the distress of another they will experience slightly less empathy, and when an individual can only see the distress of another they will experience the least amount of empathy. method participants data was collected from 81 undergraduate students (25 men, 56 women) attending the state university of new york (suny) at potsdam. the current sample was chosen through a sign-up sheet that ascribed three time periods, each on different days, for participation in the experiment. participation in the experiment was voluntary. all participants were students enrolled in a psychology course and were compensated for their participation through the award of extra credit in one psychology class. participants ranged in age from 18 to 42 years (m = 21.20 years, sd = 4.64), and two participants (2.5%) reported having children of their own. it should be noted that a sample consisting of an equal number of parents and non-parents might be more likely to produce generalizable results because empathic reactions may be strongly related to one’s personal experiences and the situation-specific components of the applied stimuli. according to the suny potsdam class standings, the participants’ year in school varied from freshmen status to senior status. demographically, the sample was composed of 79 caucasian students (97.5%) and two african american students (2.5%). measures each participant was given a demographic questionnaire that asked about age, gender, year in school, the major of the individual, and whether the participant had children of his or her own. trait empathy was measured by using the balanced emotional empathy scale (bees; mehrabian, 2000). the bees consists of a 30-item self-report scale of empathy wherein each item is be rated on a 9-point scale, ranging from –4 (very strong disagreement) to +4 (very strong agreement). sample items include, “i cannot feel much sorrow for those who are responsible for their own misery” and “i am deeply moved when i observe strangers who are struggling to survive.” the internal consistency of the bees is .87 with a coefficient alpha value of .85 and a test-retest reliability coefficient of .79. furthermore, the high correlation (+.77) that the scale holds with the original emotional empathic tendency scale (eets; mehrabian & epstein, 1972) suggests that the bees is a valid measure of empathy. further studies by mehrabian, young, and sato (1988), as well as various literature reviews (e.g., chlopan, mccain, carbonell, & hagen, 1985), have supported its validity and have identified various tendencies of high-empathy individuals compared to low-empathy individuals (e.g., macaskill, maltby, & day, 2002; mehrabian, 2000; singer et al., 2004). the empathy-eliciting stimuli consisted of one 28.6second video clip of an infant child in a distressing situation (crying in a crib, unattended). each group of participants viewed the same video clip. however, one group of participants was presented with the original video format (audio and visual); a second group of participants was presented with a black screen (they only heard the audio of the clip); and a third group was presented with a soundless version of the video clip. likert scales, ranging from -4 (very strong disagreement) to +4 (very strong agreement), were used to measure the participants’ emotional states―degree of distress, participants upset response, and willingness to help―following the stimuli presentation. procedure the participants met in a specified classroom on the suny potsdam campus. all participants completed a consent form and were provided with a packet of papers―they were instructed to complete the first three pages of the packet without going onto or looking at the fourth page. the first page of the packet was a brief questionnaire that consisted of demographic information; the second and third pages of the packet included the 30 statements of the bees scale. each participant’s responses to the bees provided the data used to interpret one’s empathic trait level (see mehrabian, 2000). upon completion of the bees, each group was presented with the stimulus-type that corresponded with their designated group. the stimulus chosen for the present study was an infant child in distress. the characteristics of the child (e.g., age and gender, intensity of crying, facial/body mannerisms, etc.) and the child’s immediate surroundings (e.g., no people, absence of aid/comfort, etc.) provided the assumption that he or she was upset and in a state of distress. however, a pilot study was not conducted to determine the accuracy of this statement. the first group of participants (n = 29) was presented with the original clip of an infant child in a distressing situation (audio/visual), the second group (n = 28) was presented with the audio-version of the infant, and the third group (n = 24) was presented with the visual footage (absence of sound) of the infant. thus, the experiment utilized a between-group research design wherein participants were randomly assigned to different groups and exposed to different levels of audiovisual stimuli. participants were exposed to the audiovisual stimuli in a group-setting format. auditory stimuli and empathy 17 figure 1. mean proportional response of subjective distress, upset, and helping response as a function of empathic trait level. error bars show the mean plus or minus two standard deviations, indicating diversity in response. empathic trait levels are based on the “percentile scores and z-score equivalents” in the manual for the balanced emotional empathy scale (mehrabian, 2000). after each stimulus presentation, the participants were asked to turn to the last page of the packet and use the 9-point likert-type scales to rate their present emotional state. participants were debriefed after they completed the likerttype scales. statistical analysis all statistical analyses were calculated using spss 20.0. the hypothesis tested whether participants’ emotional states are affected by the quantity and quality of sensory information received from a stimulus. more precisely, the greatest emotional response was expected to come from the audiovisual presentation, followed by the audio presentation, and finally, the visual presentation. given that the present study included male and female participants, additional statistical tests were conducted in order to account for potential gender-based differences. a chi-square test analyzed the relationship between gender and empathy level using a critical alpha value of .05. comparisons among gender, empathy level, and stimuli presentation were examined using a multivariate analysis of variance (manova). the significant main effects were assessed using a two-way analysis of variance (anova) on each dependent variable (level of distress, upset response to the stimuli and willingness to help); alpha values were set at .016 so as to control for family-wise error (see benjamin & hochberg, 1995). the simple main effects of empathy level and stimuli presentation were examined as well; alpha values were set at .010 and .016, respectively, to control for familywise error (benjamin & hochberg, 1995). the analyses of simple main effects addressed the potential differences in response based on the empathic trait composition of each group as well as any differences based on the stimuli presentation for each empathy level. pairwise comparisons were examined, with alpha set at .003, when the simple main effects were significant. results a chi-square (χ²) test was used to examine the relationship between gender and empathy level. empathy levels, as measured by the bees, were examined as categorical variables throughout the experiment. results revealed an association between one’s gender and empathy level, χ²(4, n = 81) = 19.40, p = .001. specifically, 60% of the individuals who scored a “very below average” empathy level were male, while only 40% were female. furthermore, 48% of the participants with “below average” empathy scores were male and 17.4% of the “above average” empathy scores were found in males. the “average” and “very above average” empathy levels were 100% female. the cramer’s v calculated a moderate effect size of .489. a manova was used to assess the effects of gender, stimuli presentation, and empathic trait level on participants’ behavior (distress, upset, and helping responses). using wilks’ criterion (λ) as the omnibus test statistic, the combined dependent variables resulted in significant main effects for empathy level, f(12, 148) = 2.87, p = .001, partial η2 = .168. the main effects of stimuli presentation, f(6, 112) = 1.97, p = .076, partial η2 = .095, and gender, f(3, 56) = 0.26, p = .851, partial η2 = .014, were not significant. furthermore, neither the interaction between empathy level and stimuli presentation, f(24, 163) = 0.70, p = .848, partial η2 = .090; empathy level and gender, f(6, 112) = 1.30, p = .262, partial η2 = .065; nor stimuli presentation and gender, f(6, 112) = 0.55, p = .768, partial η2 = .029 were statistically significant. manova results also failed to indicate a significant empathy level x stimuli presentation x gender interaction effect, f(9, 136) = 0.46, p = .898, partial η2 = .024. for each of the statistically significantly multivariate effects, follow-up anovas were conducted so as to further examine the univariate effects. though the main effects of stimuli presentation were found to be nonsignificant, they are nevertheless important to the present study and therefore will be described in further detail. the only anova that was relevant to the analysis was that which corresponded to the significant main effect of empathy level. the results indicated a significant main effect for empathy level on distress, f(4, 58) = 5.28, p = .001, partial η² = .267; upset response, f(4, 58) = 5.37, p = .001, partial η² = .270; and helping behaviors, f(4, 58) = 8.50, p = .000, partial η² = .370. the means and standard deviations of empathy level are shown in table 1; the main effects of empathy level are shown in figure 1. anova results failed to indicate a musson-moyer 18 significant main effect of stimuli presentation on participants’ distress, f(2, 78) = 2.21, p = .116, partial η² = .054; upset response, f(2, 78) = 0.32, p = .725, partial η² = .008; or helping reaction, f(2, 78) = 0.07 p = .935, partial η² = .270, partial η² = .002. the differences in participants’ responses, based on stimuli presentation, are shown in figure 2. in addition, the simple main effects of empathy level and the simple main effects of stimuli presentation were assessed for each of the responses. an analysis of the differences among the five empathy levels at each level of stimuli presentation (audiovisual, audio, visual)―the simple main figure 2. mean proportional response of subjective distress, upset, and helping response as a function of stimuli presentation. error bars represent +/2 se. effects of empathy―resulted in significant empathy effects for the audio and visual participants’ distress reaction, f(4, 66) = 2.86, p = .030 and f(4, 66) = 5.20, p = .001, respectively. there were no empathy effects for the audiovisual group’s distress reaction, f(4, 66) = 0.96, p = .437. there were also significant empathy effects for the participants in the audio and visual groups with regard to how upset they felt following the stimuli presentation, f(4, 66) = 4.08, p = .005 and f(4, 66) = 3.54, p = .011, and their willingness to help the distressed individual, f(4, 66) = 5.60, p = .001 and f(4, 66) = 4.52, p = .003, respectively. however, empathy effects were insignificant for the audiovisual group’s upset response, f(4, 66) = 1.22, p = .354, and helping response, f(4, 66) = 1.38, p = .251. statistical measures were taken so as to control for family-wise error (ɑ = .016), which altered the significance of the audio group’s distress levels. an analysis of the simple main effects of stimuli presentation at each empathy level also revealed significant differences within the participants’ responses. for one, participants with “very below average” and “below average” empathy levels experienced greater distress reactions following the stimuli presentation, f(2, 66) = 4.00, p = .023 and f(2, 66) = 3.83, p = .027, respectively. however, there were no stimuli presentation effects for the “average,” f(2, 66) = 0.44, p = .645, “very above average,” f(2, 66) = 0.93, p = .398, or “very above average,” f(2, 66) = 0.27, p = .762, participants’ distress reaction. there was also a significant presentation effect for “very above average” participants’ helping response, f(2, 66) = 3.38, p = .040; those rated as “below average,” “average,” “above average,” and “very above average” were not affected. lastly, regardless of one’s empathy level, the stimuli presentation had no effect on participants’ upset response. however, no simple main effects of stimuli presentation remained after controlling for family-wise error (ɑ = .010). table 1 means, standard deviations, and anova results for effects of empathy level on behavior empathy level very below average below average average above average very above average f(4, 76) partial η² distress -1.600a -0.360a 0.429a 0.826a 1.364a 5.116* .212 (2.261) (2.215) (1.512) (1.586) (1.859) upset -1.333a 0.080a 0.714a 1.391b 1.727b 7.040** .057 (2.093) (2.216) (1.496) (1.158) (1.737) helping -0.467a 1.640b 2.571b 2.826b 3.455b 8.940** .320 (2.588) (2.099) (1.512) (1.749) (0.820) note. standard deviations appear in parentheses below means. means with differing subscripts within rows are significantly different at the p < .05 based on bonferroni’s post hoc paired comparisons. empathic trait levels are based on the “percentile scores and z score equivalents” in the manual for the balanced emotional empathy scale (mehrabian, 2000). *p < .05** p < .001. auditory stimuli and empathy 19 additional posteriori contrast analyses (i.e., pairwise comparisons) were used to further evaluate the differences in the response ratings based on the stimuli presentation and empathy levels. while no significant comparisons were yielded in the audiovisual group, many significant associations did appear regarding participants’ empathy levels and their responses to the audio and visual presentations. the results indicated a direct relationship between response and empathy level; as expected, the greatest responses were typically from participants with “very above average” empathy scores and the weakest responses generally came from participants with “very below average” empathy scores (see figure 3). empathic trait level figure 3. mean proportional response of subjective distress, upset, and helping response as a function of empathic trait level and stimuli presentation. error bars represent +/2 se. empathic trait levels are based on the “percentile scores and z score equivalents” in the manual for the balanced emotional empathy scale (mehrabian, 2000). discussion the present study examined the role that the presentation of stimuli plays in an individual’s empathic response and drew upon previous research (e.g., batson, 2005; van lange, 2008) in an attempt to provide a stimulus presentation that would elicit an appropriate empathic emotion. batson and colleagues (2005), for instance, acknowledged that only two conditions are crucial in evoking such concern: first, the target should be perceived as needing care and protection, and second, the empathizer should value the target’s well-being. based on a situation-specific response, empathic concern is affiliated with an emotional focus on an individual who is in distress rather than on oneself, endorsing a truly unselfish desire to provide help (bierhoff & rohmann, 2004; maner & gailliot, 2007). according to batson and colleagues (1995), the empathic response operates according to a ‘motivation function,’ either intensifying or amplifying one’s motivation to alleviate another person’s suffering. however, the desire to alleviate suffering is also related to one’s perception of another’s well-being, or the degree to which one values another person’s welfare. the perception of well-being is, after all, influenced by the information that is available to the individual (batson et al., 1995). however, van lange (2008) suggests that an individual’s empathy level also influences the likelihood that he or she will assist a distressed individual. in other words, regardless of situational components that may reduce one’s own stress and anxiety (i.e., exiting the situation), highly empathic people tend to report a greater need to help others who are in a state of distress. the current study addressed batson et al.’s (1995) concepts of motivation and information availability in the production of empathic responses as well as van lange’s (2008) notion wherein empathic level affects one’s willingness to help. as hypothesized, the greatest amount of empathy was elicited when an individual could see and hear another individual in distress, slightly less empathy was elicited when an individual could only hear another individual in distress, and the least amount of empathy was elicited when an individual could only see another individual in distress. participant empathy was assessed through a composite of subjective levels of distress, how upset the participant felt, and the participant’s willingness to help following the stimulus presentation. the compiled results suggest that the stimuli presentation significantly affected individuals’ level of distress, but did not significantly affect how upset they felt after the presentation or their willingness to help. participants’ baseline empathy levels were, on the other hand, predictive of perceived distress, an upset response, and a willingness to help the distressed individual. nevertheless, the interaction between stimuli presentation and empathy level remained insignificant regarding participants’ reactions to the stimuli. however, it should be noted that a significant reaction to the stimuli presentation was received from the least empathic participants (those with baseline empathy levels rated as “very below average”). the present study showed that empathic responses are most viable when an individual can see and hear the eliciting target. when visual cues are the only source of information, an individual is left with an ambiguous and incomplete framework to interpret the situation; however, auditory cues contain a more definite and clear-cut outlook of the situation. however, individuals’ empathic traits will also elicit different responses to distressing stimuli, regardless of stimuli presentation. based on this line of reasoning, one would expect individuals with “very above average” and “very below average” empathy scores to have the strongest and weakest, respectively, reactions to stimuli. however, the greatest difference in response ratings, based on stimuli presentation, came from participants with “very below musson-moyer 20 average” or “below average” empathy scores―an unanticipated, yet noteworthy, finding. there were a number of limitations to the current study. first and foremost, all of the participants were undergraduate college students at a public university. second, the study was primarily composed of psychology students or, more specifically, students enrolled in a psychology course. these factors alone constrain the generalizability of results due to similarities in age, study, education level, and ethnic/cultural diversities. in addition, nearly all of the participants in the current study reported that they did not have any children of their own. the presence of children could have, in theory, altered an individual’s response to the audio-visual stimuli by enhancing or decreasing their general affect. based on these limitations, it is possible that the sample composition could have provided skewed results. therefore, one could hypothesize that the empathic traits of the aforementioned subjects are not representative of those in the general population. lastly, neither the footage of the infant child used as empathy-eliciting stimuli nor the 7-point likert scale used to measure the participants’ willingness to help were empirically validated instruments. pilot studies would have provided greater certainty in the stimuli’s ability to bring about empathic responses while an empirically-based scale, with internal and external validities, would have provided greater certainty and confidence in participants’ responses. the current study could be extended in a variety of ways. though the current study addressed the functions that could influence one’s empathic response (see allen et al., 2002; batson et al., 2005; westbury & neumann, 2008), it did not test the differences in responses due to human-animal similarities. the results of the present study could be further generalized if participants were also subjected to videos of animals with varying degrees of relatedness to humans (e.g., apes, bears, and goats). this addition would help in concluding whether the genetic hypothesis plays a role in eliciting empathic emotions. one may also be able to interpret a relationship between genetic similarity and effective communication styles by continuing to subject the participants to the different presentation styles (audiovisual, audio, and visual). furthermore, studies have shown that some people will assist others in distress based on altruistic motivations while other people base their assistance on egoistic desires (batson, 1990; batson et al., 1995; jackson et al., 2005; van lange, 2008). in other words, people help others in one of two ways: with an unselfish regard for one’s own welfare, or with the intent to fulfill a self-beneficial goal. it would be interesting to determine whether individuals with “very below average” or “below average” empathy levels are more likely to help a distressed individual, based on egoistic means, than their counterparts. in relation, one wonders whether individuals with “very above average” or “above average” empathy levels would base their assistance on more altruistic motives. if this connection were made, evidence could be offered for both egoistic and altruistic motives, indicating differential processing of information and situations based on one’s empathic traits. the existing research on empathy lacks information detailing the effects of stimuli presentation, leaving future research open to incorporate the effects of presentation modes and methods, among other variables, on an individual’s reaction. the results of this study have therefore provided a preliminary look into the association between empathy level, information availability (based on audiovisual presentations), and elicited empathic responses. scientific exploration into the unconscious motivators that significantly influence the individual will provide further insight into why and how humans react to particular situations. references allen, m. w., hunstone, m., waerstad, j., foy, e., hobbins, t., wikner, b., & wirrel, j. 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(2008). altruism born of suffering: the roots of caring and helping after victimization and other trauma. american journal of orthopsychiatry, 78, 267-280. doi:10.1037/a0014223 thibodeau, r., jorgensen, r. s., & jonovich, s. j. (2008). anger elicitation using affective pictures: an individual differences approach. journal of individual differences, 29, 80-89. doi:10.1027/1614-0001.29.2.80 van lange, p. a. m. (2008). does empathy trigger only altruistic motivation? how about selflessness or justice? emotion, 8, 766-774. doi:10.1037/a0013967 westbury, h. r., & neumann, d. l. (2008). empathy-related responses to moving film stimuli depicting human and non-human animal targets in negative circumstances. biological psychology, 78, 66-74. doi:10.1016/ j.biopsycho.2007.12.009 acfrogd7wd_18ygeiul2bog4qdn18xemixy11-sis1wpu1z1iii6su82iml5htjmpzq5zmqj3s87srgld5-i0t8rmj33amsb6xiamu9uuvtkpzn5bl2f2kwf5caqgim= matt blanchard melanie love letter from the editors: welcome to the 20th anniversary edition of the graduate student journal of psychology, a student-run, peer-reviewed journal published by the counseling and clinical psychology department at teachers college, columbia university. much has changed since we started in 1998—indeed at that time our editors didn’t have email, and apa style was only in its 4th edition! but our two-fold mission has remained the same throughout: first, to showcase the work of masters and doctoral students in psychology from across the country and the english-speaking world. second, to be a training ground where our peer reviewers, all of them doctoral students or recent graduates, can learn the standards and procedures of academic publishing in our discipline. this volume, our seventeenth edition, includes eight empirical studies with new insights on topics such as childhood trauma and risk-taking, working with transgender clients, the h൵hfw�ri�eudlq�lqmxu\�rq�wkh�uhodwlrqvklsv�ri�yhwhudqv��dqg�pxvfoh�g\vpruskld�dprqj�\rxqj� phq��7klv�yroxph�dovr�lqfoxghv�rxu�yhu\�¿uvw�folqlfdo�fdvh�vwxg\��rq�wkh�dgdswdwlrq�ri�d�&%7� treatment to the needs of an undocumented mexican immigrant. we salute the hard work of all our authors and could not be more pleased with the results. our heartfelt thanks goes out as well to the aforementioned peer reviewers, twenty-seven doctoral students and early-career psychologists who volunteered their time to read and respond to each submission. often this meant making the tough decision to reject articles that glg�qrw�¿w�wkh�plvvlrq�dqg�vwdqgdugv�ri�wkh�mrxuqdo��(yhq�pruh�riwhq��wklv�phdqw�judssolqj� with opaque paragraphs or not-quite-right statistics, asking authors to make major revisions lq�odqjxdjh�wkdw�ihow�pruh�olnh�d�qxgjh�wkdq�d�vkryh��)ru�wkhlu�h[dfwlwxgh�dqg�¿qhvvh��zh� thank our peer reviewers, the backbone of the gsjp for the last two decades, and the decades still to come. sincerely, graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 81 psychosocial media: an argument for the utilization of online social networks as clinical adjuncts in psychotherapy jett h. stone teachers college, columbia university this paper argues for the utilization of online social networks (osns) as clinical adjuncts in psychotherapy with adolescents and young adults. while privacy and ethics are critical issues in psychotherapy, these concerns should not overshadow the various ways that an osn adjunct may enhance the therapeutic alliance and advance psychotherapeutic practice. the argument asserts that a joint exploration of osn profile pages – a mental health professional in conjunction with an approving client – may provide clinically relevant details, and a more comprehensive conceptualization of emotional and interpersonal functioning. the specific content of osn disclosures are discussed, referencing current cyberpsychology and communications research. in addition, the procedural question of when, in a therapeutic relationship, it may be appropriate to initiate a psychosocial media approach, is also addressed. comparisons are then made between osn integration and previous incorporation of personal images and visual expression in psychotherapy. the penultimate section details how osns may be viewed from a narrative psychological standpoint, and the numerous ways these new social tools can be interpreted or understood within various other psychological frameworks. lastly, this paper cites the general effectiveness of other technological adjuncts in psychotherapy, and offers final recommendations for the potential marriage of social media and psychotherapy. the speed, ease, and seeming frivolity of social media may seem antithetical to the core values of the sensitive and difficult process of psychotherapy. popular social media sites or online social networks (osns) such as facebook and twitter, are profit-seeking companies racing to claim stake in the future, and are built on the premise that consumers will publicly share personal information. conversely, psychotherapy – ideally practiced – is a healing profession that holds client confidentiality and privacy sacred, and only advances at the irregular speed of evidenced-based practice. while these distinctions may ring true, they overlook the potential role of osns as valuable clinical adjuncts in the therapeutic process. one of the challenges in psychotherapy is fine-tuning treatments and clinical strategies to match the needs of an individual. this paper asserts that social media profiles – when investigated alongside adolescents or young adults – can be powerful tools to tune into and ultimately treat present-day psychological issues. because so much personal information is shared in therapy, authorized access to osn profiles may be an important added ingredient for a complete 21st century client conceptualization; especially for the youth and young adults whose online social tools are ingrained into their daily lives. the cultural influence of osns is evidenced by the statistic that over 80 percent of teens use osns, and 92 percent of females between the ages of 14-17 use an osn site (brenner, 2012). social media adjuncts could potentially be expanded to adult populations as well. in fact, adults over the age of 18 are increasingly turning to osns, despite using them in smaller numbers: of adults who are online, 67 percent use osns (brenner, 2013). there has been recent research looking into how adults use dating sites to find potential mates (e.g. finkel et al., 2012), and how online support groups can impact-health related outcomes (e.g. rains & young, 2009). in addition, there are a growing number of older adults utilizing these social tools. thirty-four percent of internet users 65 and older use osns (zickuhr & madden, 2012). nonetheless, it seems useful to begin adapting osns as a clinical adjunct with teens and young adults who are in a critical maturation stage and are generally more vulnerable to dangerous online behavior. potentially maladaptive social networking behaviors, as well as more incidental status updates or postings, may be best discussed in therapy for teens and young adults, not only because clinicians possess the training to intervene appropriately during interpersonal dilemmas, but also because psychotherapy is inherently a venue for disclosure. in a clinical report released by the american academy of pediatrics, the authors stressed that pediatricians are in a unique pocorrespondence concerning this article should be addressed to jett stone, 166 west 72nd street #10c, new york, ny 10023. email: jettstone@gmail.com. graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 82 stone sition to educate families about the “complexities of the digital world” and cited social and health issues that online youth experience, such as cyberbullying and “facebook depression” (o’keeffe & clarke-peterson, 2011, p. 803). the authors define facebook depression as when preteens and teens spend inordinate amounts of time on facebook and, as a result, demonstrate “classic symptoms of depression” (p. 802). this argument for an authoritative intervention holds true perhaps even more so for child psychologists and other mental health professionals whose domain it is to have a strong grasp of the psychological fitness of youth. in short, a mental health professional should be adept at entering into this social domain when called upon or when deemed necessary. however, it is impossible to ignore the tensions and ethical issues in this union of new media and psychotherapy. ethical concerns and other considerations many psychotherapists are wary of osn use from a personal and professional level. understandably so, as the lines of privacy – determining what is public versus private on the internet – have become increasingly blurred. to ease this uncertainty, a growing body of literature has addressed issues of ethics and privacy as they relate to osns and mental health care (taylor, mcminn, bufford, & chang, 2010; fogel, & nehmad, 2009; debatin, lovejoy, horn, & hughes, 2009). in order to protect clinicians and their clients from inappropriate self-disclosures, clinicians are generally discouraged from following or befriending clients or potential clients on osns such as facebook or twitter (van allen & roberts, 2011). the concern is that these digital “friendships” will create a slippery slope-type cascade into a breach of confidentiality and/or privacy (gutheil & simon, 2005). in their paper, “critical incidents in the marriage of psychology and technology: a discussion of potential ethical issues in practice, education, and policy” authors van allen and roberts (2011) refer to a metaphor previously used by maheu (2010) that describes therapists’ utilization of osns as similar to drivers handling shiny new sports cars on bumpy, old roads. naturally, the sports car signifies social media, and the dirt road signifies psychotherapy. van allen & roberts’ (2011) argument is that clinicians have the tools to be innovative, but lack the “current infrastructure” to support the testing of these tools without “considerable risk” (p. 434). while the authors never explicitly refer to the potential of using osns as adjuncts in therapeutic practice, they assert that current technologies bring about significant risk, and it still remains unclear how these concerns could be better addressed (p. 438). however, it must be made clear that utilizing osns as an adjunct would be entirely distinct from befriending or following a client, as the therapist would not engage in any interpersonal osn communication with the client. while there remain unresolved issues, many therapists and institutions have been creating social media policies, and there have indeed been significant steps forward in creating more widespread recommendations and guidelines for appropriate use (myers, endres, ruddy, & zelikovsky, 2012); jent et al., 2011). regardless, privacy and ethical guidelines are critical issues when discussing the integration of social media and psychotherapy. yet the functional fixedness of osns as inhibiting the therapeutic alliance overlooks their potential as clinical adjuncts in enhancing the therapeutic alliance and advancing psychotherapeutic practice. however a purely technological, distant and asynchronous level of therapy communication may not work well. a recent australian study of individuals age 18-80 found that close to 77 percent of people prefer face-to-face therapy rather than therapy by electronic means. the authors defined electronic as “internet-based mental health assistance with or without support [i.e., communication with a therapist via email, instant messaging, web-cam or skype])” (klein & cook, 2010, p. 29). as clough & casey (2011) noted in a review of technological adjuncts in psychotherapy, a major goal has been to focus on ways that technology can “replace or duplicate face-to-face therapy” (clough & casey, 2011, p. 280). therefore this paper proposes a more transparent, face-to-face application of osns in therapy that counters the commonly held notion of osns as purely fodder for social academic research, self-promotion, or personal communication. based on a psychinfo search using the search terms “online social network,” “social media,” paired 83 psychosocial media with “adjunct” and “psychotherapy” there has been no available research to-date exploring how osns can serve as therapeutic instruments. yet a history of social science literature, along with a boom in cyberpsychology and social networking research, indicates that there may be a place for such an innovative intervention. with the explicit, endorsed permission of client or guardian (depending on the client’s age), social media access may provide a more comprehensive case conceptualization. it would be revealing to walk through an individual’s facebook or twitter profile – alongside a client – as a way of stepping inside their interpersonal world. clinicians would address or interpret online self-presentations in-person as they would for any verbal or nonverbal faceto-face disclosure, but these online disclosures may provide access to more elusive clinical content not typically shared in session. this side-by-side osn exploration would potentially allow for a fairer, more mutual interpretation of social activity rather than what often occurs asynchronously and from afar between facebook friends or twitter followers. an osn adjunct would naturally require internet service in a therapist’s office, and also necessitate that a client actively use osns. this then raises the question of whom – therapist or client – would provide the computer, mobile device or tablet in therapy sessions. while the therapist could bear the burden of providing the media, the client may feel more of a sense of control over their privacy if they use their own technology. taking the initiative and bringing in their own media would grant the opportunity to prepare an osn profile prior to a therapy session, in order to avoid stumbling upon uncomfortable photos, messages or postings. while the therapist may not explicitly request that a client alter, include, or exclude elements of their profile prior to arriving in the office, it is likely that a client will feel inclined to do so without prompt. surely, allowing this ability to curate a personal profile leaves the clinician with a more restrained version of a client’s osn presentation. nonetheless, safeguarding osn activity outweighs the rupture in therapeutic alliance that may arise from discovering social content that is embarrassing, easily misconstrued or irrelevant to psychotherapy. as the alliance develops over time, perhaps clients will grow more open to revealing aspects of their online lives. additionally, it seems necessary to remind clients to disable any instant messaging preferences (i.e. facebook chat) so as not to be disrupted by incoming messages from followers or friends in session. while these are suggestions, the therapist and client, based on their relationship, should mutually decide how to logistically and fairly incorporate osns into session to facilitate positive psychological outcomes. content of osn disclosures integrating osn into therapy sessions assumes that online disclosures provide clinically significant content. recent research indicates that clients do indeed disclose clinically relevant information online, and may also be receptive to the use of technology in therapy sessions. an individual’s thoughts, experiences, and emotions are quite often found across the web, from blogs and osns to dating websites (joinson & paine, 2007). one study, using a sample size of 400 (aged 1761) randomly selected, accessible, personal profiles in canada, developed a scoring tool that assessed the content of facebook disclosures. they recorded everything from birthdate, ability to message, phone numbers, content of profile photo and educational information to favorite quotes, music, interests, political and religious views. they found that subjects displayed approximately 25 percent of possible information for others to view on their facebook profiles (nosko, wood, & molema, 2010). the authors also discovered that there is often “highly personal, sensitive and potentially stigmatizing information” on facebook (p. 416). the authors define highly personal as “details that could be used to locate or identify an individual, and could be used to threaten or harm another” such as email address, employer and job position (p. 410). nosko, wood, & molema (2010) also define stigmatizing as “sensitive personal information that could result in stigmatization within society” such as religious views, political views, birth year, sexual orientation, about me sections, and photos (p. 410). such studies looking at online disclosure patterns do not necessarily reveal the whole story of how disclosure operates on osns. this is because users, over 84 time, become more aware of how they can alter their default privacy settings, as was shown in one longitudinal study of 5,076 facebook users at carnegie mellon university (stutzman, gross, & acquisti, 2013). many osn disclosures – perhaps the most highly emotional, personal and therefore pertinent to mental health practitioners – are shared privately or shared only among a limited set of friends or followers, especially with the advent of more advanced privacy settings. therefore, a large portion of salient osn activity is inaccessible to researchers working only with public data. these disclosures add another layer to nosko, wood, & molemas’ (2010) operational definition of highly personal and stigmatizing. given their sensitive content, these more behind-closed-doors social interactions may be useful to address in-person, in a private therapeutic environment. online disclosures may be especially prevalent in adolescents and young teens that use osns obsessively or even just frequently. research indicates that the younger the age, the more personal information is likely to be shared on facebook profiles (nosko, wood, & molema, 2010). there has also been evidence to support the idea that online self-disclosure is used to rehearse offline disclosure in pre-adolescence and adolescence, especially for boys (valkenburg, sumter, & peter, 2011). this implies that online disclosures may be highly reflective of offline behaviors that a therapist might otherwise not have the opportunity to witness or understand given limited client contact. or, perhaps a therapist would be able to corroborate online behaviors with in face-to-face behaviors and thus come to a more confident, complete conceptualization of the client. other preliminary research indicates that osns such as facebook contain useful clinical information. one study looked at publicly accessible college student facebook status updates, and used dsm criteria to determine whether these disclosures showed signs of depressive symptoms or major depressive episodes (moreno, egan, & brockman, 2011). from the 200 facebook pages, they found evidence to support the notion that students do display symptoms of depression on their profiles. twenty-five percent of the studied facebook profiles displayed dsm criteria for depressive symptoms, while 2.5 percent met criteria for a major depressive episode. additionally, moreno, egan, & brockman (2011) conclude that those who receive online reinforcement from friends are more likely to be public in expressing their symptoms. despite the stigmas associated with mental health disclosures, facebook appears to be a safe place for many young adults to disclose personal details because of the support of their social networks (moreno, egan, & brockman, 2011). other research shows that increases in depression may be a direct result of negative social media interactions, and that osn activity is a medium where psychological problems are apparent in dysfunctional interpersonal interactions (feinstein, bhatia, hershenberg, & davilia, 2012). another study found that problematic internet use, defined as online behavior that negatively impacts social and emotional functioning, is present in about four percent of high school students in the u.s., and is associated with levels of depression, substance use, and aggressive behaviors (liu, desai, krishnan-sarin, cavallo, & potenza, 2011). it is often considered symptomatic of an impulse control disorder (shapira et al., 2003). other, potentially more dangerous, behaviors such as cyberbullying, or internet aggression, have also increased in prominence (e.g. hinduja & patchin, 2008; ybarra & mitchell, 2004). researchers have begun to compare cyberbullying to more traditional bullying. one study with adolescents found that cyberbullying increases with age and amount of time spent using the internet (walrave & wannes, 2009). therefore if a clinician were to incorporate osns into their sessions with adolescents and young adults active on osns, the topic of cyberbullying – as victim or perpetrator – may arise. recent research indicates that students differentiate between offline and online bullying: in online environments they make less of a distinction between bully and victim and differentiate between the specific modes of bullying, i.e. messages or pictures (law, shapka, hymel, olson, & waterhouse, 2012). since they make such distinctions, it is therefore important that clinicians have at least a basic understanding of how adolescents and young adults interpret cyberbullying, as well as an understanding of the various working mechanisms of osns. such an understanding on the part of the therapist would also aid in helping youth explore stone 85 more adaptive utilizations of these popular tools. in general, psychotherapy is a revealing process. psychotherapists are privileged to have unique access to the “inner, private life” of individuals (shedler, 2006, p. 44). social media offers just one more path to a person’s private, subjective world. a psychosocial media approach may be one means of exploring sources of suffering. complicating matters, however, is the fact that this inner, private life is often on display publicly in cryptic, maladaptive or more selected, adaptive self-presentations. some research has found that people make more intimate self-disclosures in computer-mediated communication as opposed to face-to-face communication (tidwell & walther, 2002). other research, including a systematic review of 15 studies comparing online and offline self-disclosures, indicates that disclosure of personal information online is not necessarily greater than it is in offline environments. rather the mode of communication, the relationship between communicators, and the context of the online interactions seem to better moderate the degree of disclosure (nguyen, sun, & campbell, 2012). another group of researchers, after a review of the existing articles on psychological factors contributing to facebook usage, propose a model that focuses on two personality traits as motivation for using facebook – the need to belong and need for self-presentation (nadkarni & hofmann, 2012). disclosing online (versus offline) perhaps more easily satisfies these two personality traits. one study (suler, 2004) examined the internet’s “disinhibition effect,” whereby people are more likely to self-disclose online, and appear uninhibited relative to their offline selves. this effect describes two different forms of inhibition found online: benign inhibition and toxic inhibition. suler defines the benign version as “a process of working through – an attempt to better understand and develop oneself, to resolve interpersonal and intrapsychic problems or explore new dimensions to ones identity” (p. 184). suler differentiates this from toxic inhibition or a “blind catharsis, a fruitless repetition compulsion or acting out of pathological needs without any beneficial psychology change” (p. 184). these two theories may be helpful in not only in interpreting osn profiles, but also in understanding the recent rise of popular mobile applications such as snapchat that allow users to send fleeting, risqué photo and video messages to each other. these snapchats disappear from a recipient’s phone after only a few moments, encouraging users to share pornographic content. while a clinician should never have access to such intimate social content, these examples illustrate uninhibited behavior and the willingness to share or perhaps over-share very personal information in new media environments. while the continuum between suler’s notion of benign and toxic inhibition may be difficult to determine just yet, in future decades more trained mental health professionals will be likely confronted with social media-related issues. thus, it is important for them to make sense of – but not overly interpret – the many emotions, personalities, unconscious drives and cognitions behind these osn presentations and behaviors. shame and timing of a psychosocial media adjunct another major concern may be that osn access engenders feelings of client shame. one criticism may be that social media access disrupts the natural unfolding of disclosure, or induces shame before the therapeutic alliance has been established. because these two points are important to consider, the timing of a psychosocial media intervention may play a vital role in its effectiveness. in one study of adults undergoing face-to-face psychotherapy, initial disclosures generated shame and anticipatory anxiety, but eventually, over time, produced feelings of safety, pride and authenticity (farber, berano, & capobianco, 2004). farber and colleagues’ multi-method study further found that disclosure can provide a sense of relief, and that keeping secrets inhibits the process of therapy. participants expressed a desire for therapists to pursue their secrets more actively by answering the question: “once in a while i wish she [therapist] would guess them [secrets]” (p. 343). perhaps osn profiles can strengthen the therapeutic alliance by substantiating guesses about such secrets. farber et al.’s study was conducted with an older age group than the target demographic of discussion, but a strong psychosocial media 86 therapeutic relationship is similarly important with youth and has shown to be an important factor in successful youth therapy outcome (karver, handelsman, fields, & bickman, 2005. therefore integration of osns may be a tactic best employed after several sessions to ensure that a therapeutic relationship has been firmly established and online profiles can be placed in context with previous in-person disclosures. alternatively, for some adolescents and young adult clients, a psychosocial media adjunct may prove more fruitful during the beginning stages of therapy. research shows that the therapeutic alliance generally forms in the beginning phases of psychological treatment and helps to predict positive psychotherapy results (henry & strupp, 1994; horvath, 1993; martin, garske, & davis, 2000). scrolling through a client’s profile may initially increase clients’ feelings of anticipatory shame. yet for some individuals – especially for those who are shy or socially anxious – it may reduce such shame compared to face-to-face disclosures. online resources, in their varied forms, can often help facilitate social relationships and overcome shyness (maczewski, 2002; valkenburg, schouten, & peter, 2005). osns are inherently engagement tools, and if a non-engaging or shy client actively uses online social tools prior to treatment, these tools can perhaps provide clues about how to engage the client by colorfully exhibiting his interests, attitudes, beliefs and interpersonal style. osn access may ease disclosure during the beginning – critical – phases of therapy by engendering feelings of positive regard, which also play an important role in positive psychotherapy outcomes (farber & doolin, 2011). in a general way, osn integration may engender a sense of congruence because the therapist is actively seeking to understand and appreciate the generational interests and interpersonal world of the client. a recent study looked at the course of action by clinicians that increases depth of elaboration and therapeutic alliance (lingiardi, colli, gentile, & tanzilli, 2011). the depth of elaboration is defined as the “dimensions of the quality of the psychotherapy sessions,” essentially whether they are powerful/ weak, valuable/worthless, deep/shallow, full/empty and special/ordinary (p. 391). one key finding indicated that relational patterns play a role in both depth and alliance. it is therefore important to help “explore, with the client, their interpersonal issues, identifying recurring themes and relational patterns in clients’ past relationships…” (p. 398). the study also found that therapists could increase the depth of elaboration and therapeutic alliance by focusing interventions on client emotions, especially those regarded by the client as unacceptable (i.e. anger, resentment, envy). it seems that both client relational patterns and affect are evident on osn profiles, which may be useful for a clinician to question. if therapists or clients believe that social media access would potentially disrupt the alliance or generate misleading information, then it should not be utilized. for those who do not share personal details on osn or are not active users, this instrument of investigation may be especially ineffective. there is no manual on how to interpret social media activity in therapy sessions just yet. there is, however, ample literature supporting the use of photography and autobiographical storytelling as adjuncts in therapy. osns seem to be a combination of both. visual expression in psychotherapy sharing and viewing photographs and videos is one of the biggest allures of facebook. there are over 300 million photographs uploaded daily on facebook alone, making it the most popular photo uploading service on the web (facebook, s-1 filing, 2012). also becoming increasingly popular are photo and video sharing, organizing and editing applications and sites such as pinterest, instagram, youtube and vine, and these could also take on meaning in a therapy session, especially because images are subjectively taken and interpreted (banks, 2001; coover, 2004; dicks, soyinka, & coffey 2006; lister & wells 2001; pink, 2004). in 1980, fryrear surveyed previous research on phototherapy and identified 11 documented uses of photography in psychotherapy: evoking emotional states, developing skills, facilitating verbal behavior, modeling, socialization, self-confrontation, help in making diagnoses, fostering expression and creativity, documentation of therapeutic changes, prolonging of meaningful experiences, and helping to promote verbal communicastone 87 tion between the therapist and client (fryrear, 1980). recent literature has further suggested that images can be interpreted as objects of communication rather than just memory (van house, 2011), and can be used as an adjunct in treating an array of disorders including alcohol abuse (dollinger, rhodes, & corcoran, 1993), schizophrenia (phillips, 1986), and eating disorders (wessels, 1985), as well as populations including: family therapy (kaslow & friedman, 1977; ruben, 1978) and adolescents (blinn, 1987; vardell, mcclellan, & fryrear, 1982). the act of exploring photographs in particular has shown to help clients conjure past events and memories, unearth emotions about interpersonal relationships, relate images from the past to the present, and form a better understanding of identity. osns – with their emphasis on personal photos – may be of particular use in therapy to address excessive concerns or idealizations of body image for those suffering from eating disorders or body dysmorphic disorder. psychologist and art therapist judy weiser in her paper, “ ‘see what i mean?’ photography as nonverbal communication in cross-cultural psychology” argues that photography is a form of nonverbal communication that can be interpreted as the “… conscious and unconscious self, moments of importance chosen for whatever personal reasons to be frozen in time forever, and if deemed successful, kept and treasured as items of value” (p. 245). she later explains how photo-exploring techniques, in a phenomenological and existential model can “guide discoveries where words cannot go” (p. 254). based on her use of photography as a therapeutic tool, she argues that clients rarely understand the extent to which they reveal themselves in their photographs. in addition, she points out that even a lack of photos is telling because people don’t keep photos of people or moments they do not cherish, and these voids of people and relationships are areas that can initiate further questioning. weiser’s paper however was written prior to the advent of interactive online photo sharing, which implies that newer, more interactive forms of photography may bring about even more explicit projections. through simple digital communications such as commenting, “liking,” “tweeting” and even “retweeting” individuals create their perceived stimulus, because photos begin to “take on a life of their own, almost apart from our process of visual perception” (p. 263). in addition, the comments beneath shared photos or videos on osns provide clues as to conveyed identity, and can therefore be a lens into a patient’s interpersonal feedback (p. 276) – perhaps more so than a photograph with no associated activity from a network of friends or followers. in order to better understand a client’s interrelating system as a whole, it may behoove a therapist to interpret osn disclosure from a narrative psychological perspective. osns as narrative another important component of facebook, likely unbeknownst to its over one billion users, is that it is an emotionally-laden, narrative-generating tool. in many ways, psychotherapy is also the process of guiding people in formulating their life stories. psychologist and writer nancy mcwilliams (2004) spoke to the narrative capabilities of psychotherapy, “...we regard the project of psychotherapy as a joint effort to develop a narrative that makes sense of a person’s subjective experience and personal problems” (p. 139). on facebook in particular, a new generation is quite literally constructing their life timelines. while visiting the profile of a “friend” one can scroll through – chronologically – all of the pictures, comments, quotes, “likes,” going back to the very day that they signed up for the social network (depending on the specific aspects of their profile that they choose to share). facebook has become an interactive autobiography of sorts. this is powerful, and considering the amount of time teenagers and adults spend on facebook, these online self-presentations may play a role in shaping self-identity (valkenburg, schouten, & peter, 2005). so what does this collage of social activity – friends, family life, interests – actually mean, and how can it effectively be harnessed in a clinical setting? psychotherapists might glean a more comprehensive conceptualization of their client if they do so from a narrative framework. as psychologist and legal expert jerome bruner (1991) wrote in his paper narrative construction of reality, “…we know altogether too little about how we go about conpsychosocial media 88 structing, and representing the rich and messy domain of human interaction” (p. 4). narratives represented on osns may provide a clue. psychologist theodore sarbin (1986) believed that narrative was a root metaphor for psychology and that human functioning is inherently contextual (sarbin, 1986). he argued that narrative is so embedded in human functioning that it is easily forgotten as a metaphor for psychology. similarly, osns are becoming embedded into the culture of a new generation, becoming root metaphors for psychology. even the founder of facebook and former undergraduate psychology major at harvard university, mark zuckerberg described his company as being “as much psychology and sociology as technology” during a 2011 speech (larson, c. desert news. mar 25, 2011). psychotherapists can play a critical role in helping shape their clients’ personal narratives through joint investigation of their osn profiles. one proposed method of doing so is to examine online photographic narratives (photo albums) through the lens of gender and sexual identity (kaufmann, 2007). kaufmann describes distinct layers of interpretation in analyzing online photographic narratives, one of which is the message itself. when an individual views an image on a computer screen, they are “actively and subjectively” building meaning, more so than in movies because there is more interactivity on the web and the viewer can be in “one, two, or a hundred different places at once… focus turns inward and internal fantasy becomes ‘real’, and the outer world diminishes” (p. 10). in some ways, as tangible as thoughts and images are on osns, they are also representations of fantasy. another question to consider is why certain photos are chosen as profile photos and others as large cover photos (the long images spanning the top of the newly-designed personal facebook profiles.) facebook and twitter in particular are constructed in such a way that allows users to emphasize certain idealized images over others, to emphasize and promote biographical details, attitudes, and interests. on facebook, one photo is the profile image, a representation of a person. the larger background photos are additional space to provide context and further expressions of individuality. narrative psychology, a field of study and practice, provides principles that may inform the integration of osn and psychotherapy. in his paper “metaphor and medicine,” psychiatrist jack coulehan describes patients as understanding their suffering in a “narrative way whether their physicians realize it or not” (coulehan, 2003, p. 87). coulehan further argues that narrative should be an essential aspect of contemporary medicine and be bound to the tools of medicine. he says that words, images, metaphors and symbols are integral in day-to-day practice and that medicine is not above or beyond culture. perhaps the tools of narrative may be even more adeptly applied to clinical psychology, a healing practice rooted in emotion, empathy and disclosure. osn profiles offer insight into the experience-near language, metaphors and symbols of a client’s interpersonal world. when utilizing osns, it may even be useful to question and test for accurate understanding and perception of content, a process of reflection pioneered by carl rogers (rogers, 1986). hypothetical examples of such questions might include: am i correct in saying that you are telling others with this photo album that you are fun loving and adventurous? or, based on your sarcastic or negative status updates, it seems like this week was pretty tough for you, am i right? by better understanding the story an individual presents on their profile, a therapist may glean a better understanding of their interpersonal world and how they order events outside the confines of the clinical office. richert (2006) states that the goal of psychological treatment is to help a person actively construct healthy narratives where the person – as opposed to outside forces – is the author. yet the question remains: in what larger theoretical framework might a psychosocial media approach effectively work? modes of psychosocial media in their review of technological adjuncts in psychotherapy, clough and casey (2011) note that there has been “very little research examining the suitability of technological adjuncts to different types of therapy” and argue that “future research should address whether particular therapies are more amenable to making use of adjunctive technologies than others” (p. 290). perhaps richert’s (2006) mode of integrating narrative psychology into psychostone 89 therapy may provide clues as to how osns can be integrated into psychotherapy using a larger psychodynamic or cognitive-behavioral framework. based on the tone, language and mood presented, the nature of the client’s story may reveal itself and can be used as a basis for selecting a therapeutic approach (richert, 2006). in his paper on the integration of narrative psychology into psychotherapy, richert argues that a useful way to categorize client stories is by distinguishing between their “agency” and “communion” (bakan, 1966),the former being the sense of individuality and pursuit of personal goals, and the latter signifying the pursuit of “shared goals of the common good” (richert, 2006, p. 91). richert labels an individual’s sense of agency or communion as “relatedness” – how a person positions himself toward others – and believes that it has an impact on the therapy relationship. essentially he differentiated how individuals rely on external information or rely more on their own inner experiences and intuition (richert, 2006). both seem to be present in osns. perhaps some client’s relatedness towards others lean more towards agency over communion, and vice versa. although osns are generally built to share information publicly, they are not always mechanisms for the act of sharing in the “common good.” despite the public-nature of facebook, much of what is shared contains richert’s (2006) notion of agency i.e. preferred news articles, group affiliation, self-image, and self-identity and other personal attitudes. richert fits various theories into “agentic” and “communal” classifications. in particular, he argues that the analytic, behavioral, person-centered and gestalt theory fit within the “agentic” bucket because they focus almost exclusively on the individual, whereas cognitive, narrative, existential, solution-focused and interpersonal therapies fit best in a more communal classification because they focus more on connectedness with others (richert, 2006, p. 99). there seems to be a number of ways to interpret an individual’s osns. each clinician could incorporate or apply his or her own therapeutic framework in helping to utilize osn client profiles. for example, a psychodynamic framework may connect a client’s maladaptive online behaviors with past familial relationship patterns, allowing for a more visual understanding of relational functioning. alternatively, a cognitive behavioral approach may challenge the cognitive distortions a client expresses about the comments or feedback he or she is receiving on their profile and implement behavioral modifications, i.e. changes in the frequency of osn use. in his 2001 paper, davis introduces a cbt model for treating internet addiction and explores the way exposure therapy and behavioral changes can potentially bring about positive psychological outcomes for internet addiction: exposure therapy might include keeping the client away from the internet for a period of time, having the client observe that nothing negative actually happens if they are offline, and finally, having the client observe his or her own cognitive reactions to the internet by multiple exposures to various internet functions (p. 194). after observing a client’s osn behavior alongside them (exposure to various internet functions), a client may be more receptive to making behavioral changes. in general, when it comes to technological adjuncts, therapists with cognitive behavioral backgrounds more frequently endorse new technologies in psychotherapy (mora, nevid, & chaplin, 2008). other examples of technology used in psychotherapy it is important to note that psychotherapy has not completely spurned new media. clough & casey’s review (2011) identified six key areas in which technology has been used in psychotherapeutic practice: mobile phones, personal digital assistants (pdas), biofeedback, virtual reality (vr), computer games and electronic questionnaires. a number of recent studies have found that internet-based interventions – particularly for cbt (cognitive behavioral therapy) – are promising in reducing symptoms of mild to moderate depression (e.g. foroushani, schneider, & neda, 2011), anxiety (e.g. craske et al., 2009) and panic disorder (e.g. klein, richards, & austin, 2006). mental health professionals today often promote the use of video conferencing tools such as skype or email to correspond with their clients, alpsychosocial media 90 though most practitioners agree that it is best used as a supplement to face-to-face meetings. still, osns constitute a different media platform. most established psychologists rarely use osns themselves, and lack knowledge to provide a supervisory guidance (taylor, mcminn, bufford, & chang, 2010). as mentioned, internet-cognitive behavioral therapy (icbt) has proved to be a useful vehicle for cbt, and in many instances is as equally effective as faceto-face cbt. while these advancements are positive utilizations of emerging media, they are mere facilitators, as opposed to remnants of human interaction, attitude, emotion and personality. while burgeoning mechanisms such as skype, email, chat, virtual reality exposure therapy, icbt and mobile applications can grease the wheels of disclosure and enhance the therapeutic process, they do not generally contain the elaborate content of unconscious emotions and conscious expressive representations found in osns. conclusion the 2009 presidential task force on the future of psychology practice (american psychological association, [apa], 2009) recommends that psychologists be trained “to use and integrate technologies to provide quality services” (p. 5). social scientists are being encouraged to utilize and tap into the psychology behind the digital landscape, but the question remains: what implications do these self-disclosures and self-presentations on osn have for clinicians? social tools such as facebook, twitter, tumblr, instagram, as well as dating sites and apps have collectively attracted billions of users who have created billions of virtual interpersonal connections and shared countless articles of personal information. these points of contact and presentations are filled with clues as to how individuals express themselves and manage relationships in a digital ecosystem. in addition, it has raised questions about how people use osns and how personalities are reflected in its usage. while osn personality data remains inconclusive, recent findings indicate that personality processes are salient on osn and, more often than not, parallel the processes in direct, face-to-face environments (gosling, augustine, vazire, holtzman, & gaddis, 2011). going back in timeline fashion on facebook, there are traces of personality, previous love interests, political affiliations, attitudes about current events, words of wisdom, biographical information, the crowd-sourcing of advice from ones network, displays of frustration, aggression or perhaps even cyberbullying or suicidal behaviors. all of these contain hints of individuation, agency, and interpersonal styles or communion. while these traits and behaviors exist on a continuum of therapeutic importance, all are uniquely significant. in essence, while osns are filled with trivialities and banalities they additionally contain abundant exclamatory material that color the emotional well being of clients and may provide greater therapeutic context and content. as social media technology has advanced and diversified over the past several years, the number of osn users has expanded beyond college campuses. this is especially true of facebook. yet questions also remain as to how facebook use differs from everyday face-to-face communication, or from other media sources such as television, radio or video games (which are also expanding their services to the web and becoming more socially-oriented). some researchers argue that internet-based communication is a combination of many past media advancements (bargh & mckenna, 2004), but given the addictiveand interactive-nature of facebook – over 250 million photos uploaded daily and over 100 billion friendships (facebook, s-1 filing, 2012) – it is clear that osns are a much more public and measurable medium seemingly ripe for utilization in therapy. understandably, some clients and therapists will view this proposed psychosocial media intervention as a breach of privacy or a shallow endeavor. it may indeed be true that only those mental health professionals and clients already conversant in osns would profit from this joint exploration. another apprehension is that a client’s social activity would include comments and/or photos from unwitting friends or followers. presumably, these friends and followers would consider their osn interactions private or, at least, limited to a controlled following. perhaps even more concerning is the possibility that a clinician personally recognizes individual(s) who are visible on a client’s osn. this could create a constone 91 flict of interest and raises further questions regarding how client privacy issues differ in the digital space. nonetheless, in the same way a fireman must find the location of a blaze, a therapist must tirelessly work to locate the core of emotions. if the emotional fire rests somewhere in a person’s digital domain, then there a therapist should cautiously turn. however even if a direct osn approach is not feasible, a more indirect, hands off approach may be more comfortable. it seems reasonable to inquire about osn activity in therapy, especially for adolescents, young adults, or those individuals who spend an inordinate amount of their time using this technology. questions might include: how much time do you spend online? are you on facebook or twitter? how many friends/followers do you currently have? are you ever bullied online? these questions can open a new path into the unconscious, as well as bring to light present cognitions, emotions and maladaptive behaviors. in doing so, they may strengthen the therapeutic alliance. an individual’s personal osn profile may be safer being explored alongside a trained mental health professional who maintains perspective and a pulse on their emotional sensitivity and overall functioning versus friends, family or acquaintances who are not clinically trained. the “likes,” posts, pokes, pictures, comments, group membership, friendships, re-connections of the so-called facebook generation will become part and parcel of their social and emotional schemas as they grow into adults. likewise even older adults will assimilate new social technology into their existing interpersonal schemas. understanding and exploring the psychology behind these often-seemingly trivial social tools can be beneficial to the 21st century therapist. in coming years, clients will be increasingly shaped by their online ecosystems. while remaining careful, clinicians should understand and embrace this technology if and when appropriate. references bakan, d. 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(2012). pew internet: older adults and internet use. in pew internet & american life project. retrieved march 11, 2013, http://www.webwisedom.com.previewdns.com/wp-content/uploads/2012/06/ pip_older_adults_and_internet_use-final-1.pdf. stone gsjp volume 16 final graduate student journal of psychology 2015 vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 47 pregnancy intentions and happiness: psychological predictors of breastfeeding in a national sample lindsey wallace, rebecca chad, and melissa rodriguez teachers college, columbia university unintended pregnancies (mistimed or unwanted) are linked to lower rates of breastfeeding, yet little research to date has investigated the role of feelings of happiness about the pregnancy on maternal health behaviors. using data from the 2002 national survey of family growth, we examined whether breastfeeding initiation/duration was explained by (1) socio-demographic characteristics of mothers and (2) pregnancy intentions/feelings of happiness ri �prwkhuv��3uhjqdqf\�lqwhqwlrqv�kdsslqhvv�idfwruv�vljqlàfdqwo\�h[sodlqhg�dq�lqfuhdvh�lq�wkh�pxowlsolfdwlyh�rggv�ri � initiating breastfeeding better than a model with socio-demographic variables alone, g2 (5, 798) = 3622.5. participants who indicated their pregnancies were unwanted or too soon breastfed for a shorter duration in comparison to those who said it was the right time; these effects remained after controlling for socio-demographic characteristics. feelings of happiness about the pregnancy did not alter the odds of initiation or affect the duration of breastfeeding. keywords: breastfeeding initiation, breastfeeding duration, pregnancy intentions, happiness about the pregnancy while much research has investigated unintended pregnancies and their implications for maternal and infant health, less attention has been placed on the relationship between health behaviors and women’s thoughts and feelings about being pregnant (blake et al., 2007). one particularly important health behavior that is worthy of further investigation due to its provhq�sk\vlrorjlfdo�dqg�sv\fkrorjlfdo�khdowk�ehqhàwv�wr� both mothers and infants is initiation and duration of breastfeeding (davis, savitz, & graubard, 1988; lawrence, 2000; mortensen, michaelsen, sanders, & reinsich, 2002; newcomb et al., 1994; visness, kennedy, & ramos, 1997). the physiological beneàwv�ri �kxpdq�euhdvw�plon�duh�qxphurxv��dqg�lqfoxgh� anti-infective, immunologic, and allergy protective properties; infants who are breastfed demonstrate a reduction in infections and lower rates of child onset malignancies, such as acute leukemia (davis et al., 1988; lawrence, 2000). research has also demonstrathg�wkh�khdowk�ehqhàwv�ri �euhdvwihhglqj�iru�prwkhuv�� including an association between breast stimulation and the control of excessive postpartum hemorrhaging, as well as a decreased risk of premenopausal breast cancer (newcomb et al., 1994; visness et al., 1997). breastfeeding has also been shown to have advantageous psychological associations, including long range developmental and intellectual outcomes for the breastfed infant, and a unique mother-infant attachment bond (mortensen et al., 2002). despite these optimal health outcomes for both infants and mothers, fewer than one third of us infants are breastfed exclusively for the recommended duration of more than 6 months, followed by continued partial breastfeeding for at least a year (“american academy,” 2013; chen, johnson, & rosenthal, 2012). successful breastfeeding depends on multiple factors related to the mother, infant, and the environment, and there are a variety of barriers which inhibit initiation and continuation of breastfeeding, such as the mother returning to work, lack of access to breast pumps, sore nipples and pain, and access to free formula (haughton, gregorio, & pérez-escamilla, 2010). we recognize that not all women are physically able to breastfeed and some may experience gliàfxow\� lq� erwk� lqlwldwlqj� euhdvwihhglqj� dqg� frqtinuing when it proves challenging (kelleher, 2012). socio-demographic factors and breastfeeding � 'hvslwh� wkh� zhoo�nqrzq� ehqhàwv� ri � euhdvwfeeding in the existing literature, disparities exist in breastfeeding behavior among various population groups (centers for disease control and prevention [cdc], 2011). a variety of factors are associated with a mother’s decision or ability to initiate and continue breastfeeding, including personal characteristics such as age, race/ethnicity, education, socioeconomic status, intrapersonal characteristics, sources of support, childcare status of the infant, and available breastfeeding interventions (celi, rich-edwards, richardson, kleinman, & gillman, 2005; dennis, 2002; li, darling, maurice, barker, & grummer-strawn, 2005). research shows that across race, white non-hispanic mothers breastfeed at a higher rate than black mothers (smith-gagen, 48 hollen, walker, cook, & yang, 2014). additionally, studies have shown that black women have a shorter duration of breastfeeding after 6 months (27.9%) compared with white (45.1%) and hispanic (46%) mothers. by 12 months, only 12.9 % of black mothers still breastfeed in comparison with white (23.6%) and hispanic (12%) mothers (cdc, 2011). furthermore, breastfeeding mothers tend to be older with higher levels of education (jones, kogan, singh, dee, & grummer-strawn, 2011; taylor & cabral, 2002). socio-economic status tends to be higher for those who initiate breastfeeding (piper & parks, 1996; taylor & cabral, 2002). among low-income pregnant and postpartum women who receive nutrition and health services through the women, infant, and children (wic) program, the largest supplemental food program in the united states, only half of participants report breastfeeding their youngest child (haughton et al., 2010). research demonstrates that participation in wic may actually inhibit women from breastfeeding. according to ryan and zhou (2006), for mothers with infants at least 6 months of age, wic status was actually the strongest negative determinant of breastfeeding; mothers who did not participate in wic (but were eligible) were twice as likely to breastfeed for at least 6 months compared to those who were enrolled in the program (ryan & zhou, 2006). thulier and mercer (2009) suggest that free samples and distribution of infant formula through wic inhibits women from initiating and continuing breastfeeding. the role of wic on low-income women’s breastfeeding behavior cannot be ignored when considering the reasons why women of lower socio-economic status tend to initiate breastfeeding less often and have trouble maintaining it for 6 months or more. pregnancy intention and breastfeeding since about half of the pregnancies in the united states are unintended, pregnancy intentions, including mistimed or unwanted pregnancies, have been studied in relation to health behaviors, including breastfeeding (finer & zolna, 2014). several studies have linked unintended pregnancies to lower rates of breastfeeding (cheng, schwartz, douglas, & horon, 2009; taylor et al., 2008). unwanted pregnancy, in particular, is associated with less initiation of breastfeeding (joyce, kaestner, & korenman, 2000a). furthermore, research has demonstrated that when both parents intend to conceive, children are the most likely to be breastfed, while discrepancies between the parents regarding pregnancy intentions result in orzhu�udwhv�ri �euhdvwihhglqj��6shflàfdoo\��fkloguhq�duh� breastfed at lower rates when the mother does not intend to conceive but the father does, as compared to when the mother does intend to conceive but the father does not (korenman, kaestner, & joyce, 2002). inconsistent with previous research, cheng and colleagues (2009) found that mothers with mistimed and unwanted births were as likely as mothers with intended births to initiate breastfeeding; however, mothers with mistimed and unwanted pregnancies were less likely to continue breastfeeding for 8 weeks or more. cheng et al. (2009) hypothesized that continuing to breastfeed when it becomes challenging may be more gliàfxow�iru�prwkhuv�zkr�ehfrph�suhjqdqw�xqlqwhqtionally compared to those with intended pregnancies. psychological factors and breastfeeding intention vs outcome furthermore, researchers have investigated the effects of other psychological factors on breastfeeding intentions and outcomes. noel-weiss, rupp, cragg, bassett, and woodend (2006) found that the prwkhu·v�frqàghqfh�lq�khu�delolw\�wr�euhdvwihhg�zdv� positively correlated with breastfeeding duration. research by fairlie, gillman, and rich-edwards (2009) demonstrated that women with high pregnancy-related anxiety and prenatal depressive symptoms are less likely to plan to breastfeed; however, these symptoms were not associated with failure to initiate breastfeeding in this study. most research, though, indicates that prenatal breastfeeding intentions predict postnatal breastfeeding behaviors (forster, mclachlan, & lumley, 2006; lawson & tulloch, 1995). previous research has also demonstrated that women intending to breastfeed have higher scores on maternal-fetal attachment than those not intending to breastfeed (foster, slade, & wilson, 1996). other research has found a modest relationship between prenatal attachment and exclusive breastfeeding intentions, in that high maternal-fetal attachment is correlated with the intention to breastfeed excluwallace, chad, rodriguez 49 sively; however, this relationship did not hold after controlling for other relevant covariates such as perceived support and employment status (lear, 2013). pregnancy-related happiness and health outcomes while previous research has investigated feelings of pregnancy-related anxiety, pregnancy intention, and maternal-fetal attachment, some research has investigated mothers’ perceived well-being and happiness during pregnancy. su (2012) demonstrated that mothers with unintended births experienced declines in overall happiness and well-being postpartum (rather than just pregnancy-related happiness) relative to childless women. sable, washington, schwartz, & -rujhqvrq��������vshflàfdoo\�h[soruhg�zrphq·v�ihhoings of happiness about having a baby. pregnancy-related happiness was positively correlated with social support and negatively correlated with loneliness and family relationship problems (sable et al., 2007). further research has investigated the link between pregnancy intentions and happiness about being pregnant, and the associated risk for adverse effects for the mother and the infant (blake et al., ������� $� vljqlàfdqwo\� kljkhu� sursruwlrq� ri � zrpen who were unhappy about being pregnant (in comparison to those who were moderately happy or happy) reported having smoked cigarettes in the past week, having been depressed in the past month, having experienced intimate partner violence in the past year, and having drunk alcohol or used drugs during the pregnancy (blake et al., 2007). additionally, a woman’s happiness about being pregnant was more strongly associated with the above-mentioned behavioral and psychosocial risk factors than pregnancy intention, indicating that pregnancy-related happiness may be more related to prenatal care initiation/utilization and pregnancy outcomes than pregnancy intentions (blake et al., 2007). investigation of pregnancy-related happiness and breastfeeding � %dvhg�rq�wkh�àqglqjv�ghprqvwudwlqj�wkh�uhodwlrqship between pregnancy-related happiness and prenatal risk factors, further research into breastfeeding, which is one major component of maternal health behavior, may also reveal an association with pregnancy-related happiness. even though blake et al. (2007) found that pregnancy intentions and pregnancy-related happiness are strongly correlated, sable (1999) states that measuring pregnancy intentions may not eh�d�vxiàflhqw�sur[\�iru�suhjqdqf\�dwwlwxghv��&rqvlgering that pregnancy intentions and pregnancy-related happiness may differentially impact maternal health behaviors, research needs to expand on the role of maternal psychological factors. although various soflr�ghprjudsklf�idfwruv�kdyh�ehhq�lghqwlàhg�dv�suhdictors of breastfeeding practices, the added impact of psychological factors (feelings of happiness and wantedness) remains limited. given the public health costs of prenatal and postnatal programs which proylgh� hgxfdwlrq� derxw� wkh� ehqhàwv� ri � euhdvwihhglqj� behavior, it would be advantageous to better understand such psychological factors, rather than simply socio-demographic factors alone. in addition, a better understanding of these psychological factors may help explain low rates of breastfeeding by elucidating wkh�uhdvrqv�vrph�zrphq�kdyh�gliàfxow\�zlwk�lqlwldtion and prolonged duration, including experiences of physical discomfort and pain (kelleher, 2012). present research � :h� vhhn� wr�àoo� wklv� olwhudwxuh� jds� e\� lqyhvwljdwing the relationship between wantedness and feelings of happiness about the pregnancy in relation to breastfeeding initiation and duration. our research question is: do wantedness and feelings of happiness about the pregnancy explain initiation and duration of breastfeeding when controlling for vrflr�ghprjudsklf� idfwruv"� &rqvlvwhqw� zlwk� suhylous research, we hypothesize that mothers with unintended pregnancies and feelings of unhappiness about the pregnancy are less likely to initiate breastfeeding and more likely to breastfeed for a shorter duration, compared with mothers whose pregnancy was intended and who are happy about their pregnancy. in addition, we hypothesize that demographic characteristics, such as education, race, age, and sryhuw\� ohyho�zloo� vljqlàfdqwo\� suhglfw� lqlwldwlrq� dqg� duration of breastfeeding, as is consistent with previous research. overall, however, we hypothesize that feelings of happiness and wantedness of pregpregnancy intentions and happiness 50 nancy will better explain variation in breastfeeding outcomes than socio-demographic factors alone. method data in order to investigate these questions, we used data from the national survey of family growth (nsfg), which is a large periodic and population-based survey (nsfg, 2002). the nsfg has been conducted by the national center for health 6wdwlvwlfv� vlqfh� ������ ,w� zdv� frqgxfwhg� àyh� wlphv� with a national sample of women periodically between 1973 and 1995. a sixth periodic survey was conducted in 2002, which included both men and women. we used data from the 2002 wave that interviewed 12,571 men and women on factors affecting birth rates, pregnancy rates and women’s reproductive health. it contains information on 13,593 pregnancies and 9,148 births from 5,033 women. from the sample of 5,033 women, we created a sub-sample of women whose pregnancy resulted in a live birth, and who answered the questions based on wkhlu�àuvw�fklog��zkhwkhu�lw�zdv�dq�rqo\�fklog�ru�qrw��,q� order to create this sub-sample, we excluded individuals who had lost a pregnancy, aborted their pregnancy, or were currently pregnant. the sub-sample includes 4,413 participants. it is worth noting then that the sample only includes responses of those women referring wr�wkhlu�àuvw�fklog��:kloh�wklv�pd\�srwhqwldoo\�olplw�wkh� generalizability of the results, this exclusion criterion is based on previous research which suggests that mothers are likely to choose the same feeding method for each of their children based on how they fed wkhlu�àuvw�fklog��uhjdugohvv�ri �wkh�qxpehu�ri �fkloguhq� they have (taylor et al., 2008). considerations of this assumption will be made in the limitations section. measures breastfeeding initiation/duration��7kh�àuvw�ghpendent variable selected was initiation of breastfeeding. participants were asked whether they breastfed their child at all, so this is a binary outcome measure for either yes or no. the second dependent variable selected was a continuous outcome measure for duration of breastfeeding measured in weeks. to check for non-normality we constructed a pp-plot and histogram, which compared the cumulative probabilities of the normal distribution with the distribution of residuals. our pp-plot showed that our data was voljkwo\�vnhzhg�wr�wkh�uljkw��7r�à[�wklv�qrq�qrupdoity problem, we transformed our y dependent variable (duration of breastfeeding weeks) by taking the natural log and running our regression model again. non-normality was no longer a problem after transforming the dependent variable. all further analyses with this continuous dependent variable were conducted with logged duration of breastfeeding in weeks. those who breastfed their child for less than one week were coded as 0.5 to indicate an average between 0 weeks (no breastfeeding) and 1 week. participants who reported that they were still breastfeeding their child were excluded from analyses because duration of time was impossible to ascertain. socio-demographic characteristics. demographic variables included age, poverty, education, and race. both age and poverty level were measured as continuous variables. poverty level was the percentage of the poverty level for the year 2001; participants who exceed 500 percent of the poverty level were grouped together. education was also a continuous variable, which measured years of completed schooling. race was a categorical variable and included hispanic, non-hispanic black, non-hispanic white, and non-hispanic other. hispanic was used as the reference category in all analyses. intentions and feelings about pregnancy. intention variables included wantedness of pregnancy and feelings of happiness about the pregnancy. wantedness of the pregnancy was scored as a categorical variable, and included the response options of too soon, right time, unwanted, indifferent, and don’t know. participants whose answer was don’t know were coded as missing. right time was used as the reference category in all analyses. feelings of happiness were measured on a continuous scale where 0 phdqv�wkh�sduwlflsdqw�zdv�yhu\�xqkdss\�wr�àqg�rxw� that she was pregnant, and 10 means the participant zdv� yhu\� kdss\� wr� àqg� rxw� wkdw� vkh�zdv� suhjqdqw� statistical analysis initiation of breastfeeding. logistic regression was conducted to explore the relationship bewallace, chad, rodriguez 51 tween the dependent variable (initiation of breastfeeding) and the independent variables. omnibus tests were used to determine whether socio-demographic factors (age, poverty, education, and race) predicted breastfeeding initiation, and whether socio-demographic factors with intentions/happiness variables predicted breastfeeding initiation. a log likelihood ratio test was used to investigate whether a model with socio-demographic factors (age, poverty, education, and race) and wantedness/happiness about the pregnancy explains an increase in the multiplicative odds of breastfeeding better than a model with only socio-demographic factors. indiylgxdo� frhiàflhqwv� uhvxowlqj� iurp� wkh� vhfrqg� frpparison were examined to determine which factors duh� vljqlàfdqw� lq� suhglfwlqj� euhdvwihhglqj� lqlwldwlrq� duration of breastfeeding. ordinary least squares (ols) regression was used to examine the relationship between the dependent variables and the independent variable (the logged duration of breastfeeding in weeks). since little research exists establishing an association between breastfeeding behaviors and happiness about the pregnancy, we decided to conduct two incremental f-tests. the àuvw� lqfuhphqwdo� )�whvw� frpsduhg�zkhwkhu� d�prgho� with socio-demographic factors (age, poverty, education, and race) and wantedness/happiness about wkh� suhjqdqf\� h[sodlqhg� d� vljqlàfdqw� sursruwlrq� of the variation in logged duration of breastfeeding better than a model with socio-demographic variables alone. the second incremental f-test was structured the same, except that the second model included socio-demographic factors and only wanthgqhvv� yduldeohv�� ,q� dgglwlrq�� lqglylgxdo� frhiàflhqwv� resulting from the second comparison were examined to determine which variables were significant in predicting logged breastfeeding duration. results sample characteristics table 1 describes the characteristics of our sample. women who initiated breastfeeding, regardless of the duration, comprised 60.6% of the sample, while 39.4% did not breastfeed at all. the average duration of breastfeeding in our sample was 16.37 weeks (sd = 25.60) with a minimum duration of 0 and a maximum of 208. this indicates that the average length of breastfeeding was about 4 months. participants were 48.7% white, 22.5% black, 24.5% hispanic, and 4.3% non-hispanic other. the average percentage of the poverty level was 228.58, which for a family of 4 was about $40,000 per year in 2001 (“annual update,” 2001). average number of years of schooling was 12.78, and the mean age was about 23 years old with a standard deviation of about 0.5 years. the average for feelings of happiness about the pregnancy was 7.97 out of 10. almost half of the participants reported that their pregnancy occurred at the right time (47.5%), 7.8% reported they wanted it later, 31.5% indicated it was too soon or mistimed, 1.4% didn’t care, and 11.8% reported that the pregnancy was unwanted. predictors of breastfeeding initiation table 2 shows results of the logistic regression analyses. results revealed that the socio-demographic factors (age, race, education, and ses) explain an increase in the multiplicative odds of breastfeeding initiation,�ƶ2 (5, 3643) = 442.75, p < .001. the model predicts 67.6% of breastfeeding initiation correctly. nagelkerke r2 = .151, meaning that 15.1% of the variation in breastfeeding initiation is explained by socio-demographic variables. the full model with socio-demographic and intention/happiness factors dovr�vljqlàfdqwo\�h[sodlqv�dq�lqfuhdvh�lq�wkh�pxowlsolcative odds of breastfeeding initiation, ƶ2 (11, 798) = 80.48, p < .001. the model predicts 72.5% of breastfeeding initiation correctly. nagelkerke r2 = .127, indicating that 12.7% of the variation in breastfeeding initiation is explained by socio-demographic and intention/happiness factors. results from the likelihood ratio test indicate that the full model, including socio-demographic and intentions/happiness, explains an increase in the multiplicative odds of initiating breastfeeding better than a model with socio-demographic variables alone, g2 (5, 798) = 3622.5. � 8srq�dqdo\]lqj�wkh�frhiàflhqwv�lq�wkh�ixoo�prgho�� the odds of initiating breastfeeding decrease by .1% for an increase in one year of age, holding constant all other factors, p = .024, (exp(b) = 0.999). the odds of initiating breastfeeding decrease by 15% for one more year of schooling, holding constant all other pregnancy intentions and happiness 52 � � table 1��sample characteristics of women from their first, live birth � ____________________________________________________________________________� variable valid missing mean std. dev percent� � breastfeeding initiation 3738 675 60.6� breastfeeding duration 3403 1,010 16.37 25.60� education 4413 0 12.78 2.55 -� poverty 4413 0 228.58 151.16 -� age at pregnancy outcome 4413 0 2308.4 529.14 -� hispanic 1080 24.5� white 2150 48.7� black 995 22.5� other 188 4.3� happiness 827 3586 7.97 2.94 � wantedness: right time 2094 47.5 later 343 7.8� too soon, mistimed 1390 31.50� didn’t care/indifferent 61 1.4� unwanted 519 11.8� don’t know 6 .1� � wallace, chad, rodriguez 53 � � table 2��logistic regression analyses predicting breastfeeding initiation from sociodemographic characteristics and wantedness of pregnancy variables� � variable� � model 1� � � � model 2� � � coefficient� se� exp(b)� coefficient� se� exp(b)� constant � 2.34**� .22� 10.37� 1.297*� .65� 3.66� age at pregnancy � -.001**� .0001� .99� -.0005*� .0002� .99� poverty level income� -.001**� .0003� .99� -.001� .0006� .99� education� -.15**� .02� .86� -.15**� .04� .86� white� .71**� .10� 2.03� .67**� .22� 1.94� black� 1.32**� .11� 3.74� .97**� .26� 2.63� other� .24� .20� 1.27� .47� .43� 1.60� later� -� -� -� .10� .34� 1.11� too soon, mistimed� -� -� -� .15� .22� 1.17� indifferent� -� -� -� .77� .84� 2.16� unwanted� -� -� -� .53� .33� 1.70� happiness� -� -� -� .06� .04� .99� model chi-square [df]� 442.751 [6]� -� -� 80.484 [11]� -� -� block chi-square [df]� -� -� -� 3622.5 [5]� -� -� % correct predictions� 67.6� -� -� 72.5� -� -� nagelkerke r2� .151� -� -� .134� -� -� * p < .05 ** p <.01� � � � � � � � � pregnancy intentions and happiness 54 factors, p < .05, (exp(b) = .85). the odds of initiating breastfeeding increase by 94.4% for white mothers compared to hispanic mothers, holding constant all other variables, p = .003, (exp(b) = 1.94). the odds of initiating breastfeeding increase by 163.4% for black mothers in comparison to hispanic mothers, holding constant all other variables, p < .001, (exp(b) = 2.63). socio-economic status, non-hispanic other, feelings of happiness, and all of the intention variables (i.e. later, too soon, indifferent, unwanted) were not vljqlàfdqw� idfwruv� lq� wkh� lqlwldwlrq�ri �euhdvwihhglqj� predictors of breastfeeding duration table 3 describes the results of the ols regression on breastfeeding duration. in order to determine wkh�lqáxhqfh�ri �vrflr�ghprjudsklfv�dqg�suhjqdqf\� intentions/happiness about the pregnancy on breastfeeding behavior, an omnibus analysis of variance test was conducted. it showed that socio-demographics dqg�lqwhqwlrqv�kdsslqhvv�zhuh�vljqlàfdqw�lq�h[sodlqing the logged duration of breastfeeding, f(11, 650) = 3.53, p < .001. an incremental f-test, however, did not demonstrate that a model with socio-demographic factors and wantedness/happiness variables better explains breastfeeding duration than a model with socio-demographics alone, )¨ (5, 435) = 1.54, p > .05. therefore, we sought to evaluate a model that did not include happiness to be pregnant, only socio-demographic and intention variables. this decision zdv� odujho\� lqáxhqfhg� e\� suhylrxv� uhvhdufk� zklfk� has demonstrated that pregnancy intentions predict breastfeeding, and the lack of research establishing a link between feelings of happiness and breastfeeding outcomes (dye, wojtowycz, aubry, quade, & kilburn, 1996; li et al., 2007; taylor & cabral, 2002). � ,q� rughu� wr� ghwhuplqh� wkh� lqáxhqfh� ri � vrcio-demographic and pregnancy intention variables on duration of breastfeeding, an omnibus analysis of variance test was conducted. it revealed that socio-demographics and wantedness of pregnanf\� zhuh� vljqlàfdqw� lq� h[sodlqlqj� wkh� orjjhg� gxration of breastfeeding, f(10, 2163) = 4.70, p < .001 (table 3). an incremental f-test then demonstrated that a model with socio-demographic and intention factors better explains breastfeeding duration than socio-demographic factors alone, )¨ (4, 2163) = 4.44, p = .001. it is important to note that while a model including socio-demographic factors and wantedness of pregnancy variables better explains breastfeeding duration, socio-demographic factors only explain 1.1% of the variation in breastfeeding, and wantedness explains .6% more variation in outcomes, adjusted r2 = .017, p = .001. � $qdo\vlv� ri � wkh� frhiàflhqwv� uhyhdov� wkdw� dv� djh� increases by one year, duration of breastfeeding increases, holding constant education, poverty, race, and wantedness of pregnancy; however this does qrw� uhdfk� vwdwlvwlfdo� vljqlàfdqfh�� ơ� = .00004, p > .05 (table 3). as income level increases, duration of breastfeeding increases, holding constant all other variables; yet this increase is not statistically significant, ơ = .00003, p > .05. as years of completed schooling increases by one year, duration of breastfeeding increases by .02 weeks, holding constant all other variables; however, this increase is not statiswlfdoo\� vljqlàfdqw�� p > .05. the average difference in breastfeeding between hispanics and whites is .03, holding constant all other variables, p > .05. this means that white women breastfed a longer duration than hispanic women controlling for other factors, exw�wklv�gliihuhqfh�lv�qrw�vwdwlvwlfdoo\�vljqlàfdqw��7kh� average difference in breastfeeding between hispanics and blacks is -.08, holding constant all other variables, which means that blacks breastfed a shorter duration in comparison to hispanics, holding constant all the other variables, but this difference is not stawlvwlfdoo\�vljqlàfdqw��p > .05. the average difference between hispanics and individuals from other ethnic backgrounds, holding constant all other variables, is .18, indicating that individuals from other ethnic backgrounds breastfed a longer duration than hispanics, controlling for all other variables, but this differhqfh�grhv�qrw� uhdfk�vwdwlvwlfdo� vljqlàfdqfh��p > .05. in terms of wantedness of pregnancy, the average difference between those whose pregnancy came later than desired compared to those who said it was the right time is -.12, meaning that those whose pregnancy came later than desired breastfed a shorter duration than those who said it was the right time�� wklv�gliihuhqfh�zdv�qrw� vljqlàfdqw� wkrxjk��p > .05. the average difference between those who said their pregnancy was too soon compared to those who wallace, chad, rodriguez 55 � � � � � � � � � � � table 3��multiple regression analyses predicting breastfeeding duration from sociodemographic characteristics and wantedness of pregnancy variables� � � model 1� model 2� variable� coefficient� se� coefficient� se� 95% ci� � � � � � � lower � upper � constant � 2.16**� 1.49� 2.43**� .17� 2.101� 2.758� age at pregnancy outcome � .000*� .00� .000� .00� .000� .000� poverty level income� .000� .00� .02� .00� .000� .000� education� .02� .01� .03� .01� -.001� .05� white� .03� .07� -.08� .07� -.09� .16� black� -.12� .08� -.08� .09� -.25� .08� other� .21� .13� .18� .13� -.08� .44� later� -� -� -1.2� .09� -.31� .06� too soon, mistimed� -� -� -.18**� .07� -.31� -.05� indifferent� -� -� -42� .24� -.89� .04� unwanted� -� -� -.34**� .09� -.53� -.15� adjusted r2� .01� -� 0.17� -� -� -� f� 4.85� -� 4.70� -� -� -� � r2 .01 � f 4.44 * p < .05 ** p <.01 � pregnancy intentions and happiness 56 said it was the right time was -.18, holding constant all other variables; this indicates that those who felt their pregnancy was too soon breastfed a shorter duration than those whose pregnancy was at the right time��wklv�gliihuhqfh�lv�vwdwlvwlfdoo\�vljqlàfdqw��p = .006, 95% ci [-.31, -.05]. the average difference between those who said they felt indifferent about their pregnancy timing was -.42, holding constant all other variables. this indicates that those who felt indifferent about whether they wanted their pregnancy breastfed a shorter time than those who felt it was the right time��exw�wklv�gliihuhqfh�zdv�qrw�vljqlàfdqw��s�!� .05. the average difference between those who said their pregnancy was unwanted and those whose was at the right time, holding constant all other variables, was -.34; therefore, women whose pregnancy was unwanted breastfed a shorter duration than those who indicated it was at the right time.� 7klv� frhiàflhqw� lv� vwdwlvwlfdoo\�vljqlàfdqw��p < .001, 95% ci [-.53, -.15]. � ,q� vxp�� wkh� rqo\� vwdwlvwlfdoo\� vljqlàfdqw� frhiàflhqwv� duh� too soon and unwanted; women who endorsed their pregnancies as either too soon or unwanted breastfed for a shorter duration than those who said theirs was at the right time. as mentioned previously, preliminary analyses revealed that the data was non-normal, so we transformed our dependent variable (duration of breastfeeding in weeks) by taking the natural log. other assumption checks were performed to identify any problems relating to homoskedasticity, linearity, outliers, leverage, or lqáxhqfh�srlqwv�� dqdo\vhv� uhyhdohg� wkdw� uxqqlqj� wkh� incremental-f� whvw� zlwkrxw� lqáxhqfh� srlqwv� \lhoged a negligible change in outcome variation and ]hur� gluhfwlrqdo� fkdqjh� lq� wkh� yduldeoh� frhiàflhqwv� discussion overall, our results replicate previous research which indicates that breastfeeding initiation is explained by socio-demographic variables (age, education, ses, and race); however, socio-demographic and intention/happiness factors better explain the initiation of breastfeeding than socio-demographics alone. the full model is able to predict breastfeeding initiation with 72.5% accuracy and explains 12.7% of the variation in initiation of breastfeeding. even though our vdpsoh�rqo\�lqfoxghg�gdwd�iurp�prwkhuv·�àuvw�eluwkv�� these results might possibly generalize to breastfeeding outcomes at any birth because previous research has demonstrated that mothers are likely to choose the same feeding method for each of their children edvhg�rq�krz�wkh\�euhdvwihg�wkhlu�àuvw�fklog��7d\oru� et al., 2008). however, in consideration of the fact that pregnancy intentions, pregnancy-related anxiety and happiness, social support, and a multitude of other factors can vary from birth to birth, it seems likely that mothers may have different initiation/duration of breastfeeding from birth to birth. therefore, these results should be interpreted with caution, and may be generalizable only to new mothers. in line with previous research, we found that older mothers are more likely to initiate breastfeeding than younger mothers. inconsistent with previous research, in our sample, individuals with less education are more likely to initiate breastfeeding than those with more years of schooling (jones et al., 2011; taylor & cabral, 2002). although most studies have demonstrated that more education is associated with an increased likelihood to initiate breastfeeding, the interaction between race/ethnicity and education as it relates to initiation of breastfeeding remains to be determined (chin, meyers, & magnus, 2008). it is possible that such an interaction went undetected in our sample, resulting lq� àqglqjv� wkdw� duh� lqfrqvlvwhqw�zlwk� wkh� olwhudwxuh�� consistent with recent studies, we found that white mothers are more likely to initiate breastfeeding than hispanic mothers (cdc, 2011). our model suggests that black mothers are more likely to initiate breastfeeding in comparison to hispanic mothers, though this is not the typical trend in the literature (cdc, 2011). there is literature to suggest that acculturation status affects breastfeeding behaviors for hispanic women, such that more acculturated women tend to have lower initiation/duration of breastfeeding. therefore, varying degrees of acculturation among the hispanic women in our sample (perhaps more acculturated women) may contribute to why our results indicated that black women were more likely to initiate breastfeeding (ahluwalia, d’angelo, morrow, & mcdonald, 2012). our hypothesis that intentions/happiness factors help to predict initiation of breastfeeding better than sowallace, chad, rodriguez 57 flr�ghprjudsklf�idfwruv�dorqh�zdv�frqàuphg��krzever, these results should be viewed with caution because pregnancy intentions and happiness about wkh�suhjqdqf\�gr�qrw�vljqlàfdqwo\�dowhu�wkh�rggv�ri � initiation of breastfeeding as individual covariates. furthermore, our results show that breastfeeding duration is explained by socio-demographic factors and wantedness of the pregnancy. our original hypothesis was not supported because feelings of kdsslqhvv�glg�qrw�khos� wr�h[sodlq�d� vljqlàfdqw�surportion of the variation in duration of breastfeeding, but a model with just wantedness of the pregnancy and socio-demographic factors does indeed explain a higher proportion of the variance in breastfeeding duration than just socio-demographic factors alone. this result should be interpreted with caution, however, because wantedness of the pregnancy only explains .6% more of the variation in breastfeeding outcomes than socio-demographic factors alone. consistent with previous research, as age, education, and income levels increase, duration of breastfeeding increases (jones et al., 2011; piper & parks, 1996; taylor & cabral, 2002); these results should be viewed with care because they do not reach statistical vljqlàfdqfh��5hvxowv�lqglfdwhg�wkdw�erwk�zklwh�zrphq� and women from other racial/ethnic minorities (who are not white, black, or hispanic) breastfed their child for a longer time than did hispanic women, and black women breastfed a shorter duration than +lvsdqlf�zrphq��$owkrxjk�wkhvh�frhiàflhqwv�duh�qrw� vwdwlvwlfdoo\� vljqlàfdqw�� suhylrxv� uhvhdufk� vxjjhvwv� that white women breastfeed for longer durations than minority women, though the results tend to be mixed (chen et al., 2012; jones et al., 2011; thulier & mercer, 2009). other research suggests that there are no differences in breastfeeding duration between different racial/ethnic groups, except that black women tend to breastfeed less often than women of other racial/ethnic categories (thulier & mercer, 2009). women with unwanted pregnancies or pregnancies that occurred too soon breastfed for shorter durations than those who indicated theirs was at the right time; those who felt their pregnancies came later than desired or were indifferent about it also breastfed iru�d�vkruwhu�wlph��exw�wkhvh�frhiàflhqwv�glg�qrw�uhdfk� vwdwlvwlfdo� vljqlàfdqfh��2yhudoo� wkrxjk�� wkhvh� uhvxowv� replicate previous research which supports that unintended, unwanted, or mistimed pregnancies are associated with a shorter duration of breastfeeding (cheng et al., 2009; taylor et al., 2008). results did not support the hypothesis that feelings of happiness would explain breastfeeding outcomes, in that more positive feelings would yield a longer duration of breastfeeding, but a logistic regression revealed that feelings of happiness taken together with intention variables and socio-demographics did predict higher rates of breastfeeding initiation above just socio-demographics. in sum, women’s intentions and desires about her pregnancy do help to explain breastfeeding initiation and duration better than socio-demographic factors dorqh�� exw� wkhvh� uhvxowv� qhhg� ixuwkhu� fodulàfdwlrq� women with unintended pregnancies and negative pregnancy-related feelings may have a challenging time initiating and sustaining breastfeeding for the recommended length of time. unintended pregnancies and negative feelings surrounding the pregnancy pd\�pdnh�lw�pruh�gliàfxow�iru�wkh�prwkhu�wr�idqwdsize about her infant and create a psychological bond with the infant that continues after birth. for these women, there may be a denial of the reality of the pregnancy and a lack of recognition of the infant, its needs, and the role of motherhood, possibly translating to physiological and psychological disengagement in maternal health behaviors, including breastfeeding. future research should explore these hypotheses. limitations one limitation is that our sample only included zrphq�zkr�zhuh�dvnhg�derxw�wkhlu�àuvw�eluwk��:kloh� previous research suggests that a mother tends to replicate her breastfeeding behavior with each subsequent birth (taylor et al., 2008), feelings of happiness and wantedness of the pregnancy may change from pregnancy to pregnancy based on a variety of factors. thus, it would be advantageous to examine a model that takes into account multiple births in order to better elucidate the relationship between breastfeeding behavior and happiness/wantedness of pregnancy. it zrxog�eh�ehqhàfldo�wr�frpsduh�d�zrpdq·v�suhjqdqf\� intentions/feelings of pregnancy-related happiness and breastfeeding initiation/duration for each analogous birth to determine if shifts in intentions/feelpregnancy intentions and happiness 58 ings correspond to shifts in breastfeeding behavior. another potential confound in our sample is the lqáxhqfh�ri �d�glyhuvh�duud\�ri �vrflhwdo�qrupv�uhjduging breastfeeding behavior. many women experience a cultural expectation to breastfeed, which has been equated to being a “good enough mother” (stearns, 2009). feminist scholars explain that the medical and cultural mandate for women to breastfeed places an undue burden on women, especially those who choose not to breastfeed or who cannot breastfeed (stearns, 2009). examining women’s internalized expectations of “good mothering” behavior during pregnancy, along with pregnancy-related anxiety and happiness, may help to better explain their prenatal and postnatal maternal behaviors. other groups may experience the opposite cultural standards regarding perinatal behaviors, and are ensconced in communities that embrace formula as the preferred method of feeding (chin, meyers, & magnus, 2008). these variations in societal expectations are critical to take into account when addressing breastfeeding behavior, yet were unaccounted for in our sample. another limitation is that we did not investigate the father’s feelings of happiness or wantedness about the pregnancy. the father’s sentiments about wkh� suhjqdqf\� pd\� lqáxhqfh� wkh� prwkhu� gxulqj� gestation, as well as after birth (vaaler et al., 2011). previous research has demonstrated that disagreement between the parents’ intentions predicts the mother’s instability in pregnancy intention, which pd\�lq�wxuq�lqáxhqfh�euhdvwihhglqj�ehkdylru��-r\fh�� kaestner, & korenman, 2000b). further research by chang, valliant, and bomba (2012) supports the strong evidence for a gender gap in breastfeeding knowledge and attitude (men tend to view breastfeeding as less favorable and formula feeding as more favorable in comparison to women). therefore, the relationship between the mother’s feelings about the birth and breastfeeding may be far more complex, and interact with her partner’s feelings to lqáxhqfh�wkh�lqlwldwlrq�dqg�gxudwlrq�ri �euhdvwihhglqj� one potential confound is that all the data from the nsfg was collected retrospectively. joyce et al. (2000b) found that in their sample, 30% of the women who reported their pregnancy to be unintended during pregnancy reported that their pregnancy was intended after delivery. although other research has suggested that prospective assessments are not necessarily superior to retrospective reports of unintended fertility (joyce et al., 2000b), we cannot rule out the possibility that retrospective reporting may have confounded the results of our analyses. in regards to the data, another limitation is that our sample is drawn from the 2002 wave of the nsfg. although this was the most recent wave of the study available, it was twelve years ago. these results should be interpreted with caution since the social climate surrounding breastfeeding has inevitably changed since then, making the results of this study slightly dated. another limitation is the way that pregnancy-related happiness was measured in the nsfg. the interview contained only one question about happiness, which asked participants to rate on a scale of one to ten how happy they felt when they found out that they were pregnant (one meaning that they were very unhappy to be pregnant and ten meaning they were very happy to be pregnant). the limited operationalization of the construct of pregnancy-related happiness, combined with a possible social desirability bias, may have contributed to our lqvljqlàfdqw�àqglqjv�zkhq�frqgxfwlqj�rxu�dqdo\vhv�� directions for future research future research should identify potential moderators in order to examine why those who indicate their pregnancies are too soon or unwanted tend to breastfeed for shorter durations. we suggest that women with unwanted or mistimed pregnancies may kdyh� d� gliàfxow� wlph� dwwdfklqj� wr� wkhlu� lqidqwv� erwk� before and after birth. since research has demonstrated that women with higher levels of maternal fetal attachment have intentions to breastfeed (foster et al., 1996), one way in which challenges forming an attachment bond may manifest is through breastfeeding, because the mother may lack the mowlydwlrq�wr�ihhg�qdwxudoo\�zkhq� lw�suryhv�gliàfxow�ru� when formula feeding is convenient. another way that unwanted sentiments during pregnancy could manifest after birth is through a lack of warmth and responsiveness to the infant’s needs, which can cause an insecure attachment bond between mother and child (ainsworth, blehar, waters, & wall, 1978). wallace, chad, rodriguez 59 since higher sensitivity to an infant’s needs is associated with a longer duration of breastfeeding, an absence of breastfeeding may be a sign that the mother is struggling with developing an attachment to her child (britton, britton, & gronwaldt, 2006). research should investigate whether feelings of unwantedness prenatally translate to a lack of warmth and responsiveness after birth. future studies should also explore different ways to measure feelings of happiness, wantedness, and satisfaction with the pregnancy throughout gestation in order to better understand how sv\fkrorjlfdo� idfwruv� lqáxhqfh� srvwqdwdo� ehkdylruv�� similar to our research, other studies investigating feelings about the pregnancy also use a single item question, rather than a valid scale, to measure pregnancy-related happiness (blake et al., 2007; sable et al., 2007). it would be advantageous for researchers to develop and validate a scale measuring pregnancy-related happiness in order to capture the nuances of the construct better than a simple one-item measure can provide. another methodological consideration for future research is to use an acculturation scale in addition to the demographic variable of “race”. previous research indicates that among hispanic women, those who are less acculturated initiate and continue breastfeeding longer than those who are more acculturated (ahluwalia, d’angelo, morrow, & mcdonald, 2012). the addition of acculturation as a socio-demographlf� idfwru�pd\� lqáxhqfh� wkh� lqlwldwlrq�gxudwlrq� udwhv� of breastfeeding and more accurately capture the experience of individuals who immigrate to another country. it would be interesting to learn how acculturation interacts with pregnancy intentions/feelings of happiness about the pregnancy in regards to prenatal and postnatal behaviors for immigrant mothers. future studies should also make a distinction between wantedness of the pregnancy and pregnancy intentions. in the present study and in current research, these two constructs are used interchangeably; however, these are potentially two separate constructs. for example, a woman who may not have planned to get pregnant may still want the pregnancy once she learns that she is pregnant. conversely, a woman who intends to get pregnant may realize that she does not want to be pregnant once it occurs. 7kh�àhog�ri �uhvhdufk�vxuurxqglqj�suhqdwdo�dqg�shulnatal behaviors may make further advances by clarifying the distinction between these two constructs. furthermore, even though we suggest an association between pregnancy intentions and breastfeeding outcomes, there are several societal, environmental, and health factors that may impact or be associated with breastfeeding. these factors include prenatal care, working before and after birth, the amount of maternity leave taken, acculturation, and smoking before and after birth. work barriers may limit the amount of time that the mother has with her infant dqg�pdnh� lw� gliàfxow� iru� khu� wr� vxffhvvixoo\� euhdvwfeed. in addition, socio-economic status may serve as a moderator between postnatal employment and breastfeeding. we acknowledge these factors and limitations, yet push researchers to ask what psychological idfwruv�pd\� lqáxhqfh�ru� lqwhudfw�zlwk�euhdvwihhglqj� behavior as well, since experiences of happiness and prenatal attachment-seeking behaviors by the mother may predict the likelihood of breastfeeding outcomes. future research should explore whether psychological factors may help to address why some women do not intend to breastfeed, do not initiate breastfeeding, experience pain and discomfort with breastihhglqj��dqg�zk\�wkh\�vwrs�ghvslwh�lwv�khdowk�ehqhàwv� conclusion overall, our results show that when controlling for socio-demographics, pregnancy intentions may lqáxhqfh� wkh� gxudwlrq� dqg� lqlwldwlrq� ri � euhdvwihhging. pregnancy intentions and happiness about the pregnancy did contribute to an increase in odds of breastfeeding initiation, but these variables were not vljqlàfdqw� suhglfwruv� lqghshqghqwo\�� %uhdvwihhglqj� gxudwlrq� zdv� lqáxhqfhg� e\� suhjqdqf\� lqwhqwlrqv� while controlling for socio-demographic factors. breastfeeding behavior has been a topic of interest in a variety of sectors, from public health to psychology, gxh�wr�lwv�khdowk�ehqhàwv�iru�wkh�prwkhu��vxfk�dv�srvlwlyh� postpartum health outcomes (newcomb et al., 1994; visness et al., 1997) and advantageous psychological associations (mortensen et al., 2002). breastfeeding has also been associated with several physiological and psychological health beneàwv� iru� wkh�fklog�� vxfk�dv� lqfuhdvhg� lppxqh�v\vwhp� pregnancy intentions and happiness 60 functioning, long range developmental outcomes, and a secure mother-infant attachment bond (davis et al., 1988; lawrence, 2000; mortensen et al., 2002). research into breastfeeding behavior has focused heavily on socio-demographic factors, particularly on socio-economic status and how breastfeeding initiation and duration can be enhanced through health education for low-income parents. we argue that interventions designed to improve breastfeeding should include evaluation of the mother’s feelings about her pregnancy, and ways to address feelings of unwantedness/unhappiness. poleschuck and woods (2014) recommend that health psychologists should assist women who express surprise, ambivalence, or frustration about the pregnancy with exploring their feelings, reframing their expectations, garnering social support and resources, and preparing for the impending changes of a newborn. the assistance from a psychotherapist may help to improve a variety of perinatal behaviors besides just breastfeeding, such as nutrition, smoking, and responsiveness to the infant’s needs. research should explore how psychosocial zhoo�ehlqj�dqg�lqwhqwlrqv�derxw�wkh�suhjqdqf\�lqáxence perinatal health behaviors and the psychological attachment formed between mother and child. while incentives and health education can be used to improve breastfeeding among women, attending to the sv\fkrorjlfdo� yduldeohv� zklfk� lqáxhqfh� euhdvwihhging outcomes could have lasting implications for the physical and mental health of both the mother and wkh�fklog�zklfk�wudqvfhqg�idu�sdvw�wkh�àuvw�\hdu�ri �olih� references ahluwalia, i. b., d’angelo, d., morrow, b., & mcdonald, j. a. 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(2006). breastfeeding, sensitivity, and attachment. pediatrics, 118(5), 1436-1443. doi:10.1542/peds.20052916. celi, a. c., rich-edwards, j. w., richardson, m. k., kleinman, k. p., & gillman, m. w. (2005). immigration, race/ethnicity, and social and economic factors as predictors of breastfeeding initiation. archives of pediatrics & adolescent medicine, 159(3), 255. centers for disease control and prevention. (2011). national immunization survey. provisional breastfeeding rates by socio-demographic factors among children born in 2007. retrieved from www.cdc.gov/breastfeeding/data/nis_ data/2007/socio-demographic_any.htm chang, y., valliant, m., & bomba, a. k. (2012). gender differences in knowledge and attitude regarding breastfeeding. international journal of consumer studies, 36, 342-351. chen, p. g., johnson, l. w., & rosenthal, m. s. 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(2002). consequences for infants of parental disagreement in pregnancy intention. perspectives on sexual and reproductive health, 34(4), 198-205. /dzuhqfh�� 5�� �������� %uhdvwihhglqj�� %hqhàwv�� ulvnv�� alternatives. current opinion in obstetrics and gynecology, 12, 519-524. lawson, k., & tulloch, m. i. (1995). breastfeeding duration: prenatal intentions and postnatal practices. journal of advanced nursing, 22(5), 841849. li, r., darling, n., maurice, e., barker, l., & grummer-strawn, l. m. (2005). breastfeeding rates in the united states by characteristics of the child, mother, or family: the 2002 national immunization survey. pediatrics, 115(1), e31-e37. mortensen, e. l., michaelsen, k. f., sanders, s. a., & reinisch, j. m. (2002). the association between duration of breastfeeding and adult intelligence. the journal of the american medical association, 287(18), 2365-2371. newcomb, p.a., storer, b.e., longnecker, m.p., mittendorf, r., greenberg, r., clapp, r.w.,… macmahon, b. 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(2006). lower breastfeeding rates persist among the special supplemental nutrition program for women, infants, and children participants,1978-2003. pediatrics, 117(4),11361146. pregnancy intentions and happiness 62 smith-gagen, j., hollen, r., walker, m., cook, d. m., & yang, w. (2014). breastfeeding laws and breastfeeding practices by race and ethnicity. women’s health issues, 24(1), 11-19. stearns, c. a. (2009). the work of breastfeeding. women’s studies quarterly, 37(3&4), 63-80. taylor, j. s. & cabral, h. j. (2002). are women with an xqlqwhqghg� suhjqdqf\� ohvv� olnho\� wr� euhdvwihhg"� the journal of family practice, 51(5), 431-436. taylor, j. s., geller, l., risica, p. a., kirtania, u., & cabral, h. j. (2008). birth order and breastfeeding initiation: results of a national survey. breastfeeding medicine, 3(1), 20-27. doi:10.1089/ bfm.2007.0006 thulier, d. & mercer, j. (2009). variables associated with breastfeeding duration. journal of obstetric, gynecological, & neonatal nursing, 38, 259268. doi:10.1111/j.1552-6909.2009.01021 united states department of health and human services. national center for health statistics. national survey of family growth, cycle vi, 2002. icpsr04157-v1. ann arbor, mi: institute for social research [producer], 2004. ann arbor, mi: inter-university consortium for political and social research [distributor], 2008-10-01. doi:10.3886/icpsr04157.v1 vaaler, m. l., castrucci, b. c., parks, s. e., clark, j., stagg, j., & erickson, t. (2011). men’s attitudes toward breastfeeding: findings from the 2007 texas behavioral risk factor surveillance system. maternal and child health journal, 15(2), 148-157. visness, c.m., kennedy, k.i., ramos, r. (1997). the duration and character of postpartum bleeding among breastfeeding women. obstetrics & gynecology, 89(2). wallace, chad, rodriguez graduate student journal of psychology 2010 – volume 12 _____________________________________________________________________________________________ foreword 2 letter from the editors ashley b. bullock and brian j. sherman current issues error! bookmark not defined. managed care and the mental health professions: history and effects on outpatient care gregory erickson, teachers college, columbia university error! bookmark not defined. race-matching in psychotherapy: findings, inconsistencies, and future directions jerren weekes, university of cincinnati original research error! bookmark not defined. impact of an elderspeak in-service training on resident well-being, self-esteem, and communication satisfaction lonnie s. bradford and christian m. end, xavier university error! bookmark not defined. engaging in the hookup culture: a self-discrepancy perspective elizabeth victor, duke university error! bookmark not defined. a brief report: a facet-level analysis on relationships between mindfulness and attachment styles angela e. lee-winn, yuet juhn tse, gareth holman, and jeremy luk, university of washington clinical considerations error! bookmark not defined. onset or exacerbation of ocd during pregnancy: clinical characteristics and etiological considerations eleni vousoura, teachers college, columbia university error! bookmark not defined. panic disorder subtype gastrointestinal response: phenomenon and treatment recommendations allison bonifay, kevin j. ashworth, and johan rosqvist, pacific university other error! bookmark not defined. .................................................................................................................... instructions to authors 2 error! bookmark not defined. ....................................................................................................................................... recruitment volume 18_3 teachers college, columbia university department of counseling and clinical psychology dear reader, after a three-year hiatus and a change in leadership, we are thrilled to present volume 18 of the graduate student journal of psychology (gsjp), a peer-reviewed journal consisting of empirical and theoretical articles written by researchers of all levels in the field of psychology. this volume is especially unique as it was produced in the midst of the covid-19 pandemic. thanks to the joint effort and dedication of all those involved, this volume upholds the core principles of the journal by creating a space for student learning and fostering professional development within the field of psychology. graduate students often have few opportunities to demonstrate their proficiency in research design in a professional public forum. the mission of this journal is therefore to bridge this gap between the graduate student and the professional. the gsjp provides an avenue for academic growth by covering all elements pertaining to the publication of a scientific manuscript. this includes the writing process, submission preparation, and editing and reviewing of final manuscripts. additionally, the journal continues to emphasize its commitment to the publication of underrepresented works within major journals. the gsjp prioritizes sound methodological quality and replicability over the magnitude of effect sizes, and considers studies for publication without regard for the statistical significance of results. this unique aspect of the gsjp intends to counteract the effect of publication bias toward significant effects in the field of psychology as a whole. the present issue exemplifies the sustained effort to adhere to these goals. when the journal was last published, the world looked much different. accordingly, this issue represents a sample of the diversity of manuscripts submitted for publication during a period colored by both strain and resilience. as a relic of the pandemic, the reader will find articles related to covid-19 and the themes and issues that arose during stay-at-home orders including: healthcare, race and racism, family dynamics, and parenting, written by authors and researchers from different corners of the world. the articles demonstrate a wide range of sound methodological designs and adhere to the 7th edition of the publication manual of the american psychological association. the present volume is representative of the hard work and dedication on the part of the authors, peer-reviewers, editorial board, layout editor, and all others who have been involved in this process. we are eternally grateful to all of them. we would especially like to thank our faculty sponsor, dr. randall richardson-vejlgaard, whose guidance and support throughout this publication process has been invaluable. please feel free to share your thoughts and comments with us at gsjp@tc.columbia.edu or on our instagram page @gsjp_journal. editorial team, daniella ekstein, curreen luongo, neha parvez, juno pinder, mitsu puri & claudia rodriguez l 68 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university secondary traumatic stress among mental health professionals: implications for graduate training programs alicia key, m.a. and katie rider, m.a. ball state university secondary traumatic stress (sts), which involves symptoms that mimic post-traumatic stress disorder, results from indirect exposure to trauma through caring for or working with traumatized individuals. not surprisingly, given their frequent provision of services to trauma survivors, mental health professionals are among those at highest risk of developing sts. accordingly, the present review sought to fill a gap in the literature by addressing the implications of sts for psychology graduate programs responsible for training mental health professionals. it is suggested that training programs can make three types of changes—curricular, environmental, and direct service related—to reduce student risk for, and enhance resiliency in the face of, sts. indirect exposure to trauma, such as caring for or working with traumatized individuals, can lead to secondary traumatic stress (sts; shoji et al., 2014). given that provision of services to trauma survivors is a common element of the work performed by mental health professionals, it is not surprising these professionals are among those at highest risk of developing sts (cieslak et al., 2014). with up to 14% of mental health professionals experiencing sts, the following review seeks to fill a gap in the literature by addressing the implications of sts for psychology graduate programs responsible for training mental health professionals (buchanan, anderson, uhlemann, & horwitz, 2006). to this end, sts will first be clearly defined and distinguished from similar terms. the symptoms of sts and resulting consequences, along with both risk and protective factors, will then be discussed. finally, the implications of sts for graduate training programs in applied forms of psychology will be assessed. specifically, it is suggested that training programs can make three types of changes—curricular, environmental, and direct service related—to reduce student risk for, and enhance resiliency in the face of, sts. sts: an overview definitions and characteristics the terms sts, compassion fatigue, burn out, and vicarious traumatization have often been used interchangeably (bell, 2003; ben-porat & itzhaky, 2009; salston & figley, 2003). nevertheless, while there is considerable overlap in terminology, there are subtle differences that distinguish these terms from one another. sts specifically refers to symptoms that mimic post-traumatic stress disorder (ptsd) in those professionals who work with victims of trauma (baird & kracen, 2006; bell, 2003), while compassion fatigue focuses on the depletion of emotional, physical, and spiritual strength of human service workers due to their great expense of empathy for their client (merriman, 2015). essentially, the term sts focuses on specific symptoms, while compassion fatigue uses a broader definition to include the counselor’s overextension of empathy as a source of later symptoms. alternatively, burn out is generally the term used to refer to emotional exhaustion, accompanied by reduced feelings of personal accomplishment, and feelings of cynicism that interfere with an individual’s ability to adequately perform their job (green, albanese, shapiro, & aarons, 2014). lastly, vicarious traumatization refers to broad and overarching negative changes in professionals’ views of themselves, their work, and the world as a result of being exposed to their clients’ traumatic experiences (bell, 2003; ben-porat & itzhaky, 2009; buchanan et al., 2006). in essence, burn out focuses on the end result of emotional exhaustion—not being able to perform one’s job—while vicarious traumatization refers to significant cognitive changes in professionals’ world views. as sts, compassion fatigue, burn out, and vicarious traumatization all refer to emotional distress and traumatization in some way, there is understandably some overlap. for instance, symptoms of sts include override (hidden running head text): key, rider secondary traumatic stress keywords: sts, traumatic stress, graduate training programs please address correspondence regarding this article to: ambrooks4@bsu.edu 69 secondary traumatic stress intrusive memories of a client’s trauma, hypervigilance, irritability, feelings of grief and sadness, difficulty sleeping, difficulty concentrating, avoidance of traumatized clients and traumatic material, and reductions in compassion or empathy for traumatized clients (collins & long, 2003; figley, 2002). not surprisingly, mental health professionals who experience sts suffer from high rates of burnout and dissatisfaction in their work (collins & long, 2003). because of these symptoms of sts, they may also experience compassion fatigue (figley, 1995). it is not surprising that as a result of these sts symptoms, mental health professionals may attempt to cope in destructive ways. for instance, they may detach from their clients in attempts to avoid further traumatization, or they may overly identify with clients, attempting to exert control over overwhelming material and taking responsibility for their clients’ well-being (collins & long, 2003). overly identifying with clients is particularly troublesome as it can lead to clients censoring what they share in attempts to protect their therapists from the pain of their traumas. risk factors several studies have indicated that a significant portion of human service workers, mental health professionals in particular, experience sts (birck, 2001; cieslak et al., 2013). cornille and meyers (1999) found that 37% of their sample of 183 child protective workers showed clinical levels of sts (birck, 2001). among 126 master’s level outpatient and inpatient social work professionals, alenkin (2011) found that 60% experienced symptoms of sts (kintzle, 2013). kintzle, yarvis, and bride (2013) found that 59% of their sample (n = 70) endorsed at least one symptom of sts, with 33% of their sample endorsing 5 or more symptoms and 8% endorsing symptoms at a moderate to severe level. because sts appears to be occurring at such an alarming rate and not only affects the mental health professional, but also can lead to residual effects on clients, it is important to note the risk factors involved. these risk factors include extreme empathy for clients (baum, rahav, & sharon, 2014; bell, 2003), emotional contagion (baum et al., 2014), gender (kassam-adams, 1995), a history of trauma (bell, 2003), a lack of experience in working with trauma (morrison, 2007), a large caseload of traumatized clients (buchanan et al., 2006), and a lack of workplace support (schauben & frazier, 1995). extreme empathy for clients can lead to sts, as the pain of the client is deeply felt by the practitioner (baum et al., 2014). while empathy for a client is generally thought to be a positive characteristic of practitioners, it can become a problem when practitioners begin to place themselves in their traumatized client’s shoes and in so doing begin to exhibit ptsd-like symptoms (bell, 2003). as it stands, “educators have not been as effective in teaching students about the potential personal hazards in using empathy with clients who have experienced trauma” (nelson-gardell & harris, 2003, p. 6). teaching students and trainees about this potential hazard would conceivably allow trainees to become aware of the risk and the symptoms should they begin to experience them. along with empathy, emotional contagion may also play a factor in increasing vulnerability to sts (baum et al., 2014). emotional contagion refers to the degree to which being around individuals with certain emotions causes one to begin feeling those same emotions. thus, when a client experiences deep emotions after a trauma, the practitioner may begin to internalize some of those emotions, developing sts. gender is another risk factor for the development of sts. just as research has shown the female gender to be a risk factor for ptsd (brewin, andrews, & valentine, 2000), researchers have also found that women are especially vulnerable to sts (baum, 2014). it is theorized that in regards to sts, it is by virtue of women consistently scoring higher on measures of empathy and emotional contagion than men that they are more vulnerable to developing sts (baum, 2014; kassam-adams, 1995). another reason women may be at higher risk of developing sts is that many women have a personal history of interpersonal trauma (tang & freyd, 2012). those with a history of trauma, such as childhood abuse, may be at greater risk for experiencing symptoms of sts (bell, 2003; cunningham, 2003). this is an important factor to consider given that it has been estimated more than one-third of mental health professionals have experienced childhood abuse (buchanan et al., 2006). the current literature on sts for those with a history of trauma is somewhat limited, however (zerubavel & wright, 2012). because the symptoms of sts are the same as ptsd, with the difference being the 70 key, rider origin of the trauma, future research should take care to distinguish between sts and ptsd in providers with a history of trauma. if clinicians exhibit re-experiencing symptoms, such as nightmares or flashbacks, it is important to assess if these symptoms are related to a personal trauma or the trauma of their client. if the symptoms are related to the client’s trauma, this would be considered sts, and not ptsd (collins & long, 2003). it is important to note that a history of trauma does not necessarily lead to sts. in fact, follette, polusny, and milbeck (1994) determined that mental health professionals who had dealt with personal trauma evidenced a higher degree of positive coping skills when faced with client trauma than did those without a personal history of trauma. the authors concluded that personal trauma experiences force people to develop the coping skills necessary to deal adaptively with traumatic material. not having developed coping skills to deal with trauma may be one reason that inexperience in working with traumatized individuals is a risk factor for sts. accordingly, trainees and beginning mental health professionals are at heightened risk for sts (schauben & frazier, 1995). this is also why a lack of support is a risk factor for sts. without proper guidance and support, individuals who have never experienced working with traumatized clients may quickly become overwhelmed. workplace support, in general, is very important in preventing sts and decreasing the feelings of isolation that often develop as a consequence (schauben & frazier, 1995). a workplace environment that discourages open communication about therapist emotions, distress, and need for self-care greatly increases the odds of sts (schauben & frazier, 1995). the number of traumatized individuals on any given mental health professional’s caseload is also related to the likelihood of developing sts (buchanan et al., 2006; meyers & cornille, 2002). similarly, the severity of the trauma clients have experienced may be related to the likelihood of therapists developing symptoms. indeed, as buchanan and colleagues (2006) found, repeated exposure to the graphic details of clients’ trauma stories, particularly those involving interpersonal violence, increases the likelihood of mental health professionals developing sts (bober & regehr, 2005). working with traumatized children may also put therapists at an even greater risk for sts symptoms than working with traumatized adults (beaton & murphy, 1995). because sts is defined by symptoms of ptsd, it is reasonable to hypothesize that risk factors for ptsd may play a part in the development in sts. future research is needed to fully assess this hypothesis; however, it may be wise for clinicians and those in charge of training clinicians to bear in mind the risk factors for developing ptsd. these risk factors include socioeconomic status, age, type of trauma experienced, exposure to general life stressors, tendency towards avoidance coping, level of education, psychiatric history, and race (brewin, andrews, & valentine, 2000; sareen, 2014). in sum, the research on sts indicates that extreme empathy (baum et al., 2014; bell, 2003), emotional contagion (baum et al., 2014), gender (kassam-adams, 1995), a personal history of trauma (bell, 2003), a lack of experience in working with trauma (morrison, 2007), a lack of workplace support (schauben & frazier, 1995), and a large caseload of traumatized clients (buchanan et al., 2006) are all risk factors for developing sts. protective factors though there are many risk factors for sts, there are also protective factors that may prevent sts (baum et al., 2014; bell, 2003; buchanan et al., 2006; schauben & frazier, 1995). these factors include training and education, experience in working with traumatized clients, and good supervision (boscarino, figley, & adams, 2004; collins & long, 2003; ortlepp & friedman, 2002; pearlman & mac ian, 1995). training mental health professionals regarding trauma work can prepare them for the difficulties they may not have expected. specifically, training and education regarding the importance of self-care when working with traumatized clients, as well as the coping skills that can be employed to handle graphic and disturbing materials, can protect practitioners from becoming overwhelmed in the face of client trauma and developing sts (eidelson, d’allesio, & eidelson, 2003). in the same way that education and training can prepare mental health professionals to hear traumatic material, experience working with traumatized clients can serve as a protective factor against sts (collins & long, 2003). clinicians who have already worked with traumatized clients may be aware of what to expect and, consequently, may not become as overwhelmed as those who have not previously served traumatized clients (pearlman & mac ian, 1995). longer working 71 secondary traumatic stress hours and larger caseloads, however, have shown to increase sts, as described previously (birck, 2011). as such, having worked with a smaller caseload of traumatized clients consistently over a longer period of time may be largely advantageous over a larger caseload of traumatized clients in a shorter period of time. along with education and training for sts, supervision can play a protective role by normalizing sts for the supervisee (morrison, 2007). after all, it has been argued that sts is almost inevitable for trauma workers (collins & long, 2003). researchers have shown that normalizing sts in the context of supervision in such a way as to de-stigmatize those that struggle with sts symptoms can aid in their recovery (morrison, 2007). in addition, salston and figley (2013) suggest that having regularly scheduled supervision and the ability to consult with a supervisor as needed can prevent sts or even ameliorate its effects. thus, quality supervision that would serve as protection against sts would include supervisor normalization of sts symptoms, consistency of regularly scheduled supervision, and supervision being used for consultation purposes. apart from training and education, experience in working with traumatized clients, and good supervision, there may be further protective factors against sts that research has yet to fully explore. namely, as stated above in the discussion of the risk factors for sts, the same protective factors against ptsd may play a role in protecting against sts. while future research should be conducted to support this notion, the protective factors related to ptsd can still be kept in mind. these factors include positive self-esteem, optimism, and social support (frazier et al., 2011; maercker & horn, 2013). implications for graduate training programs therefore, as is apparent, sts is a workplace risk for the mental health professional (figley, 1995). accordingly, considering that one of the fundamental goals of graduate training programs in applied forms of psychology is to provide students with the knowledge and skills necessary to excel as providers of mental health services (american psychological association [apa], 2013), one might assume that consideration of sts has long been a standard element of such graduate programs. however, even a quick perusal of the relevant literature (figley, 1995; figley, 2002; maslach & goldberg, 1998) and training program standards (apa, 2004, 2013) reveals this is not the case. indeed, despite recognition over the years by leaders in the sts field of the critical role training programs could play in educating about and preventing sts (figley, 1995, 2002), at present sts remains largely overlooked at the graduate training level. the remainder of this paper will explore how this oversight might be remedied by examining three categories of implications of sts for the graduate programs in psychology responsible for training mental health professionals—curriculum implications, program environment implications, and departmental direct service experience implications. curriculum implications according to the apa’s (2010) ethical principles of psychologists and code of conduct—the foremost ethics code in the mental health professions and the code to which all psychologists are held—it is the responsibility of graduate training programs in psychology to “take reasonable steps to ensure that the programs are designed to provide the appropriate knowledge” (p. 9). there is little question that knowledge of sts is appropriate knowledge for any graduate student planning to pursue work in the clinical arena. estimates indicate that among those most likely to seek mental health services, rates of trauma exposure are high (craine, henson, colliver, & maclean, 1988; hanson, hesselbrock, tworkowski, & swan, 2002; mauritz, goossens, draijer, & van achterberg, 2013), and, as demonstrated above, routine provision of mental health services to traumatized individuals results in the development of sts for a significant minority of mental health professionals (cieslak et al., 2014). consequently, one of the foremost implications of sts for graduate training programs in psychology is the necessity of incorporating teaching on sts into the curriculum (figley, 1995). in regards to the form this teaching might take, several topic areas seem particularly relevant. for one, students should be informed of the symptoms of sts (figley, 2002), as well as the risk and protective factors. provision of such information has the potential to markedly diminish the impact of sts on mental health professionals, for clinicians equipped with knowledge of sts during their graduate training would be better able to quickly recognize and address 72 key, rider the symptoms of sts should they develop the condition. moreover, knowledge of the risk and protective factors would enable students to begin remediating any risk factors they might possess and enhancing their protective factors while still in training, in turn, lessening their chances of developing sts upon their entrance into the field as licensed clinicians. another relevant topic area graduate training programs in psychology should consider incorporating into their teaching on sts involves the client factors associated with heightened risk of mental health professionals developing sts. as mentioned previously, research suggests that client age matters, such that those mental health professionals who work with traumatized children are more likely to develop sts than are those who work with traumatized adults (beaton & murphy, 1995). further, there is evidence to suggest that risk of sts varies by the etiology of clients’ trauma. for example, a number of studies have demonstrated that engagement with clients who are victims of interpersonal violence (e.g., intimate partner violence, child abuse, rape, torture) is particularly likely to incite sts in mental health professionals (bober & regehr, 2005). equipping students with this knowledge while in graduate school would permit them to make judicious choices as to the various types and combinations of trauma survivors they elect to treat once operating in the field as licensed clinicians. a final topic area graduate training programs in psychology would be remiss not to integrate into their teaching on sts concerns cultural considerations. there is a substantial body of literature indicating that ptsd manifests differently in different cultural groups. avoidance and numbing symptoms, for instance, have been found to be a relatively uncommon manifestation of ptsd in non-western settings (hinton & lewisfernandez, 2011). conversely, both palinkas, petterson, russell, and downs (2004) and hinton, hinton, pich, loeum, and pollack (2009) determined that manifestation of ptsd in the form of frightening nightmares occurs far more frequently in non-western settings. somatic symptomology also appears to be considerably more common in certain cultural groups than in others (hinton & lewis-fernandez, 2011). although study of cultural variation in symptomology has not yet been extended explicitly from ptsd to sts, given the marked parallels between the two conditions there is every reason to believe that manifestation of sts varies by cultural background as well (baird & kracen, 2006; bell, 2003). accordingly, graduate training programs in psychology would be wise to include information on these cultural variations as part of their teaching on sts so as to ensure that trainees of divergent cultural backgrounds are informed regarding how sts may influence them differentially due to their distinctive heritage. a second curricular implication of sts for graduate training programs in applied forms of psychology concerns the inclusion of at least some specialized trauma training as a standard element of the curriculum. as mentioned previously, the rates of trauma exposure and trauma-related disorders among those who seek mental health treatment are high (craine et al., 1988; hanson et al., 2002; mauritz et al., 2013). subsequently, it is safe to assume that the preponderance of mental health professionals will be exposed to client trauma at some point in their careers. therefore, given the evidence that suggests specialized trauma training protects mental health professionals against sts development when faced with client trauma (eidelson et al., 2003; ortlepp & friedman, 2002), it seems that inclusion of this training into graduate training programs as a fixed curricular element would prove beneficial for the vast majority of students. environment implications the existence of sts as a work-related hazard for mental health professionals also has compelling implications for the departmental environment cultivated by graduate training programs in psychology. for many students, departmental practicum experiences constitute their first real and sustained exposure as clinicians to the world of direct service provision. consequently, it is probable that for a sizable portion of students, this experience is largely responsible for shaping their perception of the features that comprise an appropriate work environment for mental health professionals. while this is a heavy responsibility for training programs, it can also be regarded as a prime opportunity to model for students the type of work environment research has shown functions as a protective factor against sts (boscarino et al., 2004; orltepp & friedman, 2002). for example, morrison (2007) determined that a supportive, open workplace environment in which workers are encouraged to dialogue with their colleagues about 73 secondary traumatic stress the feelings and fears that arise in response to work with traumatized clients protects against sts. likewise, coster and schwebel (1997) highlighted the importance of workplace environments that purposefully endeavor to normalize, and thus to destigmatize, sts. similarly, moran (2002) emphasized the value of workplace environments in which humor is embraced. consistent, widespread efforts by graduate training programs in psychology to cultivate a workplace environment in their own training clinics that exudes these protective factors would undoubtedly produce great dividends, as it would equip students with first-hand awareness of what a healthy workplace looks like. this, in turn, would enhance students’ ability following graduation to identify and avoid sts facilitative workplace environments. a starting point for programs aiming to institute the aforementioned environmental changes might be to execute a confidential survey of students for purposes of ascertaining student perceptions of the department climate. that is, do students perceive that open discussion of the feelings and fears they experience in response to their work with traumatized clients is welcomed and will not reflect poorly on their clinical evaluations? likewise, do students report that appropriate humor is embraced and cultivated by clinical faculty or do they regard stoicism as the norm? programs could then use the information gleaned from these surveys to structure their approach to instituting necessary environmental changes. the specific form these changes take will depend on the distinctive environmental weaknesses that are identified, as well as on the available resources and skill set possessed by department personnel. departmental direct service implications the final category of implications of sts for graduate training programs in psychology concerns the direct service experience students accrue through required participation in departmental training clinics (apa, 2013). there is no reason to assume that students working with clients in such clinics are immune to sts. rather, quite to the contrary, it is probable that students working in these settings are actually more susceptible to sts than is the average licensed professional working in the field. research has repeatedly demonstrated that lack of experience working with traumatized individuals is a risk factor for sts development (abu-bader, 2000; cunningham, 2003; pearlman & mac ian, 1995), and graduate students—as a consequence of their status as students in training—inherently possess minimal hands-on experience providing mental health services to all types of clients, traumatized clients included. the fact that students working in departmental training clinics may be at heightened risk of developing sts due to their limited clinical experience implies that the graduate programs that house these clinics need to make special efforts to operate the clinics in such a way that risk of student development of sts is minimized. fortunately, there are a number of steps graduate programs can take to decrease the likelihood that their students will develop sts as a consequence of providing services in the departmental clinic. for example, both boscarino and colleagues (2004) and ortlepp and friedman (2002) established that quality supervision is a major sts preventative factor. this indicates that graduate training programs should ensure all students engaged in departmental clinic work are provided with regular, quality supervision in which discussion of the personal effects of exposure to client trauma is encouraged. correspondingly, careful client screening is crucial in order to prevent students from being assigned clients whose trauma level warrants treatment by a professional with more experience than is possessed by most beginning clinicians. lastly, in light of the strong relationship between high caseloads and sts (kadambi & truscott, 2004), it seems prudent for training clinic leadership to carefully monitor student caseloads in an attempt to protect students from becoming so overwhelmed that sts ensues. a related concern involves whether graduate training programs should routinely assess students for sts during their tenure in departmental training clinics. on one hand, such assessment seems warranted. after all, the licensed professionals who administrate departmental training clinics have a responsibility to protect the clients served within those clinics from harm (apa, 2010) and, as has previously been established, sts has great potential to impair the quality of the services that a mental health professional provides (collins & long, 2003; figley, 1995, 2002). on the other hand, institution of department-wide screening procedures for sts— particularly if certain screening results are associated with student remediation—could cultivate a department climate in which students conceal their symptoms, thereby diminishing the likelihood that those students 74 key, rider suffering from sts will receive the assistance of which they are in need. therefore, due to the ethical complexities involved, graduate training programs in psychology should approach the implementation of routine sts screening in departmental clinics with much foresight and deliberation, taking special pains to consider and balance the needs of both clients and trainees. conclusion in closing, the experience of sts and its very troubling symptoms, is a distinct possibility for all individuals who devote their professional efforts to providing mental health services to hurting people (cieslak et al., 2014). accordingly, it only makes sense that education about and prevention of sts should become a standard element of every psychology graduate program responsible for training mental health professionals. as detailed above, three types of changes training programs could begin to make immediately to better equip students concerning sts involve curricular changes, department environment changes, and direct service experience changes. given that these proposed forms of change have received limited attention in the research literature, future research efforts should be aimed at evaluating their effectiveness and practicality from an empirical standpoint. additionally, if and when training programs adopt the proposed changes described herein, objective and quantitative evaluation of the impact of the changes on the clinical efficacy of the students enrolled in these training programs should follow. moreover, research aimed at ascertaining rates of sts among graduate psychology students is called for to provide a clearer picture of the extent of the impact of sts on the graduate trainee population, as is research that explores what distinguishes graduate training programs with high rates of sts among students from those with low rates. ultimately, the hope is that sts education and prevention will become a widespread focus of all graduate training programs in applied forms of psychology. the more students who are sent into the field of mental health work are adequately equipped to identify and successfully manage the sts, the more traumatized clients will be able to receive the services of which they are desperately in need. references abu-bader, s. h. 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(2012). the dilemma of the wounded healer. psychotherapy, 49(4), 482–491. doi:10.1037/a0027824 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 3 fragmented selves: recall of self-referenced adjectives and the selfschema in schizophrenia fahad rahman lahore university of management sciences the self-schema has been implicated in the social and cognitive disabilities found in people diagnosed with schizophrenia. it is hypothesized that the self-schema is relatively disorganized and unstable in schizophrenia patients compared to healthy individuals. few studies have examined this hypothesis in the literature, as the self-schema in schizophrenia is not yet fully understood. testing this hypothesis, mean recall for 20 adjectives was compared between 20 adult male participants with schizophrenia and 20 adult male nonclinical participants under two levels of processing: semantic and self-referential. results showed that self-referencing facilitated memory (i.e., the selfreference effect). there was a significant difference in the mean recall of the nonclinical participants under the two encoding conditions, but this difference was not significant for schizophrenia patients. that is, schizophrenia patients showed a global impairment in word recall compared to the nonclinical participants, and the self-reference effect was not shown. accordingly, treatment should aim to ameliorate these deficits in self-concept and social cognition in addition to the standard rehabilitation repertoire.  the self is a concept that has stirred much passionate debate in philosophical and psychological literature. renee descartes (1641) put forth the idea that the ability to have self-awareness (i.e., being able to reflect on one’s own inner cognitive and emotional states, and monitor one’s behavior), is a necessary condition to gain the status of full personhood and is a proof of one’s own existence. kihlstrom et al. (1988) have defined the self as a mental representation of everything a person knows about him or herself. a person’s selfknowledge can be roughly divided into perception-based knowledge (i.e., self-image) and meaning-based knowledge (i.e., self-concept). the self consists of a memory structure that has abstract representations of all the past experiences of an individual. if there are deficits in the self of an individual, that may affect the mental health of that person in substantial ways. therefore, understanding the specific nature of the self-schema in schizophrenia may allow us to prevent and treat the disorder more effectively. the self-reference memory (srm) effect the role of the self-schema in memory processes is often investigated using the depth of processing (dop) incidental recall paradigm (craik & tulving, 1975), in which participants process a list of words at different levels of depth. depth refers to the extent or amount of processing that a stimulus receives, and it is positively correlated with the strength and subsequent recall of the stimulus. for example, fahad rahman, department of humanities and social science, lahore university of management sciences. fahad rahman is now at the department of counseling and clinical psychology, teachers college, columbia university. correspondence concerning this article should be addressed to fahad rahman, 500 riverside drive, apartment 605, new york, ny 10027. email: fr2275@tc.columbia.edu the structural coding task involves rating whether a given word is written with capital letters or lowercase letters. other words are rated according to either phonemic or semantic rating tasks, which involves processing whether the word rhymes with another word or processing the meaning of the word, respectively. after the rating task the participants are asked to recall the words they remember in a surprise recall test i.e., the participants are not told about the recall test in advance. an influential meta-analysis of the self-reference effect by symons and johnson (1997) analyzed various studies on the srm effect in order to investigate whether there is a unique mnemonic advantage to the role of the self in recall. their analysis showed that the srm effect was indeed shown in majority of the studies and was a robust phenomenon. the authors argued that self-referential coding was sufficient―although not necessary―to promote superior recall of information because it promotes the processing of new information and helps relate it to previously stored related information. furthermore, the involvement of the self-schema in the encoding stage provides superior recall by providing a compatible retrieval condition involving the same related self-schema items that were present during encoding. rogers, kuiper, and kirker (1977) wrote that it was the wellstructured and relatively stable nature of the self-schema that makes it such a powerful memory structure, stating that “in order for the self-reference to be such a useful encoding process, the self must be a uniform, well-structured concept” (p. 686). self-schema deficits in schizophrenia the exploration of the srm effect in different populations, especially among those with psychopathology, can provide us with information about the nature of their selfschema and executive abilities. for instance, the nature of rahman 4 schizophrenia involves the fragmentation and disorganization of numerous cognitive processes, such as attention, perception, memory and appraisal (carter & flesher, 1995). the disorganization and fragmentation of the self-schema and self-experience among schizophrenia patients is considered a crucial and important aspect of the disorder (guller, 1966; mishara, 2007). therefore, the dop paradigm can elucidate the nature of these self-related cognitive deficits and potentially provide us with targets for therapeutic interventions. although there has not been much research on selfschema deficits in people with schizophrenia, there is some preliminary support for the hypothesis that the self-schema may play an important role in schizophrenia. for instance, schizophrenia patients often report having unclear selfawareness or self-concept. guller (1966) investigated the stability of the self-concept of people with schizophrenia and found that their self-concept was very variable and resulted in inconsistent self-descriptions. guller (1966) claimed that schizophrenia has an important “self-concept disorder” (p. 279) component, which contributes to a number of the symptoms found in schizophrenia, such as an inability to plan ahead, and difficulties in effectively communicating or anticipating other’s reactions. . similarly, the self-schema of schizophrenia patients seems to be less stable over time when compared to the selfschema of non-clinical individuals. boulanger, dethier, jacob, gendre, and blairy (2009, september) compared the stability of the self-schema of individuals with schizophrenia to those with no identifiable psychopathology by asking them to define themselves on two parallel versions of a questionnaire with trait adjectives. individuals with schizophrenia had a significantly less stable self-schema than non-clinical individuals. the individuals with schizophrenia also showed more depression and anxiety, but the difference in the stability of the self-schema remained even when these other factors were statistically accounted for. furthermore, individuals with schizophrenia also have difficulty in temporal aspects of self-referential memory, such as recalling specific events in their past and generating specific thoughts about future events (d’argembeau, raffard, & van der linden, 2008). this distorted sense of continuity of the self over time in individuals with schizophrenia may be partly associated with impairments in self-awareness and the self-schema. scharfetter (1981) classified dimensions of egoconsciousness and postulated that impairment in the dimension of ego-consistency was the core feature of schizophrenia. the impairment of ego-consistency has been described as “the destruction of the coherence of one’s self, the body and the soul, as a unitary being” (kircher & david, 2003, p. 460). therefore, ego-consistency seems to be fragmented in individuals with schizophrenia, and it is a crucial concept in understanding the nature of this disorder. the srm effect shown in nonclinical samples can be attributed partly to how the self is spontaneously invoked and involved in the processing of personally relevant information (foley, belch, mann, & mclean, 1999). weckowisz and sommer (1960) showed that participants with schizophrenia used self-references less than nonclinical controls. it seems that the self-schema in schizophrenia is not spontaneously invoked or a well-rehearsed structure for personally relevant processing of information. people with schizophrenia show deficits in executive and organizational abilities and this may be another important factor in explaining why they do not show a normal srm effect. a study comparing patients with schizophrenia with those with bipolar disorder and a group of non-clinical individuals revealed that patients with schizophrenia showed poorer performance than bipolar patients in generating definitions of words and then later recalling them (rossel and batty, 2008). the authors concluded that patients with schizophrenia have impairments in their executive and organizational abilities as well as greater deficits in their search and retrieval strategies. bower and gilligan (1979) claimed that the self-schema provided efficient search and retrieval strategies and this explains why a self-reference effect is observed. therefore, if schizophrenia is marked by deficits in search and retrieval, as well as by deficits in organization, there might be a lack of a self-reference effect in people with schizophrenia. additionally, schizophrenia patients show difficulty in maintaining category boundaries, leading to the formation of vague and overextensive categories (lawrence, doughty, almousawi, clegg, & done, 2007). this may be due to the inability of schizophrenia patients to exclude contextually irrelevant items from categories. thus, it seems that the selfconcept as a category would suffer from the same documented distortions and it might be difficult for schizophrenia patients to maintain a proper self-concept or schema. since the self-reference effect depends primarily on the unity and coherence of the self-schema this might be another reason why patients with schizophrenia may lack the srm effect. the nature of the cognitive deficits related to the selfschema in people with schizophrenia can be a very fruitful domain of experimental inquiry because it will help explain some vexing questions about the nature, etiology, and treatment of this disorder. experimental studies on nonclinical populations have shown repeatedly that the depthof-processing experimental design is useful for tapping into the self-schema and understanding how the self is involved in normal social cognition and self-cognition. similarly, this experimental design has elucidated the nature of the selfschema in other forms of psychopathology, such as depression (davis & unruh, 1981; derry & kuiper, 1981); therefore, we can expect to find interesting and useful insights into the self and the social cognition of schizophrenia patients using this procedure. in fact, a recent study used a personality adjectives recognition dop paradigm in order to examine whether patients with schizophrenia show the mnemonic advantage of self-referential encoding as compared to structural and social desirability (i.e., a type of semantic encoding) encoding self-schema in schizophrenia 5 (harvey, lee, horan, ochsner, & green, 2011). interestingly, patients with schizophrenia had similar memory recognition of personality adjectives compared to the controls in the structural and social desirability conditions, but they had significantly less memory recognition than controls in the self-referential condition. this points to a specific selfcognition deficit, presumably in the self-schema, rather than depicting broader social cognition impairments or neurocognitive impairments in executive functions. a cognitive model of schizophrenia schizophrenia usually develops in vulnerable individuals during the transitory phase between late adolescence and young adulthood (carter & flesher, 1995). according to erik erikson’s (1968) stages of life theory, this period is marked by a need to define one’s identity and the expanding of social roles. the expanded social roles that a person occupies put increased demand on the individual to develop an increasingly complicated and extensive self-schema. thus, considerable cognitive skill and energy is involved in the formation of a self-schema. these developmental demands can produce a good deal of stress and anxiety in individuals (carter & flesher, 1995). according to the vulnerability theory of schizophrenia (zubin & springer, 1977), certain individuals have neuropsychological and cognitive deficits that make them vulnerable to schizophrenia, such as attention deficits and lack of cognitive flexibility. these cognitive deficits are implicated in the emergence of schizophrenia precisely during the phase of life in which the individual is expected to form a complicated self-schema that makes him or her functional in adult society. it is hypothesized that psychotic breaks may affect the already vulnerable self-schemas of individuals and can lead to distorted appraisals, beliefs and thoughts, which may contribute to dysfunctional moods and behaviors. these processes may lead to a downward spiral eventually resulting in the individual developing schizophrenia. this cognitive model of psychosis addresses the role of automatic appraisals, which are driven by schemas in the onset and maintenance of psychosis. for instance, individuals who develop symptoms of hallucinations are more likely to go on to develop schizophrenia if they develop depressive symptoms after their hallucinatory experiences (krabbendam et al., 2005). this suggests that there might be intervening beliefs that may affect selfand other-schemas and thereby lead to depression and psychosis (krabbendam et al., 2005). the specific research question addressed by this study is whether or not people diagnosed with schizophrenia have the self-reference effect. if they do, this study will address how it is similar or different from the self-reference effect found with nonclinical people. such investigations could be particularly important given speculations that the self-schema may play a role in moderating the onset of schizophrenic symptomatology. due to the deficits in schizophrenia related to executive functions (i.e., organization and search and retrieval strategies), and to the self-schema (i.e., fragmentation, instability and cognitive distortions), it is predicted that the result of the standard dop incidental recall paradigm will be different in people with schizophrenia, as compared to the nonclinical participants, in the self-reference task. it is predicted that the mean recall of the adjectives will not significantly improve in participants with schizophrenia in the self-reference task as compared to their mean recall of the adjectives in the semantic task. specifically, it is hypothesized that either the srm effect will not be demonstrated in participants with schizophrenia or it will be significantly weaker as compared to the srm effect observed in the nonclinical participants. method design a 2 x 2 between-groups design was used in this study. one of the independent variables used was the level of processing. this was a manipulated experimental factor with two levels: semantic processing and self-referential processing. the other independent variable was the psychiatric status of the participants. this was a subject factor, rather than an experimentally manipulated factor, that had two groups: people diagnosed with schizophrenia and nonclinical participants. the participants with schizophrenia were randomly allocated, using the block randomization technique, to both conditions of the level of processing factor (semantic and self-referential) in a way to ensure that exactly half (n = 10) were divided across both levels. the same random allocation technique was done for the nonclinical participants, so that four groups were made in total with 10 participants in each group. the dependent variable used was the number of correct items recalled under free recall conditions. participants twenty adult male participants diagnosed with schizophrenia were selected from the punjab institute of mental health (pimh) and from the fountain house institute in lahore, pakistan to participate in the research project. all schizophrenia subtypes were included in the study, except schizophrenia patients who had ever experienced an episode of drug-induced psychosis. the participants with schizophrenia had no known history of brain injury, epilepsy, neurological illness, intellectual disabilities, co-existing psychiatric disorders, or drug or alcohol abuse or dependence. the participants with schizophrenia used in the study were clinically stable, chronic inpatients in a residential setting with mild to moderate symptom levels, allowing them to participate properly in the experiment. all of the participants with schizophrenia were on an antipsychotic medication for at least six months. the schizophrenia patients were recruited by informing the psychiatric administrators of the required type of patients for the research project. the authorities selected suitable patients with schizophrenia, who were evaluated for their capacity to give informed consent. these participants rahman 6 either agreed or disagreed to participate in the research project after information about the experiment was given. overall, half of the selected schizophrenia patients gave their consent to participate in the study, and there were no significant differences between those who declined to participate and those who consented to participate. only male volunteers were recruited for the study as access to female patients with schizophrenia was difficult to obtain due to cultural norms regarding gender segregation, making it difficult for a male researcher to interview female patients with schizophrenia. therefore, an equivalent all-male nonclinical sample was also required to ensure comparability of the schizophrenic and nonclinical samples. thus, 20 adult male nonclinical participants were selected from the general population. ten nonclinical participants were recruited from the undergraduate student population at lahore university of management sciences (lums) by sending a mass email calling for male participants for a psychology cognitive experiment. the other ten of the 20 nonclinical participants were recruited through purposeful sampling from different socio-economic classes, language/ethnic groups, and age groups. therefore, the participants with and without schizophrenia were matched on age, gender, and ethnicity. attempts were made to match the groups on socioeconomic status (ses) by using the last attained educational degree as one indicator. despite matching the educational attainment levels, the living conditions and unemployment among the patients with schizophrenia suggest that the current socioeconomic levels (personal or familial) of the two groups were significantly different. the nonclinical participants were asked to self-report any history of psychiatric illnesses, substance abuse or dependency, head injury, or neurological disorders and only those who reported none were recruited for the study. furthermore, the nonclinical participants were asked to report if there was any history of schizophrenia among their firstdegree relatives and only those with no such history were selected. materials a list of 20 urdu and punjabi adjectives was prepared and tested on samples of randomly selected patients and students. these samples were different from the samples used during the interventions. a sample of 40 inpatients was randomly selected from the hospital records of the two psychiatric institutions and 40 lums students were randomly selected from the university admission records. they were asked to judge whether these words were familiar to them and, in their opinion, to others in order to verify that these adjectives would be equally familiar to all experimental participants involved, regardless of educational qualification, first language, or mental health status. among the participants involved in the four experimental conditions of the study, 40% of participants’ first language was urdu and 60% of participants’ first language was punjabi, although all participants spoke and understood both languages. an equal number of adjectives had positive and negative traits or valence, and they were listed in random order. this was used to prevent the response acquiescence bias (i.e., a tendency to choose yes as an option or select a positive option without careful consideration). this was also necessary to allow the adjectives to tap both the positive and negative traits that might be represented in the self-schemas of the various participants. derry and kuiper (1981) have pointed out the importance of making sure that the experimental traits are relevant to the self-schemas under investigation. they explained that the content-specificity component of the self-as-a-schema model predicts superior recall for words that are already present in the self-schema. therefore, it was necessary to ensure that the word list did not have only positive or only negative words, as that might not effectively represent the self-schemas of participants. furthermore, the average number of letters and syllables in the positive and negative words was kept equivalent. the semantic processing condition had the same 20 adjectives, as well as either correct or incorrect definitions of each word. therefore, the participants had to determine whether the definition given for a word was correct or incorrect. this was done to obtain both “yes” and “no” answers and prevent a response bias in the semantic processing conditions. procedure each participant was read the initial list individually for encoding and then tested for recall individually. a standardized protocol was observed to keep the experimental conditions as similar as possible and to avoid any confounding demand characteristics. standardized instructions were given to each participant in urdu, and the instructions were different for the semantic and selfreferential levels but the same across the mental status groups. the participant then answered either “yes” or “no” after each of the 20 adjectives according to the instructions given, i.e., whether the adjectives described them or not (selfreferential encoding), or whether the definitions of the adjectives were correct or not (semantic encoding). all participants were given a maximum of 30 seconds, monitored by the researcher on a stopwatch, to answer after the researcher spoke each word. after the last adjective was answered, one minute was allowed to pass before a surprise recall test was administered and the participants were asked to verbally recall as many of the adjectives (not the definition sentences) as possible, in any order. the entire procedure was verbal for all participants as some of the participants were illiterate. all participants were given a maximum of three minutes for this task. after the recall test all participants were suitably debriefed. all participants were given 40 rupees (approximately $1 at the time of study, but is worth more in terms of purchasing power) as a compensation for participating in the study. the methodology, purpose and implementation of this study was approved and monitored by the lahore university of management sciences (lums) senior research study advisors. self-schema in schizophrenia 7 results analysis of variance (anova) for four independent samples was used to analyze differences in participants’ ages. the mean age of the participants was 29.25 years (sd = 7.61). there was no significant difference in the age of participants in different groups, f(3,36) = 0.26, p = .85. the data were also analyzed with a 2 (schizophrenic and non-clinical) x 2 (semantic and self-referential) anova. the level of alpha was set at .05 and it was single-tailed because the limited power of the study prevented using a twotailed alpha level. the mean recall across all conditions for semantic processing was 5.40 (sd = 2.23; min = 4, max = 9), and across all conditions for self-referential processing was 6.75 (sd = 3.00; min= 6, max= 13). the difference was significant and a main effect for level of processing was found, f(1, 36) = 4.97, p = .032, ηp 2 = .12. the mean recall across all conditions for the nonclinical participants was 7.80 (sd = 2.39; min = 2, max = 7), which was higher than the mean recall across all conditions for the patients with schizophrenia (m = 4.35, sd = 1.72; min = 2, max = 7). a highly significant main effect was found for mental status, f(1, 36) = 32.48, p < .001, ηp 2 = .47. a significant interaction effect occurred between mental status and the level of processing, f(1, 36) = 4.26, p = .046, ηp 2 = .11. a simple effect analysis (independent samples t-test) of the level of processing in the participants with schizophrenia showed that even though the mean recall for the selfreferencing group was slightly higher than the mean recall of the semantic group the difference between the means was not significant, t(18) = -0.13, p = .90, d = .061, while for the nonclinical participants there was a significant difference, t(18) = -2.84, p = .011, d = 1.34, between the means of the semantic condition and the self-referential condition (see figure 1). descriptive statistics are given in table 1, which shows that the difference in mean scores across the levels of processing was much higher for the nonclinical groups than the schizophrenic groups. table 1 mean and standard deviation of recalled adjectives as a function of level of processing and mental status of participants. level of processing schizophrenic m (sd) nonclinical m (sd) semantic processing 4.30 (2.00) 6.50 (1.96) self-referential processing 4.40 (1.50) 9.10 (2.13) figure 1. the self-referencing of trait adjectives leads to a memory boost, relative to semantic processing of the same trait adjectives, only in non-clinical participants. rahman 8 discussion the results of this study supported the hypothesis that the participants with schizophrenia would show impairments in their self-schema. the results showed that the individuals diagnosed with schizophrenia did not seem to show a selfreference effect, while there was a significant difference in mean recall between the two levels of processing for the nonclinical participants. the interaction effect between mental status and levels of processing was significant and demonstrated that the mnemonic advantage of the self is observed in nonclinical participants, whereas no such substantial advantage is seen in participants with schizophrenia. there was a significant main effect for the levels of processing; overall, self-referencing of personal information lead to a better recall than semantic association. however, the significant interaction effect between the participants’ mental status and their relative ability to recall under different levels of processing is of greater interest. there was a small difference in the mean recall of patients with schizophrenia between the semantic and self-referential conditions, but inferential analysis showed that this was a nonsignificant difference. the self-memory system (sms) model according to the self-memory system (sms) model, the reduced srm effect in patients with schizophrenia may be explained by deficits in the self-schema, cognitive distortions within the self-schema, and executive function deficits. autobiographical memories have been proposed to be a part of the self-memory system (sms), which involves different sets of self-schemas that are activated and brought into consciousness according to the goals of the working self (i.e., the part of the self-concept accessible consciously at a particular moment) (conway & pleydel-pearce, 2000). the activated self-schema brings with it a sense of continuity and coherence because it has an attached autobiographical memory bank. the working-self is primarily composed of the various executive functions involved in coordinating cognitions (including memories), emotions, and behaviors. therefore, when individuals with schizophrenia have difficulty forming a sense of self-continuity and lack a welldeveloped and coherent self-schema, it could partly be due to deficits in the executive functions that coordinate goals and memories associated with relevant self-schemas. in addition to executive functions, this model also suggests that individuals with schizophrenia may have deficits in selfschemas due to lack of effective encoding, storage, retention, and retrieval, as well as distorted cognitions. autobiographical and episodic memories are often considered the same type of memory, but recent research has shown that these can be classified as closely linked but separate memory systems (gilboa, 2004; wheeler, stuss, & tulving, 1997). these two memory systems share many neural correlates but also show distinct differences (gilboa, 2004). autobiographical memory has a larger significance for the individual in terms of self and identity than episodic memory (gilboa, 2004). episodic memories are generally information stored about events in the past together with the context in which events occurred, and are often focused on relatively recent events (wheeler et al., 1997). these events can be any information that the individual was exposed to, while autobiographical memory focuses more on information related to the self. therefore, autobiographical memory is essentially tied to the self-schema of an individual and deals with broader, more generalized memories, which can be very old. the self-schema takes significant self-related episodic memories and processes the information to create multiple retrieval cues and associations with other data points within the self-schema. hence, autobiographical memories can be cued by a diverse and general set of situations, while episodic memory cues are generally more specific. the established explanation of how the self-schema facilitates word recall is that it not only elaborates and organizes data, but also provides similar conditions during retrieval as those found during encoding. additionally, it is a spontaneous and well-rehearsed structure in the processing of trait adjectives; therefore it has a natural advantage as a mnemonic device compared to any other memory structure (bower & gilligan, 1979; klein & loftus, 1988). this study found that the schizophrenia patients did not show a selfreference effect to the same extent that nonclinical participants did, and this result can be interpreted according to the self-as-a-schema theoretical framework presented above. presumably, not only is the self-schema disorganized in patients with schizophrenia, but it is apparently not a wellrehearsed and spontaneous structure in the processing of personally relevant information. it may not provide suitable retrieval cues and conditions, and hence is not rich enough to provide elaboration of personal information (mishara, 2007; scharfetter, 1981). executive abilities deficit in schizophrenia patients with schizophrenia have been shown to have impairments in organizational and executive abilities, which might also partly explain why they do not organize personal data efficiently (lawrence et al, 2007; rossell & batty, 2008). this hypothesis is supported by our results, which showed a highly significant difference in the overall mean recall of the trait adjectives between the participants with schizophrenia and the nonclinical participants. the nonclinical participants, across both levels of processing, performed much better than the participants with schizophrenia did under each of the two conditions. thus there was a strong main effect of the mental status of the participants as the schizophrenia patients showed an overall lower recall rate of the trait adjectives. this result is not surprising as it is known that patients with schizophrenia suffer from widespread organizational and informationprocessing deficits (neuchterlein & dawson, 1984). there are general deficits in attention and an inability to selectively attend only to relevant information, leading to over-inclusive and incoherent categories (lawrence et al., 2007). furthermore, patients with schizophrenia not only show self-schema in schizophrenia 9 marked deficits in self-schema but also in semantic memory. many psychologists have concluded from the evidence accumulated that “abnormalities in semantic memory are commonly proposed to be central to cognitive abnormalities in schizophrenia” (rossell & batty, 2008, p. 63). semantic deficits have been shown in a wide variety of semantic tasks, such as categorization (rossell & david, 2006), verbal fluency (rossell, rabe-hesketh, shapleske, & david, 1999) and priming (rossell, shapleske, & david, 2000). furthermore, it is plausible that the anti-psychotic medications that the participants with schizophrenia were taking might have affected their overall attention, memory and other executive abilities resulting in an overall lower recall of adjectives. these results point to broader executive and attentional deficits among the participants with schizophrenia but the low srm effect is probably not due to these other factors alone. harvey et al.’s (2011) study shows that patients with schizophrenia show a boost in recognition memory from structural to semantic level encoding but they lack the mnemonic boost for the self-reference encoding level. this suggests that the lack of mnemonic boost is more than just the attentional and organizational deficits that lead to the overall lower recall level of patients with schizophrenia. furthermore, our study supports the results from havey et al.’s (2011) study and provides evidence that these results are seen even when using a recall paradigm. social cognitive perspective the self-schema is a very important construct that is associated with effective interpersonal skills, patterns of adult attachments, goals, emotions, identity development, and psychopathology in different disorders (conway & pleydelpearce, 2000). for instance, the cognitive model for depression has been used in research studies over the last two decades in order to highlight the role of the self-schema, and researchers now have a deeper understanding of the mediating role of selfand other-evaluations in depression (clark, beck, & alford, 1999). similarly, research has begun to explore the role of the self-schema in ptsd (brewin, 2003) and eating disorders (fairburn, cooper, & shafran, 2003). negative evaluations of the self and others have also been incorporated in cognitive models of psychosis and used to explain different symptoms, such as paranoia, hallucinations and delusions (fowler, 2000; fowler et al., 2006; freeman, garety, kuipers, fowler, & bebbington, 2002). therefore, the self-schema in schizophrenia patients is potentially an important concept to explore because it may be amenable to interventions designed to ameliorate its potentially negative role in the etiology and/or maintenance of schizophrenia. this social cognitive perspective on schizophrenia provides another potentially useful understanding of the nature of the disorder and its causal pathways. it can also help devise new and effective treatment and rehabilitation options for patients with schizophrenia. the cognitive model of psychosis claims that if cognitive appraisals and underlying schemata are modified through cbt, then it may be result in an improvement in the psychotic symptoms of schizophrenia. furthermore, there are some encouraging results concerning the use of cognitive therapy, which targets self-and other-schemas, on individuals who are at high risk for developing psychosis, potentially preventing full-blown psychosis (gould, mueser, bolton, mays, & goff, 2001; morrison et al., 2004). rehabilitative interventions currently, most rehabilitative interventions for patients with schizophrenia focus on teaching them social skills. social skills can be defined as discrete behaviors that can be standardized and rehearsed. unfortunately, these interventions frequently do not lead to better social functioning (carter & flesher, 1995). improved social skills do not sufficiently help in the navigation of a complex, fluid and dynamic social world that requires one to have mastered the art of role-taking that secondary socialization teaches. new interventions should be designed that activate secondary socialization processes (i.e., empathy, mind-reading, perspective-taking) and fill the gaps in secondary socialization skills in schizophrenia patients. carter and flesher (1995) describe socialization as “a far more inclusive construct referring to the ongoing process of adaptation of individuals to a variety of social contexts” (p. 210). a disorder-specific socialization program can be more effective in improving the social functioning of patients with schizophrenia than just focusing on social skills. the specific deficiencies shown in the self-schema and organizational abilities of patients with schizophrenia have to be adequately addressed and attempts should be made to teach individuals with schizophrenia techniques to compensate for these specific cognitive deficits. for instance, therapy can address the issue of the self-concept of people diagnosed with schizophrenia by helping them gain a clearer and more coherent concept of who they are. they could be encouraged to regularly write a journal and note their likes, dislikes, values, and habits in it and then examine the entries to find out stable patterns and traits. patients can also practice different exercises designed to boost their secondary socialization skills, like empathy. for instance, guessing what a character is feeling based on their pictures or expressions. these interventions can help the patients during social interactions by being more aware of what they want and what other people may be thinking or desiring. similarly, information processing techniques should be taught, including the use of mnemonics, to practice and develop efficient memory structures, and compensate for the lack of organizational and search and retrieval deficits. limitations while there are several benefits of this study’s findings, several limitations were also present. the small sample size may have been a major limitation of this study and further studies should replicate this study with larger samples in order to get greater power. furthermore, this study was not designed to take into consideration the effects of intelligence rahman 10 (iq) on recall performance. the iq, intellectual and cognitive functioning of the participants with schizophrenia and nonclinical participants were only indirectly measured or matched in the research design by looking at educational attainment levels. iq might have some role to play in the differences in the two mental status groups in the selfreference condition. furthermore, iq is probably related to the main effect of mental status on recall of adjectives and might have contributed to the overall lower recall of adjectives in patients with schizophrenia. another limitation of this study is the lack of equivalence of the non-clinical and schizophrenic groups in terms of socio-economic status (ses). it is possible that ses may play a role in the development of the self-schema in individuals and may result in differences in the self-schema amongst different ses groups. future studies should explore whether distinct ses groups show differences in the selfreference memory (srm) effect. similarly, studies should compare participants with and without schizophrenia on the srm effect with ses being controlled as a variable. gender may also have distinct effects on self-schema development and on the srm effect. it would be interesting to design studies to explore how the variable of gender is related to the srm effect. it is important to note that, due to the nature of the experimental design, only those patients with schizophrenia who were able to perform the cognitive tests and interact adequately with the experimenter were included. hence, the schizophrenia participants in our sample were chronically ill and were not in an acute phase or highly symptomatic. therefore, this research design should be replicated in order to establish the degree of generalizability of these results and to ascertain that the interaction effect is a reliable finding. further research should be conducted specifically to see whether these results are obtained from participants with schizophrenia who are in the acute phase of this disorder and/or with those not taking anti-psychotic medications. it has been shown that reactive schizophrenia, in which there is an intense and sudden onset of the symptoms, has a better prognosis for recovery than a slow and insidious development of schizophrenia symptoms (chapman, day, & burstein, 1961). it might be the case that the self-schema disturbances in the acute and chronic types of schizophrenia are different. this suggests that a slow and insidious development of schizophrenia symptoms involves a chronic, inherently fragmented self-schema, while in reactive schizophrenia there is only a temporary disturbance in the functioning and structure of the self-schema. future research should compare the srm effects between these two types of patients with schizophrenia, as it could help to explain why chronic schizophrenia has a worse prognosis for recovery. conclusion schizophrenia is a serious mental disorder whose symptoms and etiologies are complex and multiply determined. this study attempted to utilize the research methodology and concepts developed by cognitive psychologists, especially in the domain of selfand socialcognition, to lift this shroud a bit and see what lies beneath. the self can be considered a schema that is actively involved in the processing of self-related information. this selfschema organizes, elaborates and provides a facilitative retrieval atmosphere for personally relevant information. this study confirms previous findings that schizophrenia is marked by numerous cognitive deficits, including specific problems with the self-schema and organizational processes. the 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(1977). vulnerability: a new view of schizophrenia. journal of abnormal psychology, 86, 103-126. doi:10.1037/0021-843x.86.2.103 graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 31 parent education model for child & adolescent onset psychosis elisha agee, jaqulyn spezze, and justin underwood pepperdine university although history has shown that the onset of psychotic disorders typically begins in early adulthood, recent research has identified a specific population of children and adolescents who develop psychotic disorders at a young age. children and adolescents who develop psychotic disorders typically have a more complex course and worse prognosis than adult onset. for this reason, early intervention can be crucial. having parents and family members who actively participate in the treatment of patients experiencing psychosis greatly reduces the likelihood of relapse symptoms, while improving the quality of life of the patient and the family. this proposed model actively engages parents and other family members of children or adolescents diagnosed with a psychotic disorder in different contexts. in the model, families will participate in consultations with the primary treatment provider, giving and receiving valuable information about the best possible treatments. parents will participate in caregiver psychoeducation/support groups for additional support from other parents and caregivers with similar challenges and needs. families will also participate in family therapy as a whole in order for the family to improve communication, enhance problem-solving skills, and learn how to support the family’s unique needs. having the family involved in these different contexts of a child or adolescent living with a psychotic disorder will not only aid in the treatment of the disorder but also improve the quality of life for the entire family. parent education model for child & adolescent onset psychosis current treatment models available for child and adolescent onset psychosis are insufficient and do not take a multimodal approach. when addressing gaps in the literature in regard to treatment, it is first critical to explore and identify theoretical ideas and models to ensure that new ideas are philosophically sound before a new program is actualized. thus, the purpose of this manuscript is to develop a novel treatment program based on scientific literature that would assist clinicians in treating child and adolescent onset psychosis. the proposed treatment program is novel because the multiple modalities and components of other treatments that have been integrated in the model have been found to be efficacious. this integration was done in an effort to create a single feasible comprehensive program that eliminates many of the research and clinical gaps found in single component treatment modalities. early-onset psychosis prevalence & etiology psychotic disorders such as schizophrenia or schizoaffective disorder are serious mental illnesses that are often pervasive, life long, and crippling. such disorders occur in approximately 1% of the population worldwide and affect not only individual patients, but also their family, friends, and community (courvoisie, labellarte, & riddle, 2001). the onset of psychotic disorders usually occurs between the ages of 16 and 30, typically emerging much earlier in men than women (mcglashan & johannessen, 1996; virginia commission on youth, 2010). however, with a growing body of research, child and adolescent onset psychosis is increasingly recognized as a distinct phenomenon. furthermore, approximately 39% of men and 23% of women who develop a psychotic disorder will experience their first psychotic episode before they turn 19 (davis & schultz, 1998; gearing & charach, 2009; sharma, 2005). child-onset schizophrenia (cos) is extremely rare and refers to a child who begins displaying symptoms of psychosis prior to the age of 13 years old (virginia commission on youth, 2010). there has been variability in the prevalence of cos. however, research typically agrees that cos occurs in approximately 0.1-1% of the individuals who develop any psychotic disorder (courvoisie et al., 2001; sharma, 2005; virginia commission on youth, 2010). adolescent-onset schizophrenia refers to when the first psychotic episode occurs between the ages of 13 and 17, and manifests in approximately 4% of correspondence concerning this article should be addressed to: elisha agee, pepperdine university, graduate school of education & psychology, 6100 center drive, los angeles, ca, 90045, usa. email: elisha.agee@gmail.com. 32 individuals with any psychotic disorder (sharma, 2005). although still rare, with the onset of puberty the incidence of psychosis rises steadily (anjum, gait, cullen, & white, 2010). however, other research has noted that adolescent-onset psychosis is “fairly common” (courvoisie et al., 2001, p. 2). when referring to an individual who had their first psychotic episode or was diagnosed with a psychotic disorder during either childhood or adolescence, the term early-onset schizophrenia (eos) is used, implying that the illness developed prior to the individual turning 18 years old (courvoisie et al., 2001). for the purpose of this paper the term ‘early-onset’ will be used to indicate the emergence of a psychotic disorder prior to age 18. additionally, the term ‘psychosis’ or ‘psychotic disorder’ will be used instead of schizophrenia, schizoaffective disorder, or another specific type of a psychotic disorder. the term psychosis is generally used to represent a category of disorders. thus this paper will refer to a category of psychotic disorders, instead of the various subgroups and specific illnesses (joshi & towbin, 2002). it is not uncommon for individuals to experience depressive symptoms concurrently with their first psychotic episode and symptoms of early onset affective psychoses are very similar to early onset nonaffective psychosis, causing a notable amount of misdiagnoses (schothorst, emck, & van engeland, 2006). however, the literature on child and adolescent onset mood disorders with psychotic features is scarce, and much more research has been focused on early onset psychosis, without a specific relationship to mood symptoms (ledda, fratta, pintor, zuddas, & cianchetti, 2009). consequently, this paper will focus primarily on early onset-psychosis without the presence of mood symptoms. the rarity of early onset psychosis (eop) does not reduce the need for researchers and clinicians to focus on comprehensive and effective treatment protocols. currently, no interventions have been tailored exclusively for children, adolescents, or the families affected by eop (gearing, 2008). in fact, using current treatments for child and adolescent psychosis, less than 25% experiencing psychoses fully recover (gearing & charach, 2009). thus, there is a great need to develop a comprehensive treatment program that will increase recovery rates for eop. there are many stressors and issues associated with psychotic disorders due to its devastating and distressing course, which creates a significant amount of burden on the caregivers and social support of individuals suffering from such illnesses. additionally, hospitalizations often cost a significant amount of money, both for the families of those who are hospitalized, and for society at large (goldberg, 1991). adolescents experiencing psychotic episodes often require hospitalizations ranging from 25 to 45 days in length (gearing & charach, 2009). costs associated with psychiatric hospitalizations related to schizophrenia are in the tens of billions of dollars annually. it is reasonable to assume that if hospitalizations associated with all types of psychosis were taken into account, this number would increase (gearing & charach, 2009). the cost hospitalization is not only financial. secondary effects also occur as the child or adolescent is not in school, and consequently may have educational impairments. as a result, there may be a discrepancy between the need for, and the availability of, treatment interventions for parents and families managing eop in children and adolescents. the term psychotic refers to the presence of a pre-determined set of symptoms, such as delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior (apa, 2000). negative symptoms may also be present, and reflect the disappearance of certain abilities and emotions normally present (apa, 2000; green, 2001). examples of negative symptoms include, flat or blunted affect, alogia, and avolition (apa, 2000). more generally speaking, it may refer to alterations in typical thought processes or disruptions in thinking accompanied by the symptoms previously mentioned (joshi & towbin, 2002). according to the diagnostic & statistical manual, 4th edition, revised (dsm-iv-tr), the criteria for eop (in schizophrenia in particular) is synonymous with the adult criteria for the disorder and can reliably be used for children and adolescents (apa, 2000). the only (yet very important) difference is that children and adolescents may fail to meet expected social or academic milestones. by contrast, the criteria for adults include deterioration in functioning (sharma, 2005). although there are variations of terms describagee, spezze, underwood 33 ing similar psychopathologies, such as psychotic, psychotic disorder, and psychosis, for the purposes of this manuscript the term ‘psychosis’ will be used. the diagnostic & statistical manual, 5th edition, was recently published and includes changes to two primary psychotic disorders that relate to the idea of psychosis described in this paper. the following changes have been made to the schizophrenia category. first, the special attribution of bizarre delusions and schneiderian first-rank auditory hallucinations were removed. second, an individual must have at least delusions, hallucinations, or disorganized speech in order to be diagnosed (apa, 2013b). regarding schizoaffective disorder, once criterion a has been met there is no longer a requirement that a major mood episode must be present for the majority of the disorder’s total duration (apa, 2013b). due to the recency of its publication and the fact that research has not yet begun to study the new categories in depth, this paper focuses primarily on diagnostic criteria and research associated with dsm-iv-tr criteria for psychosis. although the dsm-iv-tr and multiple studies have identified the presentation of eop as closely resembling adult psychosis, the clinical picture of eop deviates from adult onset in a variety of ways (apa, 2000). a significant difference is that the earlier the onset of psychosis, the more severe the symptoms and prognosis appear to be (anjum et al., 2010; apa, 2013a; krausz & muller-thomsen, 1993). eop also seems to be paired with a higher prevalence of negative symptoms (apa, 2013a; schothorst, emck, & van engeland, 2006). negative symptoms are often difficult to differentiate from depressive symptoms. however, negative symptoms often seen in prodromal psychosis include reduced drive, attention problems, and anergia, and not affective symptoms such as depression, or suicidality (mcgorry, yung, phillips, 2002). children and adolescents experiencing psychosis may present cognitive impairments such as impaired concentration and ability to focus, diminished interest, incoherent speech, and confused thinking (joshi & towbin, 2002; larson, mcglashan, & moe, 1996; sharma, 2005). child and adolescent psychosis may also include extreme moodiness such as high levels of anxiety, poor emotional control, bizarre and/or stereotypy behaviors, and severe problems with building and maintaining friendships (sharma, 2005). delusions and hallucinations may be more difficult to assess in children and adolescents perhaps due to a reluctance to disclose or the more active imaginations typically seen during development, but they are often present, along with paranoia, “a preoccupation with inner thoughts” (p.1), vivid and bizarre thoughts and ideas, or an inability to distinguish dreams from reality (sharma, 2005). furthermore, delusions and hallucinations may be elaborate, with visual hallucinations being much more common in children than in adults (apa, 2013). as mentioned earlier, the onset of psychosis typically occurs between the late teens and mid thirties. although onset prior to adolescence is rare, there have been cases of psychosis documented in as young as 5or 6-year olds (apa, 2000). there are numerous etiologic possibilities and the etiology of many cases of eop is multifactorial. it is believed that the cause of psychotic disorders most commonly relates to the interaction of genetic influences, biological factors, family influences, and environmental factors (joshi & towbin, 2002; sharma, 2005). individuals may also experience psychosis as a result of brain or metabolic disorders. there may also be some causes that are still unknown. genetic deficits, prenatal viral infections, obstetric complications, and marijuana use during adolescence, have also been associated as risk factors and have predictive value for the onset of psychosis (anjum et al., 2010). recent research has indicated that youths who experience psychotic episodes prior to puberty have an increasing number of brain abnormalities and their brains may have diminished brain tissue volume (commission on youth, 2010). developmental, environmental, and cognitive influences may play an even greater role in eop than in adult onset psychosis (joshi & towbin, 2002). in fact, it has been estimated that in up to 90% of eop cases there are also behavioral and or developmental abnormalities present, such as social withdrawal, disruptive behavioral disorders, academic problems, speech and language delays, and abnormal brain growth (mcclellan & werry, 2001; virginia commission on youth, 2010). also, research has indicated that in children under the age of 12, early language deficits and motor impairments may precede the first psychotic episode. parent education model for early onset psychosis 34 it thus appears that the age of onset of psychosis may have both pathophysiological and prognostic significance. individuals with eop appear to have poorer premorbid adjustment, lower educational achievement, and more evidence of brain abnormalities (apa, 2000). further, aside from the strong inverse relationship between age of onset and prognosis, those with earlier onset of psychosis are more often males with prominent negative symptoms, cognitive impairment, and markedly impaired social functioning (apa, 2000; gearing, 2008; sharma, 2005). early intervention & primary treatment understanding the course of psychosis is crucial for recognizing and distinguishing the early warning signs of psychosis. the first stage of the illness is referred to as the prodromal stage, and is indicated by the slow and gradual development of a variety of signs and symptoms prior to development of a full psychosis (subotnik & nuechterlein, 1988; morrison et al., 2004). these symptoms consist of dysfunctional premorbid development such as social withdrawal and isolation, academic difficulties, deterioration in hygiene and grooming, loss of interests, shyness, outbursts of anger, idiosyncratic preoccupations and behaviors, and disturbances in social behavior (apa, 2000; joshi & towbin, 2002). the next stage is called the active stage, sometimes referred to as the acute stage. the active stage often consists of explicit delusions or hallucinations, strange or idiosyncratic behaviors, functional deterioration, and formal thought disorder (virginia commission on youth, 2010; moukas, stathopoulou, gourzis, beratis, & beratis, 2010). hallucinations and delusions may be less detailed or complex in nature for eop than those observed in adults. visual hallucinations may be more common in eop (apa, 2000). the recovery phase follows the acute phase and describes the time in which symptoms remit and dissipate. in the phase, there may be some ongoing symptoms of psychosis along with confusion, disorganization, dysphoria, and lability in mood (virginia commission on youth, 2010; moukas, et al., 2010). the last stage of psychosis usually consists of the residual phase, in which positive psychotic symptoms are minimal but negative symptoms may still be present, such as apathy, lack of motivation, social withdrawal, or flat affect. it is critical that caregivers are educated to recognize the early warning signs of relapse into another episode of psychosis and to understand the course of the illness. this will allow them to start treatment with their child or adolescent as early as possible. if the early warning symptoms of a relapse are recognized and early assistance and interventions are implemented, the long and disheartening course of the illness and substantial burden on the family can be minimized (kennedy et al., 2008). eop relapse rates are understudied, but it has been indicated that they closely parallel adult relapse rates (gearing, 2008). current numbers reveal that 33% of eop patients are readmitted to a psychiatric hospital within the first year of experiencing psychotic symptoms, 44% relapse within 2 years, and 58% relapse within 5 years of their first psychotic episode (gearing, 2008). these hospitalizations take a toll emotionally on both the youth and the family. they also impose a financial burden on the family and the health care system. utilizing therapeutic supports outside hospital settings reduces the financial burden to the family and is overall more cost-effective (goldberg, 1991; weiden & olfson, 1995). thus, the proposed intervention is a good fit for the eop population and useful to society as a whole. consequently, there is a substantial need for parent education and solid treatment interventions for children or adolescents diagnosed with eop in order to minimize the possibility of a relapse. furthermore, there is a great need for broader education about the risk of eop, since approximately 39% of men and 23% of women who develop a psychotic disorder will experience their first psychotic episode before the age of 19 (davis & schultz, 1998; sharma, 2005). research has found that caregivers and families with ongoing contact with mental health professionals are more likely to better cope and recover from the crisis of having a child or adolescent diagnosed with a mental illness. the child or adolescent also has a better overall prognosis (ambikile & outwater, 2012). therefore, this parent education model focuses on interventions for individuals experiencing eop and their families. it serves the purpose of inagee, spezze, underwood 35 creasing their caregiver’s and family’s knowledge of the illness, its course, and treatment. in this way, this proposed model seeks to help children or adolescents with psychosis by assisting their caregivers and family, which will in turn assist the child or adolescent. current theoretical models of treatment family consultation theoretical model family consultation is brief, flexible, and utilized per the request of the family that has a child or adolescent experiencing their first episode of psychosis (lepage, 2005). consultation is “asking the advice or opinion of an expert and as deliberating together” (marsh, 2001, p.46). usually, the first intervention the family of a child or adolescent with eop experiences is family consultation. sometimes it is the only intervention the family encounters that is specifically for the family. family consultations range from one to five sessions and typically occur during or after a crisis, child or adolescent inpatient treatments, hospitalizations, and/or family transitions. families are then referred to long-term treatment (e.g., family therapy, couples therapy, national alliance of the mentally ill, and/or individual therapy; dausch et al., 2012; marsh & lefley, 2003). mental health professionals perform family consultations, which are first implemented at initial diagnosis or first hospitalization of the youth (lepage, 2005). both the family members and the youth (if possible) are present in the consultation and the intervention is collaborative in nature. the purpose of family consultations after a child or adolescent experiences psychosis for the first time is to provide information, expert advice, support, and empathy to the family, as well as to improve family coping skills and assist in identifying and prioritizing the family’s needs (marsh, 2001). family consultations provide the means to assist the family in formulating a family service plan, addressing illness-related questions and concerns, and making the most informed decision about their child or adolescent and family as a whole (marsh & lefley, 2003). the consultation also provides a systems oriented assessment of the family’s current needs, concerns, strengths, and resources (marsh, 2001). furthermore, the family consultation is focused on problem resolutions and is goal oriented. topics of the consultation may include discussing the youth’s substance abuse disorder (if one is present), long-term treatment planning, living arrangements, and psychoeducation about the course of the illness (marsh, 2001). the consult also emphasizes the family as the primary agent of decision making regarding their child or adolescent and also as responsible for implementing those decisions. research has shown that when a family and/or the child or adolescent is informed about early psychosis and about the possible medical and psychosocial interventions, they make better informed decisions about treatment and follow-up care (lepage, 2005). therefore, family consultations appear to be extremely important to include into the proposed parent and family education program. furthermore, it is suggested that family consultations increase the family members’ self-efficacy in caring for their child or adolescent with psychosis (solomon, draine, manion, & meisel, 1996). parent support group theoretical models current treatments for eop often include multiple components, with each component contributing a valuable feature to overall management of the psychosis and its impact on the individual and their family. for example, interventions such as day care treatment centers may bring relief to parents by creating a break from caregiving and creating valuable time for parents to accomplish other responsibilities. also, providing parents time away from caregiving allows them to take part in their own income generating activities, which can directly help the management of their child’s illness due to the staggering costs of hospitalizations, emergency room visits, and medications (ambikile & outwater, 2012). group interventions for parents are also commonly used and have been found effective. the family centered program is an intervention consisting of a family focused group for youths with schizophrenia (kennedy et al., 2008). the model consists of 6 weeks of intensive 2-hour group sessions followed by six monthly booster sessions. the first hour of each session involves the family meeting together to learn and practice specific skills pertinent to living with a child or adolescent with psychosis. the skills taught focus on anger management, stress manparent education model for early onset psychosis 36 agement, and strategies for coping with problems at school and at home. the second hour consists of the family being broken up into smaller groups, such as parents and caregivers, and siblings of the individual experiencing the mental illness. each group discusses topics that are relevant to their role in the family. for example, the parents’ group focuses on mutual support and provides education about schizophrenia, symptom management, enhanced family communication, and relapse prevention. the psychoeducational multiple family group (pmfg) is an approach that is made for various models and settings, and is used for integrating caregivers and family into treatment (gearing, 2008). it is a semi-structured intervention that is flexible and focuses on competencies, not deficits, thus directly supporting the family. it combines psychoeducation and therapeutic processes to enable patients to engage in behavioral change for the family and the child or adolescent with psychosis. pmfg focuses on improving communication, medication adherence, problem solving, use of crisis intervention, symptom management, and establishment of social support and coping skills (gearing, 2008). the format consists of 5-8 families attending a closed group over a period of time ranging from 2 months to 2 years. family psychoeducation theoretical model psychotic disorders are not completely treatable by medication and almost always require adjunctive therapies (mcfarlane, dixon, lukens, & lucksted, 2003). families that participate in such treatment can have a significant effect on their relative’s outcome. successful treatment of a psychotic disorder often includes families and significant others involved in caring for the patient. they may serve many roles and fulfilling these roles can burden the patient’s support system, increasing burnout. this burnout often has negative effects on the patient’s treatment as well as the patient’s and family’s well-being (adamec, 1996; cochrane, goering, & rogers, 1997). however, if families are provided with education about the nature of schizophrenia and possess coping skills specific to the patient, they can fulfill the above mentioned roles while increasing their overall well-being (cuijpers, 1999; shi, zhao, xu, & sen, 2000). family psychoeducation provides them with useful information on the nature of psychosis, its course, and successful treatments. it teaches and enhances each family member’s ability to cope with their relative’s confusing illness. psychoeducation aims to encourage families to analyze their behavior toward their relative with psychosis, adjust their behavior to compensate for their deficits, coordinate the roles of everyone involved in the treatment and rehabilitation, and ensure that they are all attempting to achieve the same goals in a supportive relationship. practitioners help families create and maintain helpful relationships within the family unit. training family members to maintain helpful relationships with their relative and to form stable support systems is emphasized. the role of the family as directly involved in the treatment of symptoms is deemphasized, leaving that within the scope of the relative with psychosis and his or her treatment team. a family’s focus on progress and symptom reduction could impede successful treatment, whereas a family focused on support could have a very positive effect on the patient’s rehabilitation (mcfarlane et al., 2003). families may also require support and a therapeutic environment where they can process, grieve, and grow. practitioners provide empathetic engagement with the family, addressing their unique stressors and concerns and providing the continued education and ongoing support that is often necessary for families (mcfarlane et al. 2003). the intervention with the family also focuses on the enhancement of problem solving skills and improving communication skills to aid the rest of the family as a unit. programs that successfully accomplish these goals reduce hospitalizations of the patient, and decrease the patient’s positive and negative symptoms, particularly if the intervention lasts for at least three months (dyck et al., 2000; mcfarlane et al., 2003; pitschelwalz, leucht, baumi, dissling, & engel 2001). relapse prevention theoretical model serious mental illnesses, specifically psychosis, have periods of remission or times when there are few symptoms present and other times when the symptoms are worse or exacerbated (marsh, 2001). relapse of a psychotic episode is the reoccurrence agee, spezze, underwood 37 or exacerbation of psychotic symptoms, which eventually leads to interference and impairment in the individual’s daily living (levy, pawliuk, joober, abadi, malla, 2012; addington, addington, patten, 2007; moller & murphy, 1997). relapse can be associated with an increased risk of re-hospitalization, feelings of hopelessness, fatigue, and a loss of pleasure (marsh, 2001). however, research has found that approximately 93% of family members can identify the warning signs of a relapse in their relative with a psychotic disorder and approximately 80% of relapses can be prevented (amenson, 1998). relapse prevention can significantly reduce the disruption of the family’s lives and also decrease the risk of re-hospitalization of the relative with psychosis (marsh, 2001). many variables affect relapse, which include the child or adolescent (e.g., prior functioning, coping strategies, substance use, treatment adherence), family (e.g., expressed emotion, level of support), and illness (e.g., treatment responsiveness, symptoms) (amenson, 1998). although there are many variables that affect the likelihood of relapse, many of these variables can be modified to develop a relapse prevention plan. relapse occurs in stages, called the stages of relapse model. the five stages of the relapse model are: stability, early warning signs, relapse, symptom remission, and recovery (amenson, 1998). in stability (stage 1) the symptoms are controlled and there is a good quality of life for the child or adolescent. the stage of stability can be maintained if family members and child or adolescent notice and respond to the early warning signs (stage 2) before relapse occurs (stage 3; marsh 2001). early warning signs include an increase in symptomatology, a change in the child’s or adolescent’s behaviors, and alterations in biological rhythms (amenson, 1998). families can help monitor the symptoms, triggers, and warning signs they notice in their child or adolescent and also provide support and a low stress environment (marsh, 2001). in relapse (stage 3) the child’s or adolescent’s symptoms are severe and require assistance from the family to obtain immediate interventions with their mental health care provider (marsh, 2001). during relapse it is important for the family to maintain a sense of hopefulness for the child or adolescent. in symptom remission (stage 4) the child or adolescent has to follow the treatment regimen given by the treating mental health provider and usually appears to be quiet and sometimes dazed from the aftermath of the relapse and trauma of relapsing (marsh, 2001). the child or adolescent is at a high risk for relapse during symptom remission and also during recovery (stage 5; amenson, 1998). during recovery the family should focus on healing and reintegration of their child or adolescent. furthermore, the family should monitor risk factors, manage symptoms and triggers, and also enhance protective factors (marsh, 2001). therefore, this program entails increasing knowledge and skills, and changing attitudes throughout the treatment process. the program description the proposed model (presented in figure 1) utilizes a multimodal approach for parents and caregivers of children or adolescents with early onset psychosis. parents and caregivers receive support and learn skills in several different contexts. first, parents and guardians will participate in family consultations with their child or adolescent’s primary treatment provider. parents and caregivers collaborate about their child or adolescent’s individual treatment, providing and receiving important information about the treatment of the psychotic symptoms. second, parents and caregivers participate in parent support/psychoeducation groups where they learn the unique skills needed to aid in their child’s recovery while providing a safe space to process the difficulties and frustrations inherent in being a parent or caregiver of a child or adolescent exhibiting psychotic symptoms. third, parents will attend family therapy with their child or adolescent with eop and any other siblings or caretakers of the child. family therapy allows the family to learn communication and problem solving skills as the family learns to function supportively and address the needs of all its members. last, relapse prevention interventions and techniques will be interwoven and emphasized throughout all the aforementioned interventions. the program will last about 3 months, consisting of 12 weekly sessions of parent groups and family therapy, and approximately 3-5 family consultations. parent education model for early onset psychosis 38 however, all services will be available for follow-up or “check-in” sessions due to the complexity and longevity of the disorder. parents and caregivers will continue in their role as consultants throughout the duration of their child’s treatment. the target population for this treatment model is parents or caregivers of children or adolescents with psychosis who are currently under psychiatric care. this treatment model also seeks to assist with the child’s or adolescent’s transition from acute inpatient treatment to outpatient treatment. referrals will be made by treating psychiatrists or psychologists for adjunctive care. a primary targeted behavior of this treatment model will be minimization of psychotic symptoms and reduction of the risk of relapse. this will be accomplished by having all components of this program focusing on symptom management. eop is comprised of the presence of positive symptoms, such as hallucinations and delusions, negative symptoms such as alogia and apathy, and behavioral outbursts, which often put the safety of the child and others at risk. many parents and guardians have reported that the presence of such symptoms affects multiple aspects of their lives, including when these behaviors negatively impact individuals outside the family, such as neighbors, classmates, and community members. (ambikile & outwater, 2012). additionally, family support is crucial in the growth and development of their children, and is related to whether their child receives mental health services. therefore, by integrating family consultations, parent psychoeducation and support, family therapy, and relapse prevention, the child or adolescent’s treatment plan will be tackling symptom management from several different angles. the developmental needs of children and adolescents will be addressed in the proposed parent education model in various manners. the therapeutic approach would vary depending on the child and adolescent’s developmental stage and the interventions would be tailored for the child’s or adolescent’s developmental stage. for example, in family therapy the interventions and interactions will incorporate play therapy for younger children, while with adolescents interventions will be based on talk therapy. in addition, psychoeducation for the child and adolescent will be provided to the child or adolescent in a manner that is understandable to them based on their developmental stage (such as language abilities, abstract thinking capacity, and so forth). although not the primary focus of this paper, a critical aspect of this program entails close communication and active involvement with the child’s psychiatrist to ensure sufficient medication adherence and management, should medication be warranted. the food and drug administration has approved the use of some antipsychotic medications in children and adolescents with severe emotional disorders such as psychosis (harrison, cluxton-keller, & gross, 2012). both the research regarding medication and the prevalence of medication use among children and adolescents experiencing their first psychotic episode is growing, and minors are increasingly being prescribed antipsychotic medications as part of treatment (cooper et al., 2006; harrison, cluxton-keller, & gross, 2012). this change is critical since psychotropic medagee, spezze, underwood parent education model for early onset psychosis   38     figure 1. description of proposed program                                                                               38   child or adolescent’s psychotic episode referred to program by hospital, clinic, or healthcare providers recommending adjunctive care family consultation: parent and child meet with professional for intake/interviewing and assessment (3-5 sessions)   family therapy: all members in the immediate family, including patient meet weekly (12 sessions) parent support/psychoeducation group: parents/caregivers meet for two-hour weekly sessions (12 sessions) concurrent treatment elements: relapse prevention emphasis (intertwined in all aspects of treatment) medication management will continue consistently/paralleled to this program   39 ications, particularly antipsychotics, are almost always a component of, and by some are viewed as the foundation of, treatment for psychosis (seligman & reichenberg, 2007; zipursky, 2002). due to the fact that children and adolescents with psychosis are a part of a highly vulnerable population that is still growing and developing, psychiatrists would need to obtain baseline measures before initiating antipsychotic medications (e.g., body mass index, liver functioning, blood pressure, lipids) and would need to continue to monitor medically while receiving such medication (harrison, cluxton-keller, & gross, 2012). since the majority of individuals prescribed antipsychotic medication for psychosis are only partially adherent to their prescribed medication regimen, there is an even greater need for this treatment program to address and include ways to assess, maintain, or increase, adherence to medication as needed (leucht & heres, 2006). studies have indicated that poor adherence to medication is one of the major predictors of readmission to the psychiatric hospital, making individuals three times more likely to be admitted than those who are adherent to their medication treatment (gearing & charach, 2009). within the proposed treatment protocol, medication management would be monitored by the child’s or adolescent’s psychiatrist. however, psychoeducation about medication, benefits, side effects, and risk factors, would be incorporated into all aspects of treatment, starting with the initial consultation, and continuing in both family therapy and the parent/guardian support group. collaboration with the psychiatrist would also be incorporated throughout the program, to further benefit from the establishment of a cohesive treatment team or wraparound program. structure of program family consultation intervention the structure of the family consultation in the presented parent program is empirically supported by research. however, it will be modified to specifically accommodate families with children or adolescents that have recently experienced eop. the literature on family consultation focuses on families with a relative that recently experienced their first episode of psychosis, but it is not specifically geared toward families of children or adolescents. as mentioned, the majority of first episode psychosis occurs from between the ages of 16 and 30 and the incidence of childhood onset of psychosis is extremely rare. therefore, most resources for parents or caregivers are not geared for children or adolescents (under the age of 18), highlighting the necessity of this treatment model. the family consultation will range between one and five sessions. since this intervention is flexible and adaptive, if it is determined that the family needs more consultations due to re-hospitalizations and/or a crisis, the program can adapt to the needs of the family. the first session of the family consultation usually occurs shortly after the initial diagnosis or during the hospitalization of the child or adolescent. there will usually be more than one consultation because many times the family will be too overwhelmed in the initial consultation to retain all the information the consultant offers the family and/or the child or adolescent (lepage, 2005). the first consultation will include interviewing and assessing the family members and the child or adolescent (if present). the first consultation, and all other consultations, will be adjusted to be developmentally sensitive, such as interviewing the family more when the client is younger and using interviews that are developmentally appropriate. the first consultation seeks to gather information about the child or adolescent, understand what preceded the hospitalization, and describe the warning signs the family and/or child or adolescent may have noticed before the first episode of psychosis (lepage, 2005). in addition, the first family consultation assists in engaging the family or caregiver and the child or adolescent into treatment during a difficult time in order for them to become committed to continue further treatment. in the first consultation, the mental health care provider will respond to the family and child or adolescent’s most urgent concerns and needs. the consultant will assess the impact the first episode of psychosis and hospitalization had on the child or adolescent and the family, their current knowledge of psychosis, existing coping skills and social support, strengths and weaknesses, and whether or not there were any apparent preexisting family stressors (e.g., parent education model for early onset psychosis 40 life cycle transitions, separation/divorce; lepage, 2005). even in the first consultation, the consultant seeks to offer knowledge, advice, and skills to assist the family in helping their child or adolescent recover from psychosis. specifically, the consultant will offer education to the family and/or child or adolescent in order to reduce blame and guilt (lepage, 2005). the first consultation provides referrals and resources to the family or caregiver and child or adolescent, such as information for a case-manager, in order to address transportation or insurance issues. the second through fifth consultations will vary according to the needs of the child or adolescent and their family. in this program, the consultations may also include extended family members. if the child or adolescent has siblings, the siblings will be given age appropriate information and education regarding their sibling’s diagnosis, hospitalization, and treatment plan. furthermore, parents and siblings will be given a tour of the child inpatient facility in order to better inform them and ease their fears about how their family member is being treated. in the later consultations the child or adolescent and all family members will identify potential relapse signs and behaviors, and will also develop a detailed crisis plan. in addition, the family, child or adolescent, and consultant will create a discharge plan to transition the child or adolescent from inpatient to outpatient treatment. there will also be scheduled follow-up consultations after the child or adolescent has been discharged from the hospital at week one, month one, and as needed. parent/caregiver psychoeducation & support group one component of the proposed parent education model is a parent and caregiver psychoeducation and support group. psychotic disorders place a significant burden on family and caregivers due to their frequent onset during late adolescence and their lifelong course (kennedy et al., 2008). typically, parents and primary caregivers are ill prepared for their child’s or adolescent’s diagnosis of a psychotic disorder and may not know how to manage the disorder (gearing, 2008). therefore, parent groups can help counter this ill preparedness and increase caregivers’ awareness of available resources while also incorporating caregivers into treatment (kennedy et al., 2008). also, involving parents of children or adolescents with psychosis in the treatment plan enhances medication adherence and overall prognosis (gearing, 2008). such an intervention has been shown to be effective in the past, and the proposed psychoeducation and support group integrates various topics present in past efficacious parent groups (kennedy et al., 2008). previous models have had various durations, such as 6 and 8 weeks. the proposed group, however, will meet for 12 weeks (gearing, 2008; kennedy et al., 2008). parents and caregivers will meet once per week for 2 hours while their child or adolescent attends their typical day program, outpatient treatment, or daily routine of therapy and doctors’ appointments. caregivers will have their experiences normalized, receive support from people who can relate to those experiences, and hear about other caregivers’ problems that they have not experienced but might anticipate. the psychoeducational aspect of the parent group is crucial as such interventions for parents and families have consistently been correlated with improved outcomes and a reduction in relapses and hospitalizations. family psychoeducational interventions have been found to be more effective in preventing relapse than individual treatment or medication (gearing, 2008). the support aspect of the parent group will not be separate from, but rather, intertwined with the psychoeducational aspect. the integration of support groups and psychoeducation groups is not frequently seen, but the need for support is not isolated from the other aspects of the illness or the distress being caused by the illness. therefore, by incorporating support into the psychoeducation group, an optimal environment will be fostered to promote understanding and self-care, and allow for experiences to be normalized by other group members while learning about the specifics of the illness. the group will be open to parents with children of all different ages. the goal is that bringing together parents raising children and youth of different ages may provide perspective and offer further support to parents from those who have gone through similar experiences, both in terms chronological development and in the course of the psychiatric illness. the parent group will have a different topic and agee, spezze, underwood 41 theme for each session. the attendees will learn about the scheduled topic, and then share their experiences and thoughts related to the theme. the following is a brief summary of some of the main topics that will be covered in the parent group, and the various aspects of each theme that will be emphasized. the topic of ‘grief ’ will be one of the first themes covered in the parent group. primary caregivers often go through the stages of grief when their child or adolescent is diagnosed with a psychotic disorder. parents often worry about the future life of their child or adolescent, and grieve the consequences the diagnosis may have on their long-term goals for their child, such as working full-time, getting married, and having children, often recognizing that such a future is now unlikely (ambikile & outwater, 2012). it will also explore the presence of grief in relation to accepting their child’s or adolescent’s diagnosis. parents and caregivers will also be taught about the symptoms, course, and treatment of psychosis. the opportunity to learn and increase knowledge about psychotic disorders and share experiences with other parents who also have a child or adolescent suffering from a psychotic disorder empowers parents (gearing, 2008; kennedy et al., 2008). educational material will cover recognition of early symptoms of relapse, symptom management techniques, medication, de-escalating aggressive behavior, and communicating with paranoid or psychotic youth. the topic of ‘emotional coping’ is another crucial theme that will be covered in the parenting group. significant stress and a spectrum of emotions often occur as a result of caring for a child or adolescent with psychosis. parents may feel sadness, bitterness, guilt, anxiety, fear, anger, and helplessness (ambikile & outwater, 2012; gearing, 2008). coping skills will be taught to help parents manage their own emotions and reactions. the specific tools that will be taught and practiced include relaxation and stress management techniques, and changing negative thoughts. children and adolescents in general thrive on structure and boundaries, but maintaining structure and strict rules is even more essential when raising a son or daughter with psychosis. since children or adolescents experiencing psychotic symptoms have impaired judgment they may cause serious harm to themselves or others. consequently support and safety are primary considerations (joshi & towbin, 2002). although the hospital is a last resort, parents need to be able to recognize when their child or adolescent is extremely stressed and acutely symptomatic, and they must be willing to hospitalize their child with keeping their child’s best interest in mind. thus the parent group will also teach parents how to set boundaries and the importance of creating and maintaining structure, because such an environment is beneficial for managing psychotic symptoms, particularly upon discharge from the hospital (kelly, 2005). other topics of the parent group will consist of social support and strategies for maintaining a social life, coping with stigma, managing economic challenges, problem solving and communication skills training, and the development of realistic expectations. family therapy although information and skills can be crucial for successful treatment and significantly improve the quality of life for all involved, families have found it difficult to access resources and information (adamec, 1996; marsh, 1992; marsh & johnson, 1997). therefore, family therapy can effectively involve the entire family unit and draw upon the family psychoeducational theoretical model. interventions will vary according to the child’s or adolescent’s stage of development. for example, families with children may utilize elements of play while families with adolescents may utilize more traditional talk or dialectic approaches. this mode of the treatment is less structured to allow the family to direct therapy in ways that would be most beneficial to meet their needs and provides flexibility to adapt to these needs. this allows the family’s cultural values to be honored and respected. the family’s values may help create coping skills and fulfill unique roles specific to the family that has shown an increase in overall well-being of those with psychosis and their families (cuijpers, 1999; shi, zhao, xu, & sen, 2000). in these culturally syntonic ways, all family therapy should include some common elements. education about psychosis, its treatment, and guidelines to the most successful outcomes should be provided from the onset in order to disseminate importparent education model for early onset psychosis 42 ant information through the entire family. caregivers and siblings will learn about the common symptoms and courses of psychotic disorders to help them understand what they might expect. they will also understand how the disorder is treated and what some of the most effective treatments look like. families should create a crisis plan so that all members know their roles and responsibilities in emergency situations. planning for emergency situations ahead of time can reduce stress during times of crisis and help alleviate fears by normalizing the expectation of the unexpected (mcfarlane et al., 2003). families should engage in enhancing communication and identifying and solving problems, focusing on the psychosocial rehabilitation in the child or adolescent and addressing the needs of the family. families of children may focus on safety needs and who will be responsible for supervising the child, while families of adolescents may focus more on socialization and adaptive coping techniques. the therapist will aid the family in identifying strengths and needs of the family. they will then address and process issues that are most salient to them as they work together in learning to collaboratively solve problems. family therapy can help repair dysfunction in the family unit and encourage growth as a unit as family members learn to communicate and collaborate together to address the challenges that face them both as individuals and as a family. in this approach, emphasis is not placed so much on symptoms as it is on enhancing mutual support and increasing well-being and resiliency while providing a safe, calm environment that promotes rehabilitation. specifically, families should seek to understand and reduce high levels of expressed emotion in order to help facilitate recovery and prevent relapse (wasserman, de mamani, & guilia, 2012). time should also be given to address feelings of loss and grief associated with a diagnosis of a psychotic disorder (mcfarlane et al., 2003). family therapists must balance the needs of the family as a whole with the specific challenges and needs of a child or adolescent with psychosis. mcfarlane et al. (2003) gives helpful guidelines for therapists conducting the family therapy, suggesting that the therapist aid in coordinating all elements of treatment to understand what goals everyone is working toward as they pay attention to the social and clinical needs of the child or adolescent. this is best done by exploring the family’s expectations for family therapy and overall treatment and listening as partners in treatment planning and delivery. families should also be encouraged to expand their social support networks to those who can be empathetic to the unique needs and challenges of families living with someone with eop, such as the national alliance for mental illness (nami) or other multifamily groups. the main objective of family therapy is to help the family function as a unit, both to help facilitate the treatment of eop as well as to provide the support needed for a family living with someone with eop. the family’s needs and solutions are addressed as a whole. individual needs are framed as challenges for the family and solutions are generated in order to facilitate unity. assessment of outcomes in order to assess the parent education program the families will be given various measures to complete before, during, and after the proposed program. measures will focus on quality of life, level of functioning of the family, level of expressed emotion within the family, and symptom reduction in the child or adolescent. specifically, the family will be given the level of expressed emotion scale (lee), family environmental scale (fes), and quality of life interview (qoli) to assess the family’s level of expressed emotion, family cohesion and conflict, and satisfaction with family relationships, respectively (cole & kazarian, 1988). furthermore, the child or adolescent will be given the symptom checklist-90-revised to measure psychotic symptoms in addition to several other symptom scales such as the positive and negative symptoms scale (panss) and brief psychotic rating scale (bprs). in addition, the frequency and duration of hospitalizations will be monitored and tracked. critique of the proposed program the parental educational program has several strengths not only for the parents or caregivers, but also for the child or adolescent with eop. the first strength is that the program is extremely adaptable agee, spezze, underwood 43 and flexible to the needs of the family and the child or adolescent with psychosis. the program duration, content, consults, and sessions can be adjusted to the needs of the family and/or child or adolescent. by allowing for individual adaptation and deferring to the family’s values, this program may be more culturally sensitive than many manualized treatments that do not allow for adaptability. second, the program is multifaceted and offers a variety of treatment options that not only addresses the parents, but also incorporates the child or adolescent with a psychotic disorder, siblings, and extended family. third, the program is developmentally appropriate and is composed of interventions that are targeted for families and their children or adolescents under 18 years old. last, it was developed on the foundation of research supporting the current effective treatment components for working with a child or adolescent with eop and their families. the program also has some limitations and weaknesses. the intervention requires the entire family’s participation and makes significant demands of their time and energy. it may be difficult to get the “buy in” of all the family members. for instance, existing family discord may make it difficult for members to cooperate and provide the necessary support. families may also become defensive if they perceive that they are being blamed for their family member’s illness. some family members may take education and skills training as being critical of their role (i.e. judging their parenting style or viewing an older sibling as not protective enough). it is also possible that the family exhibits hopelessness in the face both of valid concerns and of stereotypes about serious mental illness. stigma may also prevent some family members from wanting to be associated with psychiatric facilities or interacting with others who are actively psychotic. additionally, adolescents may worry about losing autonomy when the family is involved with their treatment. furthermore, utilizing multimodal treatments requires cooperation and coordination between all parties. families and children or adolescents must be flexible to meet several demands. but the providers must also coordinate treatment and maneuver their schedules to allow families to participate in treatment with multiple professionals. participation of these professionals raises the cost for such treatments, both in paying the professionals and also the cost associated for transportation and work missed by parents. in addition, it should be noted that the model does not account for biological factors or psychosocial factors other than the family. some patients’ course may respond differently based on which of these components are present. conclusion the diagnosis of a mental illness can be devastating for a child or adolescent and their family, particularly if the disorder is as pervasive, debilitating, and intrusive as a psychotic disorder. currently, there are no treatment models focusing on eop tailored exclusively for children or adolescents and their families. this gap may explain the high current relapse rate, which results in great financial and emotional costs. consequently, there significant need for treatment interventions focusing on educating the family on the illness and its consequences, and strengthening family communication and functioning, both individually and systemically as a family unit. the proposed model seeks to address the need for such a parent education program. the proposed model was developed on a strong foundation of effective treatment interventions indicated by research and utilizes a multimodal approach for parents and caregivers of children and adolescents with eop. the model seeks to assist transition of the child or adolescent from acute inpatient treatment to outpatient treatment. additionally, all components of this model allow for “follow-up” or “check-in” sessions after completion of the threemonth program. ultimately, the goal of this program is to minimize psychotic symptoms, reduce the risk of relapse, and increase overall family functioning. in sum, the implementation of this comprehensive parent education program model should be considered by all health care providers when working with a child or adolescent experiencing a psychotic episode. in the future, it is recommended that this treatment model be implemented and studied for its efficacy in children and adolescents with early onset psychosis. parent education model for early onset psychosis 44 references adamec, c. 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(2002). optimal pharmacologic management of the first episode of schizophrenia. in r.b. zipursky & s.c. schulz (eds.). the early stages of schizophrenia. washington, d.c.: apa. agee, spezze, underwood 5 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university gender as a moderator in the association between childhood trauma and risk-taking propensity ashley a. huggins, stephanie m. gorka, and stewart a. shankman university of illinois at chicago previous research indicates that in response to acute laboratory stressors, males may become more risk-prone whereas females may become more risk-averse. to date, there has been limited research investigating whether these gender differences are observed in response to real-world stressors and, more importantly, whether the stress by gender interaction on risk-taking propensity (rtp) is observed long after the stressor. therefore, the current study aimed to examine whether gender moderates the association between childhood abuse (i.e., a real-world stressor) and individual differences in rtp in adulthood. a community sample of 140 adults reported on their history of childhood abuse and completed a behavioral assessment of rtp. different forms of childhood abuse (e.g., physical, emotional) were examined separately. after adjusting for age, a significant gender by childhood physical abuse and gender by physical neglect interaction on rtp was found. specifically, women with a history of physical abuse or neglect exhibited significantly less rtp; however, there was no relation between physical abuse or neglect and rtp in men. gender did not interact with emotional abuse to predict rtp. these findings support existing literature demonstrating that gender and stress interact to predict individual differences in rtp, but further extend the literature by demonstrating these gender-stress interactions exist for distal, real-world stressors. risk-taking is a cognitive-behavioral process that involves balancing the possibility of harm with reward to ultimately make decisions and guide behavior (byrnes, miller, & schafer, 1999; leigh, 1999). a large body of evidence suggests that individuals differ in their propensity to take risks and that these differences are linked to the onset and maintenance of psychopathology (aklin, lejuez, zvolensky, kahler, & gwadz, 2005; maner et al., 2007; tull et al., 2009). therefore, understanding factors that influence the development of risk-taking propensity is critical in improving clinical prevention and intervention efforts. one factor that is known to influence risk-taking propensity is biological sex. numerous studies have demonstrated that men engage in more risk-taking behaviors such as, substance abuse (nolen-hoeksema, 2004; wilsnack, vogeltanz, wilsnack, & harris, 2000), reckless driving (harré, field, & kirkwood, 1996; shinar & compton, 2004), and financial risk-taking (charness & gneezy, 2012; powell & ansic, 1997) more often than women. men may therefore have an increased likelihood of being risk-prone. in contrast, there is some evidence to suggest that women may have an increased likelihood of being risk-averse (byrnes et al., 1999; charness & gneezy, 2012). understanding rtp in adults is important given that risk-taking propensity is a bipolar trait in that too much risk-taking could lead to excessive harm, whereas too little could lead to missed opportunities for reward (e.g., avoiding social gatherings and not meeting a potential romantic partner). in other words, a certain amount of risk-taking is necessary to maximize rewards and gains. notably, emerging evidence suggests that gender differences in risk-taking may become more pronounced in response to stress. specifically, several studies have found that in response to an acute laboratory stressor, men become more risk-seeking whereas women become more risk-avoidant (daughters, gorka, matusiewicz, & anderson, 2013; lighthall, mather, & gorlick, 2009; lighthall et al., 2012). these studies have demonstrated a gender-stress interaction on risk-taking propensity in both adolescents (daughters et al., 2013) and adults (lighthall et al., 2009; lighthall et al., 2012), with both acute physical (e.g., cold pressor test) and cognitive (e.g., override (hidden running head text): huggins, gorka, shankman gender, childhood trauma, and risk-taking propensity keywords: risk-taking propensity, gender, childhood trauma please address correspondence regarding this article to: ashleyhuggins711@gmail.com 6 huggins, gorka, shankman behavior indicator of resiliency to distress; lejuez et al., 2006) stressors. the factors contributing to these gender differences are still unclear but are likely related to both biological and social processes. although the literature strongly suggests that gender and stress interact to predict risk-taking behaviors, several key questions remain. first, although laboratory tasks are effective at inducing distress, it is unclear whether these findings generalize to more real-world stressors that may more accurately map onto daily functioning. second, it is unknown whether gender by stress interactions are transient phenomena or if stress can have a more prolonged effect on gender differences in risk-taking propensity. determining the long-term effects of gender and stress is necessary to clarify the roles of these variables in the development of trait-like differences in risk-taking propensity. childhood abuse is one such real-world stressor that has been associated with persistent effects on emotional and behavioral functioning. for example, individuals reporting a history of abuse present with higher rates of psychopathology in adulthood (chapman et al., 2004; macmillan et al., 2001), including disorders associated with aberrant risk behavior. additionally, individuals with a history of abuse during childhood report higher rates of substance abuse (kilpatrick et al., 2000; mccauley et al., 1997) and anxiety disorders (li, d’arcy, & meng, 2016; lindert et al., 2014), which are associated with increased (brand et al., 2008; colder et al., 2002) and decreased (charpentier, aylward, roiser, & robinson, 2017; maner et al., 2007) risk-taking, respectively. independent of psychiatric diagnoses, abuse history has also been associated with increased risktaking propensity and sensation-seeking (bornovalova, gwadz, kahler, aklin, & lejuez, 2008). although the majority of the extant literature suggests that a history of abuse likely relates to increases in risky behavior later in life (bornovalova et al., 2008; kilpatrick et al., 2000; medrano, hatch, zule, & desmond, 2003), some research has indicated the opposite. sujan and colleagues (2014) found that individuals reporting a history of child abuse exhibited less risk-taking propensity. notably, however, none of the research examining the association between abuse history and later risk-taking propensity has examined the potential moderating effects of gender. childhood abuse has been found to alter the functioning and interplay of stress and reward circuits in the brain (hart & rubia, 2012; lupien, mcewen, gunnar, & heim, 2009; mccrory, de brito, & viding, 2012). these circuits are critical for risk-taking propensity (elliott, friston, & dolan, 2000; schoenbaum, roesch, & stalnaker, 2006), and disruption within this system may contribute to persistent alterations in risk-taking propensity following abuse. for instance, multiple studies have demonstrated that childhood trauma may alter hypothalamic-pituitary-adrenal (hpa) axis functioning— the primary stress response system. dysregulation of the hpa-axis has been found in individuals who have experienced abuse (but are free from lifetime psychopathology), suggesting that childhood trauma may permanently alter baseline hpa-axis reactivity independent of disorder status (klaassens et al., 2009). studies have also found early life stress to be implicated in diminished reward processing (dillon et al., 2009; pechtel & pizzagalli, 2011;), which may contribute to deficits in the ability to weigh risk-reward decisions effectively. these alterations in biological systems involved in stress and reward processing may therefore be related to altered risk-taking behaviors. in assessing the long-term correlates of childhood abuse, it is necessary to consider that abuse may take several forms: physical, emotional, or sexual. this distinction is especially salient because varying forms of abuse are associated with overlapping as well as unique clinical outcomes (cougle, timpano, sachs-ericsson, keough, & riccardi, 2010; macmillan et al., 2001; widom, dumont, & czaja, 2007). for example, physical abuse has been shown to be more robustly associated with aggression (banducci, hoffman, lejuez, & koenen, 2014; briere & runtz, 1990) and hyperactive amygdala reactivity (grant, cannistraci, hollon, gore, & shelton, 2011) than sexual or emotional abuse. additionally, emotional abuse may be more strongly associated with a number of maladaptive cognitions (wright, crawford, & del castillo, 2009), including low self-esteem (briere & runtz, 1990; gross & keller, 1992) and shame (hoglund & nicholas, 1995). it is also uniquely predictive of the development of eating disorders (guillaume et al., 2016; kent, waller, & dagnan, 1999). thus, the literature suggests that childhood maltreatment is a multidimensional construct and that varying forms of abuse may not impact outcomes uniformly. the purpose of the current study was to examine whether gender differences in risk-taking propensity 7 gender, childhood trauma, and risk-taking propensity are impacted by a history of childhood abuse, a traumatic—but distal—stressor, in a community sample of adults. as different forms of abuse may impact stress responding and risk-taking differently, the effects of different forms of abuse were examined separately. age was adjusted for in all analyses, as research has indicated reductions in risk-taking across development (defoe, dubas, figner, & van aken, 2015; mamerow, frey, & mata, 2016). it was hypothesized that gender would interact with childhood abuse so that, compared to individuals without a history of abuse, men with a history of abuse would have greater risk-taking propensity while women with a history of abuse would have less risk-taking propensity. to our knowledge, this is the first study to investigate the interacting effects between gender and separate forms of abuse, so there were no specific hypotheses about the effects of each type of abuse (e.g., emotional vs. physical abuse). methods participants and procedure data was collected from the university of illinois at chicago. the sample consisted of 140 adults who were enrolled in a larger study on emotional processing in families (data not yet published). in line with the aims of this larger study, participants were enrolled in the study along with one of their biological siblings. for the present study, only one individual from each sibling pair was included in order to prevent genetic/psychophysiological homogeneity. to prevent biases, one sibling from each pair was selected using a random number generator to be included in the present study. participants were recruited from the community through advertisements targeting a broad range of psychopathology, including past trauma exposure. as part of the inclusion criteria for the larger study, participants were required to be between the ages of 18 and 30 and have a full biological sibling within this age range willing to participate. individuals were excluded from participating if they had a personal or family history of psychosis or mania; were left-handed; were unable to read/write english; or had a history of head trauma with loss of consciousness. the demographics and clinical characteristics of the sample are presented in table 1. all procedures were approved by the institutional review board of the university of illinois at chicago. participants provided written informed consent after review of the study protocol. participation in the study involved completing a structured clinical interview, questionnaire battery, and set of laboratory tasks. for the current study, relevant data were collected from behavioral tasks (risk-taking propensity), questionnaires (demographics, childhood maltreatment), and clinical interview (alcohol use). laboratory tasks and questionnaires were administered in a counterbalanced order. as compensation for their participation, participants received a cash payment of $130. risk-taking propensity risk-taking propensity (rtp) was assessed using the widely-used balloon analogue risk task (bart)— auto pump, a modified version of the original bart (lejuez et al., 2002; pleskac, wallsten, wang, & lejuez, 2008). the bart models real-world risk-taking behaviors by requiring participants to balance potential reward versus loss. this assessment has repeatedly been shown to have good convergent validity with self-report measures of risk-related constructs and is predictive of the real-world risk behaviors of self-reported substance use and gambling (lejuez et al., 2002; lejuez et al., 2003). during the task, participants were presented with a total of 30 computerized balloons. as each individual balloon appeared the participant was instructed to type in the number of desired “pumps” (between 1 and 128) required to inflate the balloon. for each pump, participants earned one cent. each balloon had a randomized amount of “pumps” it would withstand before it would burst. thus, if the participant typed in a number of pumps exceeding that balloon’s limit, the balloon on the screen would consequently pop and the participant would be left without any money earned for that specific balloon. hence, the higher the number of pumps entered on the screen, the greater the amount of potential earnings one would receive, which also related to the greater risk of earning no money. the explosion point of the previous balloon was displayed in the left hand corner of the screen on each trial. participants were told that the amount of their prize money was dependent on the amount of money they accumulated during the task. all participants received a $7 payment for this task and were debriefed after completion of the full study. 8 huggins, gorka, shankman childhood maltreatment childhood maltreatment was assessed using the 28-item retrospective self-report form: childhood trauma questionnaire-short form (ctq-sf) (bernstein et al., 2003). the ctq-sf consists of five clinical scales designed to capture different forms of childhood trauma: physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse. items are rated on a 5-point scale with responses ranging from “never true” to “very often true.” the ctq-sf is widely used and has demonstrated good reliability and validity (bernstein et al., 2003). the ctq-sf is designed to produce both dimensional and categorical assessments of maltreatment. although the recruitment approach for the current sample partially targeted individuals with a history of trauma, the total and subscale scores were significantly skewed reflecting a non-normal distribution. therefore, to maximize statistical power, dichotomized ctq-sf variables were created using published cut-off scores for each subscale (i.e., 8 for physical abuse, 8 for physical neglect, 9 for emotional abuse, and 10 for emotional neglect; bernstein & fink, 1998). of note, as the current sample was not specifically recruited for a history of sexual abuse, the prevalence of sexual abuse in the current sample was low (15%), consistent with epidemiological studies (finkelhor, shattuck, turner, & hamby, 2014; putnam, 2003); as such, this subscale was excluded from the current analyses. alcohol use in order to validate the bart in the current sample, information about current frequency of alcohol use was collected as a measure of real-world risk-taking. alcohol use was assessed during a structured clinical interview during which participants were asked to report their average number of standard alcoholic drinks consumed per week (over the past six months) and number of binge episodes within the past 30 days. alcohol use was probed using a time-line follow-back technique (sobell & sobell, 1992), with participants using a calendar to indicate days on which they consumed alcohol and the number of standard drinks on each occasion. binge episodes were defined as consuming, in one sitting, ≥5 drinks for males or ≥4 drinks for females (wechsler & nelson, 2001). data analysis plan total number of entered pumps across all 30 balloons on the bart was used as an indicator of risk-taking propensity which is consistent with prior studies (e.g., daughters et al., 2013). a series of hierarchical linear regression analyses were conducted in order to test whether gender moderates the association between childhood abuse and risk-taking propensity. each individual ctq-sf scale was treated as a separate independent variable (i.e., physical abuse, physical neglect, emotional abuse, and emotional neglect) and separate models were run for each predictor. for all models, age was entered as a covariate in step 1. gender and the ctq-sf score were entered in step 2, and the gender x ctq-sf interaction term was entered in step 3. significant two-way interactions were followedup by using a simple slopes approach for dichotomous variables (aiken & west, 1991; holmbeck, 2002). results demographic and clinical comparisons results from demographic and clinical comparisons are presented in table 1. of note, males and females did not differ on any demographic variable; however, a significantly greater percentage of females reported emotional and sexual abuse than males. there were no differences for other forms of maltreatment. correlations among variables of interest are presented in table 2. notably, bart performance (i.e., total pumps) was significantly correlated with real-world risk behaviors including number of alcohol binges in the past 30 days (r = .22, p = 0.01) and average number of drinks per week over the past six months (r = .19, p = 0.02). physical abuse and neglect results of the regression analyses are reported in table 3. for the physical abuse model, step 1 was not significant (f(1, 138) = .64, r2 = .00, p = .43) and there was no main effect of age (β = .07, t = .80, p = .43). step 2 was significant (f(3.136) = 6.25, r2 = .10, p = .01). there were main effects of gender (β = -0.27, t = -3.41, p = .001) and physical abuse (β = -.19, t = -2.37, p = .02) such that male gender was associated with greater risktaking propensity and a history of physical abuse was associated with lesser risk-taking propensity. these main 9 gender, childhood trauma, and risk-taking propensity table 1 participant demographics and clinical characteristics means (sd) or percentages variable males (n = 54) females (n = 86) total sample (n = 140) age (years) 22.4 (3.2)a 22.7 (3.1)a 22.5 (3.2) ethnicity caucasian 38.9%a 44.2%a 42.1% african american 13.0%a 12.8%a 12.9% hispanic 25.9%a 27.9%a 27.1% asian american 14.8%a 8.1%a 10.7% other 7.4%a 7.0%a 7.2% bart total pumps 1860.9 (311.1)a 1623.4 (445.5)b 1715.0 (414.4) alcohol binges 1.35 (2.49)a .90 (1.62)b 1.07 (2.00) drinks per week 4.35 (6.09)a 3.08 (4.18)a 3.56 (5.01) ctq total score 35.1 (8.5)a 37.5 (13.0)a 36.54 (11.49) ctq physical abuse 27.8%a 32.6%a 30.7% ctq physical neglect 31.5%a 25.6%a 27.9% ctq emotional abuse 22.2%a 38.4%b 32.1% ctq emotional neglect 33.3%a 34.9%a 34.3% ctq sexual abuse 7.4%a 19.8%b 15.0% note. means or percentages with different subscripts across rows were significantly different in pairwise comparisons (p < .05, chi-square test for categorical variables and tukey’s honestly significant difference test for continuous variables). table 2 correlations between demographics, risk-taking propensity, alcohol use, and ctq scores 1 2 3 4 5 6 7 8 9 10 1. sex 2. age .046 3. bart total pumps -.280** .068 4. alcohol binges -.111 .043 .224** 5. drinks per week -.119 .089 .138 .731** 6. ctq total .102 .076 -.227** -.028 -.065 7/ ctq physical abuse .078 .067 -.251** -.044 -.007 .663** 8. ctq physical neglect -.067 .064 -.123 -.026 -.056 .703** .421** 9. ctq emotional abuse .145 .040 -.143 -.078 -.101 .796** .521** .415** 10. ctq emotional neglect -.023 .007 -.059 .028 -.007 .742** .273** .536** .535** 11. ctq sexual abuse .189* .094 -.231** .012 .008 .528** .232** .170* .221** .115 *p < .05; **p < .01 10 huggins, gorka, shankman effects were qualified by a significant physical abuse by gender interaction (β = -.68, t = -2.38, p = .02) in step 3 (f(4,135) = 6.26, r2 = .13, p < .001). for males, a history of physical abuse was not associated with risktaking propensity (β = .06, t = .44, p = .66); however, for females, a history of physical abuse was associated with decreased risk-taking propensity (β = -.33, t = -3.35, p = 0.001; figure 1a). similar results were found for physical neglect. step 1 of the model was not significant (f(1,138) = .64, r2= .00, p = .43) and there was no effect of age (β = .07, t = .80, p = .43). step 2 was significant (f(3, 136) = 6.28, r2 = .10, p = .001). there were significant main effects of gender (β = -.30, t = -3.68, p < .001) and physical neglect (β = -.19, t = -2.39, p = .02), in that male gender was associated with greater risk-taking propensity, and a history of physical neglect was associated with less risk-taking propensity in adulthood. again, in step 3 (f(4, 135) = 5.92, r2 = .12, p < .001) these main effects were qualified by a significant physical trauma by gender interaction (β = -.56. t = -2.09, p = .04). for males, there was no association between physical neglect and risktaking propensity (β = .01, t = .04, p = .97), but for females, physical neglect was associated with decreased risk-taking propensity (β = -.33, t = -3.19, p = 0.002; figure 1b). emotional abuse and neglect for the emotional abuse model, step 1 was not significant (f(1, 138) = .64, r2 = .00, p = .43) and there was no main effect of age (β = .07, t = .80, p = .43). step 2 of the model was significant (f(3, 136) = 5.33, r2 = .08, p = .002) and there was the expected main effect of gender, such that males exhibited higher risk-taking propensity than females (β = -.26, t = -3.15, p = .002). there was no main effect of emotional abuse (β = .-.14, t = -1.76, p = .08). step 3 was significant (f(4, 135) = 4.01, r2 = .08, p = .004); however, there was not a significant emotional abuse by gender interaction (β = -.12, t = -.38, p = .71). for the emotional neglect model, step 1 was not significant (f(1, 138) = .64, r2 = .00, p = .43) and there was no main effect of age (β = .07, t = .80, p = .43). in step 2 (f(3, 136) = 4.67, r2 = .09, p = .004), there was a main effect of gender, with male gender being associated with greater risk-taking propensity (β = -.28, t = -3.46, p = .001). there was no significant main effect of emotional neglect (β = -.07, t = -1.13, p = .26). step 3 was also significant (f(4, 35) = 3.60, r2 = .07, p = .01), but there was no emotional neglect by gender interaction (β = .20, t = .67, p = .51). discussion previous research has demonstrated that acute stress amplifies gender differences in risk-taking propensity, in that stress increases rtp in men and decreases rtp in women (daughters et al., 2013; lighthall et al., 2009). however, the studies examined to date have not investigated these stress-induced gender differences in response to real-world stressors and whether there are prolonged effects of gender and stress on rtp; thus, the aim of the current study was to assess whether a history of childhood abuse was associated with exaggerated gender differences in rtp in adulthood. results indicated that gender did indeed moderate the association between childhood abuse and adult rtp, but that this effect differed depending on the type of abuse. specifically, for women, a history of childhood physical abuse or physical neglect was associated with significantly reduced rtp, whereas for men there was no association between physical abuse or physical neglect and rtp. furthermore, the effects were specific to physical abuse and neglect as there was no interacting effect between gender and childhood emotional abuse or neglect on adult rtp. therefore, like the acute stress literature, the current findings suggest that there are gender differences in the association between childhood physical maltreatment and rtp. however, unlike the acute stress literature, gender did not impact the association between childhood emotional maltreatment and rtp. as was previously noted, prior studies have found that in response to acute stress, men show increased rtp (daughters et al., 2013; lighthall et al., 2009). in the current study, there was no association between childhood emotional or physical abuse and rtp in males. this was somewhat unexpected; however, it is important to highlight that results indicated that, on average, males exhibited greater rtp compared with females. this main effect of gender is consistent with the broader rtp literature (byrnes et al., 1999; lejuez et al., 2002) and suggests that for males, increased rtp may be a trait-like phenomena that is less impacted by 11 gender, childhood trauma, and risk-taking propensity fi gu re 1 . m ea n b a rt to ta l p um ps b y ge nd er a nd h is to ry o f p hy si ca l a bu se (a ) a nd p hy si ca l n eg le ct (b ). b ar s r ep re se nt st an da rd e rr or o f t he m ea n. ta bl e 3 re su lts fr om e ac h hi er ar ch ic al li ne ar re gr es si on a na ly si s p re di ct in g in di vi du al d iff er en ce s i n ri sk -ta ki ng p ro pe ns ity ph ys ic al a bu se ph ys ic al n eg le ct em ot io na l a bu se em ot io na l n eg le ct pr ed ic to r β t p r2 ∆r 2 β t p r2 ∆r 2 β t p r2 ∆r 2 β t p r2 ∆r 2 st ep 1 .0 0 .0 0 .0 0 .0 0 a ge .0 7 .8 0 .4 3 .0 7 .8 0 .4 3 .0 7 .8 0 .4 3 .0 7 .8 0 .4 3 st ep 2 .1 0 .1 0 .1 0 .1 0 .0 8 .0 8 .0 7 .0 7 g en de r -.2 7 -3 .4 1 <. 01 -.3 0 -3 .6 8 <. 01 -.2 6 -3 .1 5 <. 01 -.2 8 -3 .4 6 <. 01 c tq -s f -.1 9 -2 .3 7 .0 2 -.1 9 -2 .3 9 .0 2 -.1 4 -1 .7 6 .0 9 -.0 9 -1 .1 3 .2 6 st ep 3 .1 3 .0 3 .1 2 .0 2 .0 8 .0 0 .0 7 .0 0 g en de r x c tq -s f -.6 8 -2 .3 8 .0 2 -.5 6 -2 .0 9 .0 4 -.1 2 -.3 8 .7 1 .2 0 .6 7 .5 1 12 huggins, gorka, shankman childhood abuse. indeed, one twin study has shown the heritability (and thus, potential trait-likeness) of rtp varies by gender (anokhin, golosheykin, grant, & heath, 2009). considering the findings of others (i.e., daughters et al., 2013; lighthall et al., 2009; uy & galván, 2017), men may be generally more risk-prone and, in response to acute stress, this trait may be amplified. thus, although men may have a trait-like proclivity for greater risk-taking, the current study suggests that stress-associated elevations of rtp may fade in the absence of the stressor and not have robust long-term effects. however, women reporting childhood physical maltreatment exhibited reduced rtp. this finding is consistent with existing literature demonstrating that women become more conservative and inhibited in response to stress (daughters et al., 2013; lighthall et al., 2009). importantly, the results of the current study suggest that a pattern of becoming more riskaverse under stress may persist after the acute stressor is gone. in other words, it appears that previous stressors, such as childhood trauma, and not solely acute stressors, may reduce rtp in women. although this relationship was only found for women, it is not unsurprising, as previous studies have demonstrated that women with a history of childhood abuse are more likely than men to have adverse outcomes later in life, such as higher rates of depression and ptsd, in adulthood (macmillan et al., 2001; tolin & foa, 2006). thus, it is possible that women are more vulnerable to the long-term effects of childhood trauma and are more likely to experience lasting alterations of risk-taking behaviors. although speculative, some have suggested that evolutionary differences may explain why women, but not men, could be more likely to experience prolonged effects after a stressor. taylor et al. (2000) proposed that men and women exhibit different biobehavioral responses to stress, arguing that, in response to a threat, men are more likely to engage in a fight-or-flight response. however, as this type of response may compromise the safety of self or offspring, women instead become more conservative or inhibited with others, a pattern known as “tend-and-befriend.” specifically, when confronted with a threat, many women engage in nurturing (tend) and social activities (befriend) aimed to protect the self and offspring and reduce distress. researchers have speculated that, although this need to protect and nurture may be protective against imminent threat, there are possible negative consequences, including the internalization of negative emotions, such as worrying or ruminating about stressful situations (craske, 2003; hazlett-stevens, 2005). indeed, these response patterns have been thought to be linked to gender differences in externalizing and internalizing psychopathologies, for instance, with men being more likely to have alcohol and substance use disorders (brady & randall, 1999; seedat et al., 2009) and women more likely to have problems with depression and anxiety (lewinsohn, gotlib, lewinsohn, seeley, & allen, 1998; nolen-hoeksema, 1990). in light of these findings, this pattern may generalize to childhood stress and, importantly, have a long-lasting impact on risk-taking; thus, women exposed to this type of stress (e.g., childhood abuse) become reinforced with this conservative, risk averse behavioral pattern. interestingly, this finding was only specific for physical abuse and neglect, but not emotional abuse or neglect. while physical and emotional abuse often occur concurrently, they are qualitatively different. thus, it is not surprising to find that they may be associated with different outcomes. one possibility for this specific impact on risk-taking is that emotional abuse may have more internal or cognitive consequences, whereas the negative consequences of physical abuse may manifest more behaviorally. for instance, emotional abuse has been uniquely linked to a number of maladaptive cognitions (wright et al., 2009), such as low self-esteem (briere & runtz, 1990; gross & keller, 1992) and shame (hoglund & nicholas, 1995), whereas physical abuse has been linked to more behavioral consequences, such as physical aggression (teisl & cicchetti, 2007; trickett & mcbride-chang, 1995). moreover, exposure to physical maltreatment may have more of an impact on biological stress response systems than emotional abuse. grant et al. (2011) found that adults reporting a history of childhood physical abuse, but not emotional abuse, exhibited greater reactivity of the amygdala in response to sad stimuli than individuals without a history of physical abuse. the amygdala is a major component in stress and fear neurocircuitry, and hyperactive amygdala responding is considered a key biological mechanism in the onset and maintenance of anxiety disorders (shin & liberzon, 2010)—a class of internalizing disorders characterized 13 gender, childhood trauma, and risk-taking propensity by avoidance and risk-aversion (lorian & grisham, 2010; maner et al., 2007; maner & schmidt, 2006). thus, because physical abuse may alter amygdala functioning, especially in a young developing brain, it may have more of a potent impact on future affective and behavioral responding (including rtp). although the current study significantly adds to the growing literature on the etiology of rtp, there are several limitations worth noting. first, although the population was sampled to include individuals who have experienced traumatic events (e.g., childhood abuse), overall the sample had low levels of abuse requiring the use of categorical rather than continuous indices of childhood trauma. in particular, the current sample reported very low levels of sexual abuse, and thus the unique and interactive effects of sexual abuse and gender on rtp were not examined. future studies are therefore critically needed to investigate the relation between this specific form of abuse and the development of rtp. second, participants were asked to make retrospective assessments of childhood trauma which may have led to recall biases in reporting. third, the current study was cross-sectional and cannot adequately test whether the childhood trauma preceded onset of individual differences in rtp (or whether group differences in rtp were even evident in childhood). future studies should utilize a longitudinal design to test relations between gender, stress, and rtp. as such, the current findings suggest that gender and a history of child abuse may interact to predict adult rtp, but further work is warranted to better characterize this model. another critical point is that prior studies have found that a history of childhood abuse is related to increased rtp (bornovalova, gwadz, kahler, aklin, & lejuez, 2008), yet the current study did not find evidence of this positive main effect. although the present findings clearly highlight the important role of gender in determining the direction and strength of effects between childhood abuse and rtp, the lack of main effect may be considered discrepant with some prior studies. interestingly, a study by sujan and colleagues (2014) found that for self-reported measures of real-world risk-taking and impulsivity, young adults with a history of childhood abuse reported greater rates of risk-taking; however, on computerized behavioral tasks (including the bart) those with a history of childhood abuse exhibited significantly reduced risk-taking and impulsivity—consistent with the current effects observed in females. this suggests that assessment methods (i.e., self-report versus behavioral task) may influence the association between childhood maltreatment and rtp, and it is therefore unclear whether the current findings would also apply to selfreport measures of risk-taking. in sum, the current study found that gender and childhood physical abuse and physical neglect interact to predict individual differences in risk-taking. specifically, women who reported physical abuse and neglect during childhood exhibited significantly less rtp; however, there were no associations found between childhood abuse and rtp in men. this suggests that physical maltreatment during childhood may have a profound, long-lasting effect on risk-taking behavior, and that women may be particularly vulnerable to these prolonged effects. although prior work has demonstrated that gender moderates risk-taking propensity in acutely stressed individuals (e.g., lighthall et al., 2009), the current study expands this line of research by demonstrating that gender also interacts with chronic, distal stress (i.e., childhood abuse) to predict risk-taking propensity. as risk aversion has been linked to anxiety (maner et al., 2007), these findings provide some clinical utility. future studies, particularly longitudinal research, may provide insight into whether risk aversion plays a mechanistic role in the development of anxious psychopathology in adult women with a history of physical abuse and, subsequently, whether risk-taking propensity may be a target for intervention in this population. given the clinical relevance of these findings, it is important for future studies to continue to investigate the ways in which these factors interact to assess the development of maladaptive risk-taking behaviors over time. references aiken, l. s., & west, s. g. 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(2009). childhood emotional maltreatment and later psychological distress among college students: the mediating role of maladaptive schemas. child abuse & neglect, 33(1), 59–68. doi:10.1016/j. chiabu.2008.12.007 graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 45 the developmental implications of parentification: effects on childhood attachment jennifer a. engelhardt teachers college, columbia university parentification refers to the process through which children are assigned the role of an adult, taking on both emotional and functional responsibilities that typically are performed by the parent. the parent, in turn, takes the dependent position of the child in the parent-child relationship. although a small degree of parentification can be beneficial to child development, this process can become pathological when the tasks become too burdensome or when the child feels obligated to take on the role of adult. the purpose of this review is to examine the current literature concerning the effects of parentification on child attachment and the implications this may have for the present and future well-being of a child. methodological issues in current research as well as suggestions for future research are also discussed. research indicates that, due to the emotional unavailability of the caregiver, emotional parentification disrupts the development of secure attachment. the consequent formation of insecure attachments to primary caregivers, particularly the mother, results in interpersonal deficits in the child that can carry on into adulthood. the term “parentification” was first utilized in depth by boszormenyi-nagy and spark (1973) to describe a common component of relationships whereby parental characteristics are projected onto an individual. within the parent-child relationship, this process is often seen when the child performs chores or occasionally offers emotional support for a parent, and is believed to be healthy for the child as he or she begins to see the potential for him or herself in an adult role (boszormenyi-nagy & spark, 1973).  however, when the responsibilities become too burdensome, or when the child feels obligated to take on the adult position in order to maintain a balance in the family system, parentification can become pathological (hooper, 2007a, 2007b). this dysfunctional aspect of parentification is most commonly addressed in the literature, and is described as: a disturbance in the generational boundaries, such that evidence indicates a functional and/or emotional role reversal in which the child sacrifices his or her own needs for attention, comfort, and guidance in order to accommodate and care for the logistical and emotional needs of a parent and/or sibling. (hooper, 2007b, p. 323) in simpler terms, the adult essentially adopts the dependent position in the parent-child relationship, and in turn the child is expected to fulfill what are typically considered to be adult responsibilities. given the importance of childhood as a period rife with developmental tasks that will influence an individual throughout the lifespan, it is surprising to note that little  jennifer a. engelhardt, department of counseling and clinical psychology, teachers college, columbia university. correspondence regarding this article should be addressed to jennifer a. engelhardt, 49 tennyson place, passaic, nj 07055. email: j.a.engelhardt@gmail.com. research has been performed on how parentification directly affects the developmental processes of the children who experience it. the formation of attachment to a primary caregiver is considered to be one of many key tasks in child development (bowlby, 1958), and any process which can negatively influence attachment, such as parentification, warrants investigation. in actuality, the majority of research on parentification has examined a vast array of potential outcomes in adulthood (earley & cushway, 2002; hooper 2007a, 2007b, 2008; hooper, marotta, & lanthier, 2008; jones & wells, 1996; katz, petracca, & rabinowitz, 2009; macfie, mcelwain, houts, & cox, 2005; mayseless, bartholomew, henderson, & trinke, 2004), or the effects of parentification on the mental and behavioral well-being of children (earley & cushway, 2002; jacobvitz, hazen, curran, & hitchens, 2004; macfie, houts, mcelwain, & cox, 2005). in response to this lack of focus on the topic, the purpose of this review is to discuss the literature that addresses how parentification affects childhood development in particular. specifically, the scope of this review is limited to the influence of parentification on the process of attachment formation and its implications for the parentified individual’s well-being, particularly with regard to interpersonal relationships. attachment affects a variety of outcomes in areas such as identity development and differentiation, temperament, self-esteem, and, most strongly, interpersonal relationships through the development of internal working models and the corresponding interpretations of experiences (ainsworth, blehar, waters, & wall, 1978; byng-hall, 2002). an understanding of how parentification affects attachment formation not only assists researchers and clinicians in understanding, preventing, and treating the problem, but also depicts the possible pathways through which many of the observed negative childhood and adult outcomes occur. engelhardt 46 this review begins with an overview of the concept of parentification, including an explanation of the process of parentification itself as well as a summary of associated risk factors and commonly observed outcomes. this is followed by a description of attachment paradigms, incorporating parentification research to formulate an understanding of how these two processes are related to and influenced by one another. following a discussion of the existing literature, methodological and conceptual weaknesses of the empirical studies performed, as well as suggestions for future research, are provided. although parentification is classified as a type of role reversal, an analysis of research on parentification reveals that researchers often utilize the terms “parentification” and “role reversal” interchangeably, with those who do use the term “role reversal” conceptualizing it in their research as similar to the process of parentification. in consideration of this, for the sake of this review these two words will be used here interchangeably, in accordance with the terminology utilized in the studies being discussed. parentification when occurring to a pathological degree, parentification is considered by some a form of child neglect as it impedes development through the denial of basic childhood necessities and experiences (boszormenyi-nagy & spark, 1973; hooper, 2007a, 2007b). in a relationship characterized by parentification, the parent is typically unwilling or unable to uphold his or her emotional and/or physical responsibilities as caregiver (barnett & parker, 1998). the parentifying adult may relegate these duties to the child, or the child may take up these responsibilities voluntarily, despite the incongruence between the developmental requirements of these tasks and the developmental maturity of the child (aldridge, 2006; mechling, 2011). nevertheless, the child recognizes that by providing the physical care and emotional support that he or she would normally elicit from the parent, he or she can develop closeness with the parent and avoid feelings of loss and anxiety (barnett & parker, 1998). the child therefore interprets these undertakings as necessary and sees the needs of the parent and family as taking precedence over all other needs, including their own personal needs. as a result, the parentified child misses out on the developmentally appropriate and essential activities that typically characterize childhood, such as the formation of healthy interpersonal relationships, the development of secure attachment to caregivers, and the differentiation of self (boszormenyi-nagy & spark, 1973; bowlby, 1958, 1969; hooper, 2007a, 2007b). the latest report published by the children’s bureau of the united states department of health and human services (2011) estimates that 9.2 per 1,000 children experienced maltreatment in the year 2010, totaling approximately 695,000 children. of these cases, an overwhelming 78.3% involved neglect, in which a parent or guardian failed to provide appropriate care for the child, resulting in negative consequences. while data on the national prevalence rate of parentification specifically is lacking in the literature, researchers have attempted to estimate the pervasiveness of this problem in other countries, particularly in the united kingdom. for example, aldridge (2006) estimates that approximately 175,000 children serve in a caregiving role for a parent with an illness or disability each year in the united kingdom. a related study performed by doran, drever, and whitehead (2003) found that 114,000 children, or 1.4% of children in the uk, were providing some form of care that was characterized as burdensome for at least one member of their family. the health of a significant number of these children was rated as “not good,” indicating that their own needs were being neglected in their attempts to meet the needs of their family. furthermore, the researchers reported that caregiving by these children ranged in depth from a few hours per week to more than fifty hours per week (doran et al., 2003), illustrating that this problem can vary considerably in severity for children who experience it. parentification is most commonly found within dysfunctional family systems in which there is a need for the establishment of homeostasis in order for the family to function adequately. the family system characterized by parentification is thought to be deficient in some way (hooper et al., 2008) so that a lack of boundaries exists and parental versus childhood roles and behaviors are not properly delineated (hooper, 2007a). most often, one or both parents are incapacitated, commonly for physical, social, emotional, or economic reasons, and they come to depend upon the child to meet their needs and the needs of the family. specific parental risk factors found to be associated with the parentification of one or more child within the family system include maternal sexual abuse history, low maternal socioeconomic status, physical and mental illness, addiction, divorce, single-parent households, intrusive parenting styles, and adult attachment issues (barnett & parker, 1998; earley & cushway, 2002; macfie, mcelwain, et al., 2005). in each of these cases, the child is more likely to take on the parental role, voluntarily or involuntarily and to varying degrees, in order to compensate for parental deficits and to allow the family to function as a whole. instrumental versus emotional parentification when discussing parentification, it is important to note that there are two subtypes of the phenomenon, each of which may be associated with differing consequences for child development and, ultimately, adult outcomes (aldridge, 2006; hooper, 2007a; hooper et al., 2008; katz et al., 2009). the first subtype, instrumental parentification, refers to the parentification of children through the assignment of functional responsibilities, such as shopping, paying bills, cooking meals for the family, and taking care of the general logistics of running a household. this subtype, when occurring in isolation, is commonly observed in family systems in which one or both parents are incapacitated in such a way that they require daily care or are unable to fulfill these logistical responsibilities due to illness or other factors, such as having to work in order to keep the family financially parentification and attachment 47 afloat (hooper, 2007a). instrumental parentification is believed to be the less deleterious of the two subtypes for child development, as it can foster in the child a sense of accomplishment and competence when regular parental support and acknowledgement is available (aldridge, 2006; hooper, 2007a). in contrast, emotional parentification requires the child to fulfill specific emotional and/or psychological needs of a parent and is more often destructive for child development than instrumental parentification (hooper, 2007a). for example, the emotionally parentified child may be expected to gauge and respond to the emotional needs of the parent, serve as confidante and an unwavering source of support, and provide crisis intervention during times of psychological distress (aldridge, 2006; hooper, 2007b; katz et al., 2009). this subtype, which often occurs in concert with instrumental parentification, is most often found within family systems in which a parent suffers from mental illness or adult attachment issues (aldridge, 2006). in order to deal with his or her own deficits, which likely arose in childhood, the parent expects emotional or psychological support from the child without reciprocation (hooper, 2007b). as a result of the incongruence between these parental expectations and the child’s developmental age, level of maturity, and degree of understanding, emotional parentification is more strongly associated with a number of negative consequences for the parentified individual (hooper, 2007a). outcomes of parentification with regard to potential outcomes, research that has examined the experiences of parentified children during childhood reveals that these individuals report a vast array of adverse effects in response to adopting the parentified role. these children are more likely to report internalizing problems such as depressive symptoms and anxiety, as well as somatic symptoms like headaches and stomachaches (earley & cushway, 2002; mechling, 2011). parentified children are also more likely to exhibit externalizing behaviors such as aggressiveness and disruptive behavior (macfie, houts, et al., 2005), substance use, self-harm, and attention-deficit/hyperactivity disorder (jacobvitz et al., 2004; mechling, 2011). furthermore, parentification is also linked to social difficulties, particularly lower competency in interpersonal relationships (hooper, 2007a; macfie, houts, et al., 2005), as well as academic problems such as high absenteeism and poor grades (mechling, 2011). if left unresolved, these symptoms of maladjustment can continue into adulthood, causing further dysfunction throughout the parentified individual’s lifespan. despite the fact that there are known effects of parentification on individuals during childhood, such as those listed above, currently there has been limited research in this area. instead, the majority of research conducted has focused solely on the effects of childhood parentification on individual characteristics in adulthood. specifically, parentification has been shown to impede identity development and personality formation and to affect interpersonal relationships, including those with one’s own children. it has also been found to be associated with later attachment issues, mental illness, psychological distress, masochistic and narcissistic personality disorders, substance abuse, and one’s academic and career choices (earley & cushway, 2002; hooper, 2007a, 2008; hooper et al., 2008; jones & wells, 1996; katz et al., 2009; macfie, mcelwain, et al., 2005). however, researchers have speculated that in some instances, emotional and instrumental parentification may prove beneficial for individuals in adulthood. specifically, parentification can lead to greater interpersonal competence and stronger family cohesion, as well as higher levels of individuation, differentiation from family, and selfmastery and autonomy when the child experiences a low level of parentification and when the efforts of the child are recognized and rewarded by adult figures (hooper, 2007b, 2008). attachment attachment theory was developed through the work of bowlby (1958, 1969), who emphasized the importance of interpersonal bonds early in life – particularly with primary caregivers – as predictors of future well-being. the theory was expanded upon by ainsworth et al. (1978) who, through observation of parent-child interactions, classified infant behavior according to one of three attachment styles. the first of these types, insecure-avoidant attachment, is typically observed in children whose caregivers are emotionally unavailable and unresponsive to the child’s needs. these children often appear prematurely independent and consistently avoid contact with the caregiver. the second attachment type, known as insecure-resistant attachment, is observed in children whose caregivers are inconsistently available and whose behavior toward their child is unpredictable. these children display ambivalence in their interactions with the caregiver, both seeking and resisting contact, as the caregiver is seen as unreliable. secure attachment is observed in children whose parents are consistently emotionally available and responsive to the child’s needs. children who demonstrate secure attachment find comfort in the parent-child relationship, viewing the caregiver as trustworthy and therefore feeling safe enough to confidently explore the world. a fourth attachment style, disorganized attachment, was later introduced by main and solomon (1986) and was used to describe children who defied classification under ainsworth’s rubric. this attachment style is commonly seen in children whose parents are abusive or neglectful. these children often exhibit disoriented behavior that lacks a coherent stance toward the caregiver, and typically represents significant interpersonal deficits. although the four subtypes of attachment are described here, current research on the effects of parentification on attachment does so only in terms of secure versus insecure attachment and does not differentiate between the various subtypes. in consideration of this, the discussion on the engelhardt 48 effects of parentification on attachment will do so only in terms of secure versus insecure attachment in line with current research. this lack of differentiation between the subtypes of attachment is discussed in the next section as a methodological weakness of current research. the development of secure attachments to significant caregivers such as parents, and the resulting construction of internal working models which will serve as prototypes for an individual’s future relationships, is a key task of childhood (bowlby, 1958). oftentimes the attachment patterns formed during childhood, particularly with the mother, have longlasting effects in a variety of areas of an individual’s life, most importantly in the formation and maintenance of relationships throughout the lifespan (bowlby, 1969). the vast array of research on attachment has demonstrated that a child’s sense of security, overall well-being, and especially connections to others are dependent upon the early motherchild relationship and the internal working models created from this relationship (hooper, 2007b). given the fact that the process of parentification directly affects the parent-child relationship by blurring the lines that typically delineate parental versus childhood roles, it is logical to consider that parentification would have a negative impact on the child’s attachment pattern. attachment and parentification the current literature focusing on the association between parentification and childhood and adult attachment demonstrates mixed results regarding the effects of this pathological process on the attachment patterns of parentified individuals. some research demonstrates no subsequent effect of parentification on the development of secure or insecure attachment. for example, mayseless et al. (2004) found no relationship between parentification and adult attachment, although these researchers examined current adult attachment styles as a function of childhood role reversal in its broadest form and did not differentiate between parentification and other forms of role reversal such as spousification, in which the parent looks to the child to fulfill needs for companionship. in contrast, however, a large amount of literature in this area indicates that parentification leads to significant attachment issues during childhood, which often carry forth into adulthood (boszormenyi-nagy & spark, 1973; earley & cushway, 2002; hooper, 2007a, 2007b; katz et al., 2009; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005). this body of literature indicates that the parent-child relationship characterized by the parentification of the child also tends to be characterized by insecure attachment patterns between the child and the parentifying adult. whether and how this relationship comes to exist is often contingent upon the type of parentification that is experienced by the child. as stated above, instrumental parentification occurs when a parent looks to a child to handle the functional responsibilities of running a household, such as housekeeping and physically caring for family members (hooper et al., 2008). this type of parentification, when occurring in isolation, is speculated to be the less harmful of the two types, particularly in the presence of a healthy and supportive relationship with the parent (aldridge, 2006). in the absence of emotional parentification, secure attachment can be formed if the instrumentally parentifying adult maintains emotional regularity and continuous availability for the child, provides consistent emotional and psychological support, and recognizes the child’s caregiving efforts (aldridge, 2006; hooper, 2007a, 2007b). in emotional parentification, however, the child is expected to attend to the caregiver’s emotional and/or psychological needs while sacrificing his or her own needs for emotional support and attention as they are not reciprocated by the parent (hooper, 2007a, 2007b). in these instances, the development of secure attachment is severely disrupted since the child attempts to create some form of bond with the parent by providing emotional support without reciprocation (hooper, 2007a; katz et al., 2009). this disturbance of the parent-child relationship is further exacerbated by the fact that the child may experience feelings of guilt if unable to meet the parent’s expectations, and may develop a sense of obligation toward the parent without the parent feeling a corresponding sense of obligation toward the child (boszormenyi-nagy & spark, 1973). due to the emotional unavailability and irregularity of the parent, insecure attachment is typically formed (ainsworth et al., 1978; hooper, 2007a). this relationship, as it appears to the child through the process of parentification, is internalized, fostering future attachment issues throughout childhood and into adulthood (earley & cushway, 2002). specifically, these early perceptions of the self as caregiver to a dependent other may continue into adulthood. for example, many individuals who were parentified as children report finding themselves in similar relationships as adults in which they take on the caregiving role (earley & cushway, 2002). these individuals often experience anxiety over abandonment and loss, and demonstrate difficulty handling rejection and disappointment within interpersonal relationships (katz et al., 2009). this research is supported by findings that early attachment styles, particularly with the mother, remain relatively stable over time and predict attachment toward romantic partners and peers later in life (zayas, mischel, shoda, & aber, 2011). mediating and moderating effects of gender current research points to the overarching influence of the mother-child (as opposed to father-child) relationship on attachment, as evidenced by the moderating effect of parent gender on parentification (macfie, houts, et al., 2005; mayseless et al., 2004). the mother’s role is commonly seen as vital in the development of a child’s interpersonal skills (zayas et al., 2011). due to the fact that emotional parentification causes particular dysfunction in the motherchild relationship and thereby hinders the development of a secure attachment, the child is typically unable to form healthy peer relationships (macfie, houts, et al., 2005). for example, daughters’ emotional role reversal with mothers, but not with fathers, has been found to be associated with later parentification and attachment 49 deficits in well-being, expressed specifically through depressive symptoms (katz et al., 2009). this relationship between maternal role reversal and depressive symptoms in adulthood was found to be fully mediated by daughters’ attachment anxiety, a tendency to seek constant reassurance, and a fear of abandonment in interpersonal relationships that typically characterizes insecure attachment (katz et al., 2009). in other words, due to the insecure attachment formed within the mother-child (but not the father-child) relationship, the emotionally parentified girls tended to exhibit anxiety about abandonment in interpersonal relationships, leading them to experience depressive symptoms in adulthood. this conclusion is further supported by the finding that mothertoddler emotional role reversal, but not father-child role reversal, is associated with social problems during kindergarten regardless of child gender (macfie, houts, et al., 2005). this finding illustrates how the pathological attachment formed with the mother through parentification can influence social relationships, even in early childhood. these differential effects observed for parent gender suggest that the mother-child relationship may be particularly influential on child attachment and social relationships in the face of parentification, perhaps due to the role of the mother as the primary model for young children’s socialization and formation of relationships. child gender has also been found to play a role in the development of interpersonal deficits as a result of parentification and consequent attachment issues. as stated above, maternal role reversal has been found to be associated with social problems during kindergarten, regardless of the child’s gender (macfie, houts, et al., 2005). interestingly, the researchers found that child gender moderated the relationship between role reversal and interpersonal deficits. specifically, it was determined that father-child role reversal also predicted social problems, but only for male children. furthermore, the relationship between maternal role-reversal and social problems was found to be stronger for motherdaughter role reversal than for mother-son role reversal. macfie, houts, et al. (2005) speculate that same-sex role reversal may particularly disrupt the development of interpersonal skills with same-sex peers, as children learn appropriate ways to interact with others through their relationships with their own parents. while research suggests that the mother serves as a more influential force in the development of social skills regardless of child gender, fathers may serve a more specified role in that they assist in the socialization of their sons with regard to same-sex interactions. intergenerational transmission given that the parentification of children plays a substantial role in the development of attachment patterns and future relationships, it is not surprising that parentification is often transmitted across generations, in part due to issues with attachment arising in childhood and carrying forward into adulthood. despite the fact that individuals who were parentified as children often maintain their positions as caregivers in adult relationships, these individuals tend to compensate for their childhood losses by turning to their own children for nurturance and emotional needs (earley & cushway, 2002). specifically, parents who exhibit emotional role reversal with their own mothers also tend to participate in role reversal with their children, with gender specific outcomes (macfie, mcelwain, et al., 2005). mother-daughter role reversal has been found to be predicted by the mother’s role reversal with her own mother and insecure attachment to her. interestingly, however, a father who was involved in role reversal with his own mother does not himself typically participate in role reversal. instead, it was found that his wife is more likely to engage in mother-son role reversal, even if she herself did not experience parentification, in reaction to her husband’s experience of parentification (macfie, mcelwain, et al., 2005). these findings further support the assumption that dysfunction in the mother-child relationship tends to be more common and influential in the process of parentification, due to the pervasive role of the mother during young childhood as a model for future social relationships (hooper, 2008; mayseless et al., 2004; zayas et al., 2011). furthermore, parentified mothers are themselves more likely to emotionally parentify their own children in accordance with the working model of the mother-child relationship that they themselves internalized as children (hooper, 2007b). fathers, however, are less likely to do so because they tend to participate less in the social aspects of childrearing, such as teaching interpersonal skills, until their children are older (macfie, houts, et al., 2005). therefore, the transmission of attachment issues and parentification across generations appears to be moderated by parent gender, with mothers demonstrating a greater effect on child attachment development in the face of parentification. summary although there are mixed results with regard to the association between parentification and attachment, the majority of existing research suggests a cyclical relationship between the two. parental history of attachment issues often leads to the parentification of the individual’s own children, which in turn leads to attachment issues in the child that are potentially carried over into his or her own adulthood (boszormenyi-nagy & spark, 1973; earley & cushway, 2002; hooper, 2007a, 2007b; katz et al., 2009; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005). in many cases, this leads to the replication of the parent-child relationship when the child becomes a parent him or herself, resulting in the intergenerational transmission of this pathological pattern of parent-child interactions (macfie, mcelwain, et al., 2005). this is most likely to occur between mother and child, as opposed to father and child (katz et al., 2009), due to the pervasive role of the mother as a model in the orientation of young children toward social relationships (zayas et al., 2011). the child looks to the relationship with his or her mother as a prototype of all relationships. when this relationship is dysfunctional it is internalized as such, engelhardt 50 leading to problems with socialization throughout life including with his or her own children. methodological issues and future research while the literature on the association between parentification and attachment has contributed greatly to an understanding of this phenomenon and its effects on childhood development, conceptual and methodological issues exist. a careful review of the existing literature reveals that the conceptualization of parentification commonly poses methodological challenges. parentification is considered to be a type of role reversal, which refers to the broader category of relational disturbances in which an adult looks to the child to fulfill unmet needs for intimacy, parenting, or socialization by expecting the child to take on the role of partner, parent, or peer (macfie, houts, et al., 2005). other types of role reversals include triangulation, in which the child is assigned the role of intermediary between two parents (chase, 1999) and spousification, in which the adult looks to the child to fulfill intimacy needs. there is an inconsistency in the terms utilized to denote the occurrence of parentification, with some researchers referring to the process directly as “parentification” (barnett & parker, 1998; boszormenyinagy & spark, 1973; earley & cushway, 2002; hooper, 2007a, 2007b, 2008; hooper et al., 2008; jones & wells, 1996) and others speaking of the problem in terms of “role reversal” (katz et al., 2009; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005; mayseless et al., 2004). indeed, the terms are often used interchangeably. despite these differences in terminology, each of these authors is referring to essentially the same process in their research, in which a child adopts the parental role, and each author describes it as such when defining their terms. future research would benefit from a clarification of the similarities and differences between these terms and from increased uniformity of the terms and definitions employed across empirical studies and critical reviews of parentification. as stated above, the two subtypes of parentification— emotional and instrumental—have the potential to create vastly different outcomes in the parentified individual. while instrumental parentification is less destructive and can instill in the child a sense of maturity and competence, emotional parentification is rarely adaptive for the family and almost always is detrimental to child development (hooper 2007a; hooper et al., 2008). despite this knowledge, few studies on the effects of parentification distinguish between the two subtypes, instead grouping them into one overarching category of “parentification” (jacobvitz et al., 2004; jones & wells, 1996; katz et al., 2009; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005; mayseless et al., 2004). this simplification of a complex and multifaceted process severely limits the potential to uncover associations between parentification and outcomes. therefore, a second suggestion for future researchers is to distinguish between emotional and instrumental parentification and to examine how each affects child developmental tasks (such as attachment) and adult outcomes. in addition to issues regarding the conceptualization of parentification, accurate measurement of parentification poses its own challenges. a substantial proportion of studies examining the effects of parentification are retrospective in nature (hooper et al., 2008; jones & wells, 1996; katz et al., 2009; macfie, mcelwain, et al., 2005; mayseless et al., 2004). the most common type of instrument used to measure parentification, such as the parentification questionnaire (jurkovic & thirkield, 1998), requires participants to reflect on memories of past experiences. these memories may have been distorted over time, particularly if they contain negative content, and are therefore potentially inaccurate. some researchers, however, have attempted to study current parentification, utilizing both video recordings of parent-child interactions (macfie, houts, et al., 2005) as well as parent and teacher reports (jacobvitz et al., 2004). researchers wishing to examine the direct effects of parentification on children, particularly on childhood development, would benefit from continuing to utilize observational studies and multi-source ratings of current child functioning in order to understand parentification and its effects within the context of the family as a system, as opposed to relying on the memories of one individual. moreover, despite the fact that there are multiple forms of attachment (ainsworth et al., 1978; main & solomon, 1986), currently researchers typically discuss the effects of parentification only in terms of secure versus insecure attachment styles (boszormenyi-nagy & spark, 1973; earley & cushway, 2002; hooper, 2007a, 2007b; katz et al., 2009), and do not take into consideration the subtypes of insecure attachment. research that does consider the varying forms of insecure attachment only speculates briefly about their possible linkages to parentification, and does not directly test these relationships statistically (macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005). therefore, a fourth recommendation is for researchers to examine the association between parentification and the various forms of insecure attachment. more detailed knowledge about how parentification affects attachment styles in children would facilitate prevention and treatment, as these different patterns of attachment have varying influences on child and adult outcomes. a final suggestion concerns the implementation of current research findings to develop prevention and intervention strategies that address parentification, alongside the emergence of new research that tests the outcomes of such strategies. research to date has primarily focused on the impact of parentification on the parentified individual, and little has been done to explore the ways in which families might be helped to address this issue collectively (earley & cushway, 2002). however, researchers and clinicians have begun exploring ways in which family systems theory (bowen, 1966) can be applied to the problem of parentification within the context of family therapy (bynghall, 2002; hooper, 2007a). within this form of therapy the parentification and attachment 51 dysfunctional working models which characterize the parentified relationship are dismantled (byng-hall, 2002) as both parents and children come to understand how they function as a connected system of individuals. family systems therapy may aim to assist parents in reducing their reliance on their children (byng-hall, 2002) as well as in helping parentified children understand how their attachment to their parents has been affected by this reliance. a strategy at the level of secondary prevention which may prove effective is the development of treatment plans through identification of protective factors which mitigate the harmful effects of this process (earley & cushway, 2002). lastly, it has been noted that in cases where parentification constitutes severe neglect or maltreatment, temporary removal of the child or the provision of assistance to the parent through community programs may be necessary to protect the parentified child (earley & cushway, 2002). research has demonstrated that parentification can potentially lead to insecure attachment (boszormenyi-nagy & spark, 1973; earley & cushway, 2002; hooper, 2007a, 2007b; katz et al., 2009; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005). given that attachment has been shown to exert an influence on a broad array of areas in both childhood and adulthood (ainsworth et al., 1978; byng-hall, 2002), it is imperative that strategies such as those listed above be further developed in order to target the process of parentification at both the level of the child and the parent. moreover, successful interventions would have multiplicative effects by leading to intergenerational prevention. by addressing the internal working models which promote the intergenerational transmission of parentification, intervention strategies would serve to prevent further parentification by breaking the cycle whereby the parentified child becomes the parentifying adult (barnett & parker, 1998). conclusion first utilized by boszormenyi-nagy and spark (1973) to describe a ubiquitous aspect of social relationships, the term “parentification” has come to refer most commonly to the process through which a child adopts the responsibilities of an adult, with the adult, in turn, adopting the position of the child in the parent-child relationship. while much of the literature has focused primarily on the effects of parentification on adult outcomes (earley & cushway, 2002; hooper 2007a, 2007b, 2008; hooper et al., 2008; jones & wells, 1996; katz et al., 2009; macfie, mcelwain, et al., 2005; mayseless et al., 2004), researchers are beginning to explore the direct and contemporaneous effects of this pathological interaction pattern on child development (earley & cushway, 2002; hooper, 2007a, 2008; jacobvitz et al., 2004; macfie, houts, et al., 2005; macfie, mcelwain, et al., 2005). in particular, researchers have demonstrated growing interest in the implications of parentification for the development of attachment patterns among children. current literature on the influence of parentification on child development has repeatedly concluded that parentified children experience insecure attachments with the parentifying adult which tend to carry forth into adulthood, affecting future relationships with others and even potentially the parentified individual’s own children (earley & cushway, 2002; hooper, 2007a, 2008; katz et al., 2009; macfie, mcelwain, et al., 2005). although parentification is a relatively new area of research, these findings have important implications for future areas of investigation and for the clinical understanding of parentification. most importantly, findings on attachment issues arising from the experience of parentification may illuminate potential pathways through which other outcomes, such as mental illness and social problems, arise. continued research in this area would therefore enhance comprehension of the developmental implications of parentification and would increase knowledge of the ways in which parentification can lead to a variety of other outcomes throughout the lifespan. efforts to develop such an understanding would assist in mitigating the impact of parentification on the lives of those who experience it through the development of prevention and treatment programs. importantly, future undertakings in this area have the potential to address directly the pervasive social problem of child neglect. references ainsworth, m. d., blehar, m., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of the strange situation. hillsdale, nj: lawrence erlbaum associates. aldridge, j. (2006). the experiences of children living with and caring for parents with mental illness. child abuse review, 15, 79-88. doi:10.1002.car.904 barnett, b., & parker, g. (1998). the parentified child: early competence or childhood deprivation? child psychology and psychiatry review, 3, 146-155. doi:10.1111/1475-3588.00234 boszormenyi-nagy, i., & spark, g. m. (1973). invisible loyalties: reciprocity in intergenerational family therapy. new york, ny: brunner/mazel. bowen, m. (1966). the use of family theory in clinical practice. comprehensive psychiatry, 7, 345-374. doi:10.1016/s0010-440x(66)80065-2 bowlby, j. (1958). the nature of the child’s ties to his mother. international journal of psychoanalysis, 39, 350-371. bowlby, j. (1969). attachment and loss: vol. 1. attachment. new york, ny: basic books. byng-hall, j. (2002). relieving parentified children’s burdens in families with insecure attachment patterns. family process, 41, 375-388. doi:10.1111/j.1545-5300. 2002.41307.x chase, n. d. (ed.). (1999). burdened children: theory, research, and treatment of parentification. thousand oaks, ca: sage publications, inc. engelhardt 52 doran, t., drever, f., & whitehead, m. (2003). health of young and elderly informal carers: analysis of uk census data. british medical journal, 327, 1388. doi:10.1136/bmj.327.7428.1388 earley, l., & cushway, d. (2002). the parentified child. clinical child psychology and psychiatry, 7, 163-178. doi:10.1177/1359104502007002005 hooper, l. m. (2007a). the application of attachment theory and family systems theory to the phenomena of parentification. the family journal: counseling and therapy for couples and families, 15, 217-233. doi:10.1177/1066480707301290 hooper, l. m. (2007b). expanding the discussion regarding parentification and its varied outcomes: implications for mental health research and practice. journal of mental health counseling, 19, 322-337. hooper, l. m. (2008). defining and understanding parentification: implications for all counselors. the alabama counseling association journal, 34, 34-43. hooper, l. m., marotta, s. a., & lanthier, r. p. (2008). predictors of growth and distress following childhood parentification: a retrospective exploratory study. journal of child and family studies, 17, 693-705. doi:10.1007/s10826-007-9184-8 jacobvitz, d., hazen, n., curran, m., & hitchens, k. (2004). observations of early triadic family interactions: boundary disturbances in the family predict symptoms of depression, anxiety, and attentiondeficit/hyperactivity disorder in middle childhood. development and psychopathology, 16, 577-592. doi:10.1017/s0954579404004675 jones, r. a., & wells, m. (1996). an empirical study of parentification and personality. the american journal of family therapy, 24, 145-152. doi:10.1080/ 01926189608251027 jurkovic, g. j., & thirkield, a. (1998). parentification questionnaire. (available from g. j. jurkovic, department of psychology, georgia state university, university plaza, atlanta, ga 30303). katz, j., petracca, m., & rabinowitz, j. (2009). a retrospective study of daughters’ emotional role reversal with parents, attachment anxiety, excessive reassuranceseeking, and depressive symptoms. the american journal of family therapy, 37, 185-195. doi:10.1080/01926180802405596 macfie, j., houts, r. m., mcelwain, n. l., & cox, m. j. (2005). the effect of father-toddler and mother-toddler role reversal on the development of behavior problems in kindergarten. social development, 14, 514-531. doi:10.1111/j.1467-9507.2005.00314.x macfie, j., mcelwain, n. l., houts, r. m., & cox, m. j. (2005). intergenerational transmission of role reversal between parent and child: dyadic and family systems internal working models. attachment & human development, 7, 51-65. doi:10.1080/14616730 500039663 main, m., & solomon, j. (1986). discovery of an insecure disoriented attachment pattern: procedures, findings, and implications for the classification of behavior. in m. w. yogman & t. b. brazelton (eds.), affective development in infancy (pp. 95-124). norwood, nj: ablex. mayseless, o., bartholomew, k., henderson, a., & trinke, s. (2004). “i was more her mom than she was mine:” role reversal in a community sample. family relations, 53, 78-86. doi:10.1111/j.1741-3729.2004.00011.x mechling, b. m. (2011). the experiences of youth serving as caregivers for mentally ill parents: a background review of the literature. journal of psychosocial nursing, 49(3), 28-33. doi:10.3928/0279369520110201-01 u. s. department of health and human services, administration for children, youth and families, children’s bureau. (2011). child maltreatment 2010. retrieved from http://www.acf.hhs.gov/programs/cb/pubs/cm10/index.h tm zayas, v., mischel, w., shoda, y., & aber, j. l. (2011). roots of adult attachment: maternal caregiving at 18 months predicts adult peer and partner attachment. social and personality science, 2, 289-297. doi:10.1177/1948550610389822 graduate student journal of psychology (gsjp), volume 18, special issue 2022 a qualitative exploration of the intergenerational transmission of fathers’ discipline methods and involvement in child rearing fina wurm1 claire austen2 katrina mclaughlin1 harriet godfrey1 chinwe anyaorah1 aideen kenny1 laura sugrue1 1 school of psychology, queen’s university belfast 2 school of psychology, university of east london fathering behaviours such as discipline methods and involvement play a significant role in children’s development. one way in which men learn to father is through intergenerational transmission. the majority of studies regarding intergenerational transmission have focused primarily on low-income fathers who experienced harsh discipline methods or neglect as a child. this study aimed to fill a gap by exploring intergenerational transmission among participants who have varying socio-economic backgrounds and had relatively positive fathering experiences. this study was guided by the research question, “how has the transmission of fathering behaviour between generations influenced fathers’ discipline methods and involvement in child-rearing?” implementing a qualitative approach, semi-structured interviews were conducted with ten fathers who were recruited through convenience sampling. thematic analysis of the interview data resulted in three major themes: 1) contemporary and traditional fathering behaviours and involvement, 2) discipline methods and 3) changes during fatherhood. the findings indicated an intergenerational change toward more emotive, communicative and contemporary fathering involvement and a move toward constructive discipline methods. the findings also highlighted an unstudied area of intergenerational research, namely, the intergenerational influence on the changes in relationship between a father and their child as the child grows into adulthood. this study has implications for improving familial well-being. for example, by fostering necessary discourse about the generational influences that contribute to fathering behaviour and its subsequent effects on child development between generations. keywords: intergenerational transmission, fatherhood, discipline, involvement our understanding of the multifaceted concept of fatherhood is continuously adapting. over the last century, the role of fathers has changed in response to society’s understanding of masculinity and, as a result, different models of fatherhood have emerged. during the era of industrialisation, a father was solely expected to financially provide for his family and a mother was considered the primary caregiver, subsequently giving rise to the breadwinner model of fatherhood (pleck, 1984). due to © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, 137-148. graduate student journal of psychology wurm et al. the influence of world war two, the great depression and the new deal, fathers were expected to display personality traits of strength and courage (pleck, 2018). as a result, their role became less traditional as they took on the responsibility of becoming role-models to their children, rather than just providing financially for them (pleck, 2010). with the advent of increased interest in fatherhood and parenting generally in the 1960’s, john bowlby’s seminal work on attachment fostered controversial discourse on the topic of fatherhood. in particular, bowlby’s original monotropic hypothesis of attachment, which focused solely on the mother’s role and disregarded the father as a co-principle figure, acted as a catalyst for further research (bowlby, 1958). upon the influx of new research in the 1970s, the nurturing model of fatherhood was propounded which established the father as an active co-parent of equal importance (griswold, 1995). studies of fatherhood began to acknowledge the psychological (palkovitz, 2002), emotional (lamb, 2002) and economic (graham & beller, 2002) contribution a father makes to the development of his child. with the awareness of the father as a co-parent, policy makers increased their focus on fathers’ rights, establishing paid paternity leave and access to children after divorce ("paternity pay and leave", 2020). much of the recent literature on fatherhood addresses four themes: differences between fathering and mothering, the father-infant relationship, the roles fathers play in the family and how men learn to father (shears et al., 2006). one contribution of how men learn to father is known as intergenerational transmission, defined as learning from the family of origin (cowan & cowan, 1987). intergenerational transmission from father to father has been demonstrated by a small number of studies as this field is still in its infancy. a study of israeli fathers found a significant correlation between men’s satisfaction as fathers and their past and current relationship with their fathers (sagi, 1982). in addition, studies have shown that fathers imitate specific fathering skills and behaviours. for example, constructive discipline methods (chen & chaplin, 2001), warm fathering relationships (coysh, 1984), and severe discipline strategies (belsky, conger & capaldi, 2009; niu, liu & wang, 2018). furthermore, shears and colleagues (2006) identified the remodeling of behaviour when fathers experienced the absence, either physically or emotionally, of their own fathers. their findings suggested that fathers may model positive behaviour from a variety of sources, including peers and men in media if not experienced personally (shears et al., 2006). this process of learning by observation and imitation is supported by social learning theory (slt), which posits that humans’ learning and behaviours are influenced by both environmental and cognitive factors (bandura, 1977). slt applies to this present study on intergenerational transmission by focusing on how fathers’ behaviours, such as disciplining and involvement, are learnt from their own fathers and influenced by their environment as a child. the effect of discipline on a child is a strong predictor of how the child will subsequently develop (fisher & fagot, 1993; durrant, 2020). discipline is the primary topic of research in this field, and has been conducted predominantly on low-income, workingclass families, typically with negligent father role-models (belsky, conger & capaldi, 2009; niu, liu & wang, 2018; pears & capaldi, 2007; pears, capaldi & owen, 2007). the main objective of these studies was to investigate the mechanisms of intergenerational harsh or abusive discipline in order to prevent the recurring pattern between generations. harsh or abusive discipline strategies are associated with causing emotional and physical harm to the child, often on a long-term basis. the child can suffer harm to their dignity, their self-respect and esteem, and lose their positive sense of self (fisher & fagot, 1993). the alternative, positive discipline, understood graduate student journal of psychology a qualitative exploration of the intergenerational transmission of fathers’ discipline methods and involvement in child rearing as an approach to explaining desired behaviour to the child through open and clear communication (okorn et al., 2021), paints a vastly different image of child development. positive discipline has been associated with developmental outcomes such as emotional regulation, self-control, and positive social behaviours (durrant, 2020). yet despite its importance on child development, how fathers learn positive discipline is neglected in the literature. instead, research so far has elucidated valuable insights into harsh intergenerational discipline in low-income families. this study sought to explore an overlooked aspect of intergenerational discipline, notably, fathers’ experiences of discipline that was positive or mild in nature, and whether or not it continued between generations. in addition to discipline, fathering involvement has been shown to be a strong predictor of child development (mischel, shoda, & peake, 1988). in an era where middleclass fathers’ involvement is changing between generations, due to increased numbers of mothers in the workforce and divorce rates, fathers may be adopting new skills and behaviours to adapt to this shift (shears et al., 2006). research to date has focused on the effect of negligent fathering on the next generations’ fathering involvement. while the pool of studies is small, the findings provide initial support for the idea that lack of paternal involvement results in increased involvement in the next generation (shears et al., 2006; wilkinson, khurana & magora, 2013). these studies provide much needed insight into the attitude of fathers who experienced neglect as a child and how this led them to be more involved with their children. however, they do not address the behaviours associated with increased involvement. therefore, two primary gaps in the literature prevail. firstly, how fathers’ involvement is influenced generationally having had a positive fathering experience, and secondly, what behaviours are then adopted or adapted by these fathers as a result. ample studies have demonstrated that involved fathering contributes to the development of children with greater tolerance to stress (mischel, shoda, & peake, 1988), with greater ability to solve problems and adapt in situations (biller, 1993) and a host of other necessary life skills. thus, understanding how intergenerational transmission influences fathering involvement is vital for bettering the father-child relationship. this study sought to fill a gap, in light of the aforementioned literature, by exploring the intergenerational transmissions of fathering behaviour and how this influences discipline methods and involvement. given the effects that discipline strategies and fathering involvement has on a child’s development, researching the intergenerational transmission of these areas is paramount. furthermore, encouraging men to reflect on their experiences with their fathers and educating men on the influence this has had on their fathering lives may result in increased positive involvement. subsequently, this could lead to improving the child’s potential for optimal development. this positive relationship has been shown to repeat between generations, improving the well-being of families (brown et al., 2017), justifying the validity and necessity of conducting this research. this study was guided by the research question: how has the transmission of fathering behaviour between generations influenced fathers’ discipline methods and involvement in child-rearing? method design following ethical approval by the queen’s university belfast faculty of engineering and physical sciences research ethics committee, a qualitative methodology was employed. ten semi-structured interviews were conducted with fathers. themes were generated from this data using thematic analysis. this explorative study was not bound to any particular pre-existing theoretical or epistemological framework, hence thematic analysis appeared appropriate and accessible. wurm et al. graduate student journal of psychology participants a total of ten participants with at least one child participated in this study. this sample size was chosen so data would be collected until the point of data saturation, which was reached during analysis. recruitment took place in the form of convenience sampling, with each researcher recruiting and interviewing two participants. participants were known friends and family of the researchers and received no compensation for taking part. the research explored various perspectives, so did not specify demographic traits including age, marital status or ethnicity. as such, participants’ demographic traits were moderately varied (table 1.) with participant’s ages between the ages of 27 and 68 (mean age = 51.9., sd = 12.92). measures data was collected through one-to-one, semi-structured interviews. interviews consisted of ten pre-set questions (appendix 1). these questions were chosen and appropriately adapted by the researchers from a reputable qualitative study examining the intergenerational transmission of fathering styles (shears et al., 2006). the researchers all used the same semi-structured schedule (appendix 1). procedure having expressed interest in participating, interviewees were given an information sheet conveying the study’s purpose and requirements. before the interviews took place, informed written consent was obtained from each participant. one-to-one, in-person interviews lasting approximately 20-25 minutes were conducted at a time and location convenient to the participant. participants were interviewed by the researcher that recruited them as it was felt this may allow participants to feel more comfortable sharing their experiences. notably however, all interviewers were female, and were not parents themselves, which may have limited their rapport with participants. the interview schedule (appendix 1) was semi-structured, primarily utilising open-ended questions about experiences and perceptions of fatherhood. researchers used prompts and reflection to clarify the content of responses. all ten interviews were conducted during the same two-month period. interviews were audio-recorded and transcribed verbatim. by including repetition, false starts, laughter and incomplete sentences, no spoken material was lost. following the interview, participants received a debrief sheet thanking them for participating and listing researchers’ contact details and relevant organisations should they need support. data analysis braun and clarke’s (2006) thematic analysis model was employed to analyse the data. researchers analysed data from the participant that they had recruited and subsequently interviewed, meaning each researcher transcribed and coded two interviews. researchers transcribed the respective audio-recording verbatim, ensuring anonymity by assigning identification numbers (e.g., p1) and reducing identifiable names to a single initial. interviews were then read whilst listening to the audio, allowing checks for ‘accuracy’ and familiarisation with the data. researchers then conducted three primary stages of analyses; initial code generation, searching for themes, and reviewing themes. initial code generation used a combination of in-vivo and descriptive coding to code each interview, line-by-line. initial codes from the entire data set were collated in an excel file, before being searched for significant patterns or ‘themes’, which were all generated inductively. an initial table of codes and themes was then generated. these themes were reviewed by checking against the original data set, subsequently splitting, combining, or discarding some initial themes such as ‘communication’. a final table containing three a qualitative exploration of the intergenerational transmission of fathers’ discipline methods and involvement in child rearing graduate student journal of psychology core themes was then generated. this process was iterative, not linear, with earlier steps being returned to at multiple points during analyses. results the major themes that emerged from the data analysis were the following: contemporary and traditional fathering behaviours and involvement, discipline methods and changes in fatherhood. contemporary and traditional fathering behaviours and involvement for most participants, their fathering involvement consisted of behaviours deemed contemporary. fathers acknowledged the influence their experiences with their fathers had on their subsequent behaviour with the majority reporting a discontinuation of paternal behaviours perceived as more traditional in nature. these traditional behaviours, in this case referring to societal expectations of the role of the father as the breadwinner, disengaged from and with limited involvement in child rearing, were experienced by all of the fathers as children. fathers consciously were more involved in child rearing as a result and the following contemporary behaviours were identified: play and emotional guidance. play play took form in adult-lead and non-directed play with the objective of both being to spend additional quality time with their children. one father reported the absence of his own father in the evenings and his desire to avoid this behaviour by engaging in play. he reported “never [having] that much time with him” or seeing “him in the evening”. this absent behaviour was discontinued with his children as they “always did something in the evening, like playing board games”. he stated, “we spent so much time together” (p1). another father reported similar absences with his father due to him “working six days a week” and engaged in non-directed play to discontinue this behaviour and increase his involvement with child rearing. he also spoke about adapting the nature of his involvement to accommodate his son’s changing interests, reporting: “i took them out, took them to play areas, little bit later in my life, well, my son’s life, i took him to sporting occasions” (p2). emotional guidance and communication fathers reported a lack of emotional guidance from their fathers and their desire to discontinue this traditional behaviour. one father reported his experience of emotional and physical distance from his parents due to being educated in a boarding school, stating he “felt that [boarding school] created a distance because you’re away from your parents for months at a time” (p5) and subsequently avoiding emotional distance by ensuring emotional involvement in contemporary behaviours such as “being there for your children when they need you. being able to offer advice. sharing your experiences. being able to provide security and showing them the right path as far as you can” (p5). another father reported his desire to provide his daughter with non-judgemental support through open communication stating he “want[s] to make sure she feels she can tell [him] anything without judgement so [he] can help her where [he] can because it wasn’t done with [him]” (p4). the findings indicated the majority of fathers discontinued traditional fathering and became more involved in child rearing than their fathers, especially through play, communication and emotional guidance. however, one father interestingly noted the continuation of one traditional fathering behaviour: lack of touch. he reported touch in the form of hugging was “something [his] father didn’t really do to [him]” nor was it wurm et al. graduate student journal of psychology “something [he does] now either as [his] whole family is like that now” (p4). discipline methods the findings indicated fathers’ methods of discipline were influenced intergenerationally. this occurred in three ways: the continuation of positive discipline methods and strategies, the adoption of constructive discipline and open communication if this was not experienced by the fathers as children, and lastly, the continuation of physical discipline. continuation of positive discipline methods and strategies fathers that had experienced positive discipline reported their desire to continue this approach with their children. one father reported having an “easy-going dad (in relation to discipline)” who “left me to my own devices” (p9). this trusting relationship inspired his approach with his own child, “i then did that with my own daughter” (p9). constructive discipline strategies were also continued from father to father as reported by one participant, “i would use the same discipline methods my parents did. like take phones, send to room…” (p3). the adoption of constructive discipline and open communication discipline methods were influenced intergenerationally by the adoption of constructive discipline and open communication if this was not experienced by the fathers as children. one participant noted the lack of communication between him and his father regarding disciplinary consequences of his actions and adopted a “completely different” approach with his children. he noted: “i don’t think it was ever clear to me what i was supposed to do. it was kind of murky and foggy expectations […] in comparison, we spoke before we went about what we wanted to do, everybody knew what they were supposed to do, everybody was always happy” (p1). the continuation of physical discipline physical discipline was found to be intergenerationally influenced. some fathers that experienced physical discipline as children reported their dislike of using physical reprimands as fathers but acknowledged the effectiveness of this method. one father reported, “the way my parents disciplined me was very harsh and firm. they were usually physical [...]. i did tell myself when i was younger that i would never use physical discipline and i don’t necessarily agree with it, but i have used it” (p3). another participant reported not using physical discipline with his daughter but reported hypothetically using this approach if “[he] had a son and if circumstances lead to it”. i don’t think it’s right to do but it may be effective” (p4). two fathers reported experiencing this approach as children and only resorting to using this as adults on rare occasions, followed by feelings of regret. one father reported “my dad would occasionally hit one of us [...] physical reprimands was something i did not want to do other than one exemption that i highly regretted” (p9). this feeling of regret was mirrored by a second father who stated, “i do remember slapping one of my kids on one occasion and never doing it again” (p2). changes during fatherhood during childhood, paternal roles were characterised as practical and physical. for example, one father stated that key tasks included “feeding, homework and school runs” (p5), whilst another father described “taking the children out walking and riding bikes” (p7). however, fathers reported a shift in the paternal role with the onset of adolescence. one father described being able to “reason with the teenagers more” (p7), whilst another reported an increase in time spent talking, stating that they “read and discussed things together” (p2). however, this change also appeared to generate increased conflict. one a qualitative exploration of the intergenerational transmission of fathers’ discipline methods and involvement in child rearing graduate student journal of psychology participant described interactions characterised by “tempers and turmoil” (p7) and another father reported their relationship with their teenage son as being “more challenging of late” due to his frequent “challenges to authority” (p5). in response to this, the paternal role became primarily characterised by attempts to align discipline alongside, what one father described, their child’s developing “expectation of fairness and consistency” (p7). this transition appeared to be intergenerationally consistent, with fathers reporting that during childhood, the majority of time spent with their fathers was engaged in physical activities. for example, one participant described how their father ‘would have played football with [him]” (p7). during their teenage years, however, this shifted as a larger emphasis was put on discipline and conflict. one father noted that during adolescence, he and his father “disagreed on a lot of things” (p8) whilst another described “arguing” to the extent that it led to “physical discipline” (p3). another shift is then observed with the child’s transition into adulthood. one father reported that the aforementioned “turmoil between us [them] settled down” (p7). what was previously characterised by conflict, became defined by emotional support and friendship. one father reported that “as they got older, it’s more of an emotionally protective role” (p9). two participants stated that as the child becomes an adult, fathering is characterised by friendship, with one participant stating that “you become more of a friend, if you’re lucky” (p7). the nature of this shift appears intergenerationally inconsistent, as whilst participants noted changes in their relationships with their fathers at the onset of adulthood, these changes were not characterised by emotional support and friendship, but rather by distance. for example, one father described “a separation between [himself and his father]” (p7), whilst another noted that as they grew older, their father “was never around” and that their relationship became characterised by “distance” (p10). this suggests that in previous generations, upon the child reaching adulthood, the paternal role diminished rather than evolved. discussion the findings of this study demonstrated that the participants believe it is important to be involved in rearing their children. their involvement indicated an intergenerational change toward more emotive, communicative, and contemporary fathering. other studies have supported this perceptual shift in involvement between generations because of the absence of positive fathering behaviour (shears, summers, boller & barclay-mclaughlin, 2006; wilkinson, khurana & magora, 2013). however, it is important to note that in these studies, the lack of fathering was often characterised by negligence. in the current study, the participants’ fathers were generally physically available, but not involved in active parenting. yet, in both instances, the participants grew up desiring more involvement than was given. this subsequently informed their attitudes to fathering. in the current study, fathers adopted contemporary behaviours such as play, emotional guidance and communication to be present with their children. these findings indicated a strong shift in perception regarding the adoption of roles historically associated with mothering, increasing father involvement in child-rearing (wilkee, 1993). the findings showed a continuation of positive discipline methods between generations. the participants adopted constructive strategies that they did not experience as children. sagi (1982) suggests that this process of behavioural remodelling may occur by observation and imitation of other male role models, such as peers. unlike previous wurm et al. graduate student journal of psychology studies investigating physical reprimanding discipline methods (belsky, conger & capaldi, 2009; niu, liu & wang, 2018; pears & capaldi, 2007; pears, capaldi & owen, 2007), the findings indicated that the participants did not employ these strategies with their children, thus the breaking the pattern. however, some participants showed a propensity for physical discipline, regretting it immediately after it is employed. importantly, the discipline methods in other studies were severe and those fathers often had negligent role models, unlike the conditions experienced by the participants in this study. these findings suggest that when men experience mild physical discipline with fathers that present as generally positive role models, the influence inspires a remodelling to more constructive strategies. research investigating this phenomenon has not been studied before, subsequently, it is an area of future research. the relationship changes that occur between father and offspring as the child becomes an adult is an unstudied aspect of intergenerational transmission. findings indicated that the participants felt that they offered more emotional guidance as their child aged, bringing their relationship closer, shifting their role from father and child to friends. this was unlike that of the previous generation, where the participants had experienced increasing emotional distance from their own fathers as they got older. thus, it appears that fathers’ increased involvement in child-rearing from infancy contributes to a nurturing relationship in adulthood. limitations due to the cross-sectional study design and small sample size, caution should be taken regarding the generalisability of the findings. as the population was 90% white european, greater diversification is needed to understand positive role modelling and its generational influence on fathering in different cultures and ethnicities. nevertheless, this study furthered current literature in that it utilised a middle-class population sample with generally positive fathering role models. a second limitation is that interviews were conducted and analysed by different researchers. while the same semi-structured schedules were used, there may have been inconsistencies in questioning styles (i.e., probes, prompts) which may have elicited different types of responses. lastly, this study relied upon participants’ memories of their childhood. the retrospective nature of asking participants about how they were treated by their fathers may have resulted in memory errors such as misremembering or not remembering (belsky, conger & capaldi, 2009). implications the findings suggested that some participants who experienced mild physical discipline as children showed a propensity for this behaviour yet regretted employing it. accordingly, a short-term program on constructive discipline could be beneficial to educate these fathers and prevent that discipline strategy generationally. furthermore, the findings support the utility of policies that encourage involved fathering, such as paternal leave after birth (“paternity pay and leave", 2020). as evidenced in this study, boys desire an involved, active relationship with their fathers. thus, programs regarding involved fathering behaviours and strategies are also highly encouraged, especially as the benefits of attending could be passed onto generations to come. additionally, this study provides preliminary research on the influence of intergenerational transmission on the changing relationship between father and child. the findings indicated that more emotional and involved fathering when children are young, leads to closer relationships and friendship in the long run. research has yet to be done on the influence of the relationship between an elderly father and his adult child, and how this effects future generations. the implications of which would provide rich new insights into this adult relationship while elucidating attitudes and behaviours in caring for elderly parents. a qualitative exploration of the intergenerational transmission of fathers’ discipline methods and involvement in child rearing graduate student journal of psychology positive relationships between father and child have been shown to repeat between generations, improving the well-being of families (brown et al., 2017), and lives of children. this positive relationship could be fostered on a societal level by encouraging men to reflect on their experiences with their fathers and educating men on the influence this has had on their fathering lives. doing so would allow men to gain a deeper understanding of the importance of fathering which may motivate fathers to contribute more to the lives of their children. an increase in positive involvement will subsequently improve children’s potential for optimal development. conclusion the purpose of this study was to explore the intergenerational transmission of behaviour and how this influences fathers’ discipline methods and involvement in child rearing. thematic analysis of ten semi-structured interviews indicated an intergenerational change toward more emotive, communicative, and contemporary fathering involvement and constructive discipline methods. an unanticipated finding emerged indicating the relationship between father and child became closer with age, unlike that of the previous generation which experienced emotional distance. findings from this study could be used to inform further quantitative research, regarding participants with generally positive fathering experiences, to elicit more generalisable results. future research could investigate whether fathers who have experienced certain behaviours as children, such as mild physical discipline or play, have chosen to continue or discontinue these behaviours between generations. findings from this research could highlight whether a man’s experience with his father is a strong predictor of his future fathering style, and if not, it raises the question of what other source of education fathers model their behaviour on. future quantitative research could also utilize surveys to examine whether involved fathering behaviour, such as play, between a father and his infant is a predictor of relationship satisfaction between an elderly father and his adult child. the results of which could inform clinical interventions that aim to teach fathers activities which enhance engagement between a father and his infant. there are a host of parenting programs for fathers that experienced adversity, a population that undoubtedly should be prioritized. however, there is a lack of programs for fathers without this background. while targeting this population might seem unnecessary, this study has highlighted that even within generally positive relationships, negative aspects can form behavioural patterns between generations. this was particularly the case regarding mild physical discipline. additionally, within a generally positive relationship, the level of fathering involvement might not be optimal for the child’s development. this was demonstrated through statements of participants that lacked emotional involvement. therefore, programs that teach strategies in involved fathering such as play, emotional guidance and communication, and also in constructive discipline methods should be considered for fathers of all socio-economic standings and experience with adversity. as crucially, no matter the socio-economic background, fathers’ discipline methods and involvement play an integral role in the development and wellbeing of a child. acknowledgements the author declares no conflict of interest with respect to their research, authorship, and/or publication of this article. this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. this research was wurm et al. graduate student journal of psychology completed in partial fulfilment of the msc psychological sciences at queens university belfast. correspondence concerning this article should be made to fina wurm, research assistant at queens university belfast. email: fwurm01@qub.ac.uk references bandura, a., & mcclelland, d. c. 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(1993). changes in u.s. men’s attitudes toward the family provider role, 1972– 1989. gender and society, 7, 261–279. appendix appendix 1 interview questions 1. what age did you become a father, and can you remember how you felt in the first couple of months? 2. can you tell me a little bit about your children? how many do you have and what ages are they? 3. could you describe the relationship with your children now and specifically how has that relationship changed over time? 4. can you tell me how you and your wife parented your children, for example the responsibilities you may have shared or delegated, or the difficulties of co-parenting or your experience of doing it generally? paternity-pay-leave wurm et al. graduate student journal of psychology 5. can you tell me about any of the similarities or differences in the way that you disciplined your children and how you were disciplined by your parents? 6. can you describe your fathers parenting style? what kind of father was he? 7. can you describe any similarities or differences in his fathering style and yours? 8. do you think your relationship with him influenced how you wanted to be as a father? 9. what does being a father mean to you? 10. what are you proudest of about yourself, in your experience of being a father? table 1 codes and themes codes themes play emotional guidance touch contemporary and traditional constructive communication physical discipline methods practical responsibilities emotional guidance communication discipline changes in fatherhood table 2 participant information participant id age marital status no. of children location 1 59 married 2 republic of ireland 2 68 married 4 republic of ireland 3 54 married 4 republic of ireland 4 28 single 1 republic of ireland 5 61 widowed 3 england 6 43 married 3 england 7 62 second marriage 5 (3 step children) northern ireland 8 31 married 2 (1 step child) northern ireland 9 56 married 3 republic of ireland 10 58 married 1 republic of ireland 74 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university social, behavioral, and academic ramifications of video game playing in college alexa camaganacan department of psychology and philosophy, texas woman's university young adults within the college-aged range (1825) spend nearly seven hours a week on average playing video games (limelight, 2019). video game usage has been linked to positive mental health effects in both clinical and non-clinical studies as an alternative to psychiatric medication as well as reducing symptomology of psychological issues (carras et al., 2018; fish et al., 2018). psychological well-being in college students may be a significant facet of school performance (punia & malaviya, 2015). general technology usage may also be a facet in determining psychological well-being (barkely et al., 2014; bjornsen et al., 2015; lepp et al., 2014). to fully understand video gaming habits and how they may affect college students’ academic performance, the psychological factors associated with well-being should be considered. video game usage young adults within the college-aged range (1825) spend nearly seven hours a week on average playing video games (limelight, 2019). as of 2019, nearly 46% of gamers are women (gough, 2019). most gamers define themselves as ‘casual’ gamers, and mobile devices such as smartphones or tablets are the most used means of playing video games. in the us, casual single-player games, such as angry birds or candy crush, are the most popular types of games, followed by casual multi-player games (e.g., words with friends) and first-person shooter (e.g., call of duty or overwatch). additionally, 56% of frequent gamers play multiplayer games, according to the entertainment software association ([esa], 2018). other popular game genres include massive multiplayer online (mmo), simulations, real-time strategy (rts), puzzles, action, stealth shooter, combat, sports, role-playing games (rpg), and educational games (thought catalog, 2015). because of the rising usage of video games, concerns about related psychological issues have been discussed. the diagnostic and statistical manual of mental disorders, 5th edition (dsm-5) recognized internet gaming disorder, or igd, as a condition warranting further research and included symptoms such as preoccupation with gaming, continuing to focus on gaming despite the presence of problems, and jeopardizing jobs or relationships due to continued gaming (american psychiatric association [apa], 2013). continued research on igd notes men are more at risk for developing igd and igd is frequently comorbid with other psychological issues such as depression, anxiety, aggression, and obsessive-compulsive symptoms (zajac et al., 2017). additionally, igd may place an individual at risk for physical health problems, such as being overweight or obese, sleep disorders, or a heightened risk for seizures (li et al., 2017). higher levels of gameplay time were also associated with issues related to psychosocial adjustment and lower levels of life satisfaction (przybylski & mishkin, 2016). despite the potential issues that arise with poor gaming habits, video game usage has been associated with certain positive mental health outcomes. in recent years, video games have been used experimentally the purpose of this research project is to determine whether video game usage influences the psychological well-being of college students. this project seeks to understand technology usage habits among students and whether this affects school performance. previous research suggests video games may be used to treat psychological issues such as anxiety. self-report studies note video games were helpful in certain populations in coping with stress, developing positive social behaviors, and improving cognitive abilities (carras et al., 2018; nuyens et al., 2019; schuurmans et al., 2018;). since psychological well-being is a crucial factor in academic performance (carton & goodboy, 2015; punia & malaviya, 2015), the current study will examine potential relationships between gaming and college gpas. poor habits related to technological usage may lead to negative mental health outcomes. a survey examining these factors was completed by college students at texas woman’s university. the survey was composed of questions from the internet gaming disorder scale, psychological wellbeing scale, and boundary management subscale. data was tested using anovas, a tukey hsd test as a post hoc test, and eta squared. the results of the data found gaming tendencies were not significantly associated with gpa but were associated with negative mental health outcomes and increased issues with technology boundary management. the study has marked limitations, due to the lack of non-gaming survey participants and most respondents identifying as female. these findings may be useful for clinicians in treating addictive gaming tendencies. future research should examine more diverse student populations. keywords: college students, gaming addiction, gpa, boundary management, psychological well being 75 ramifications of video game playing in college to treat mental health issues. in one recent study, casual video game play (cvg) was assigned to patients who were prescribed selective serotonin reuptake inhibitor (ssri) medication (fish et al., 2018). the cvg group continued to take medication while utilizing cvg but was compared to a treatment control group that only prescribed two forms of medication. the results indicate that cvg was effective in treating symptoms associated with anxiety disorders and could be used as an alternative prescription to extensive medication (fish et al., 2018). in another recent study, a video game-based intervention addressed internalizing problems for youths with behavioral problems within residential care facilities (schuurmans et al., 2018). the study also explored the psychological effects of treatment on youths’ mentors. both youth groups in the study received ongoing psychotherapy or prescribed medication as recommended by clinicians; however, only the experimental group received the game intervention. at the end of the study, the group that participated in the video game intervention self-reported improvements in both anxiety and externalizing problems immediately after the study and at a 4-month follow-up. the study also indicated improvements in the mentors’ anxiety levels at the immediate follow-up (schuurmans et al., 2018). another form of clinical research on video games used game intervention to treat negative mental health outcomes and used in-game behavior to predict treatment outcomes. in a study conducted by wols et al. (2018), a video game intervention was used to teach children coping methods for anxious behaviors as well as define children’s behaviors as “engaged” or “avoidant/safety” based on in-game actions (wols et al., 2018). the researchers noted that game-based interventions could be useful in tailoring engaging interventions for children, and the game itself could be useful in recognizing specific anxiety-related behaviors to be targeted in therapy (wols et al., 2018). non-clinical trial research on video game usage and positive mental health outcomes have also shown notable results. carras et al. (2018) interviewed military veteran gamers about their experiences and how gaming assisted with aspects such as coping or wellbeing. most of the individuals in the sample reported post-traumatic stress disorder (ptsd) symptoms or some other form of trauma-related issues. while many of the veterans reported they used gaming as a means of distraction from their mental health issues, the interactivity and narrative focus of games can help veterans develop insight into their own thoughts and feelings, which is useful for clinicians in assessing suicidality. video games offered veterans opportunities for leadership and social opportunities through multiplayer games; these virtual spaces helped veterans develop support systems that are a major element in recovery interventions (carras et al., 2018). a dutch study examined the relationship between competitive video game usage and children’s social development in conduct problems, peer relations, and prosocial behaviors (lobel et al., 2019). the results did not indicate any significant changes in prosocial behaviors but found that children who played competitive games reported improvements in conduct problems and peer relations. the researchers note that competitive gaming in the home environment should be viewed within the context of self-improvement and comradery (lobel et al., 2019). a study conducted by stiff and kedra (2018) examined the effects of intergroup social video game play on reducing prejudice. participants in the study either played the game alone or with an outgroup partner and were told their opponent was either human or computer-controlled; all participants rotated between the four conditions of the study. the results of the study indicated that participants who played collaboratively with outgroup members also reported higher levels of favorability towards the outgroup. stiff and kedra (2018) concluded the findings of their study could be a potential utility of video games in reducing prejudice between groups. lastly, specific video games may be useful for improving cognitive functions in specific aspects such as top-down control and processing speed (nuyens et al., 2019). research was compiled from multiple studies and focused on specific cognitive aspects such as attention, task-switching, and time perception. many studies examined by researchers noted cognitive flexibility relative to task-switching was higher in gamers compared to non-gamers and gamers exhibit a higher global attention level and processing speed. lastly, the literature also indicates that gamers display higher sub-second time perception, but research in this aspect is still largely limited (nuyens et al., 2019). in general, video games have the potential to improve different facets of psychological health. 76 camaganacan psychological wellbeing and academics psychological well-being describes multiple facets of functioning that relate back to overall psychological health. psychologist carolyn ryff divided psychological well-being into six major categories: self-acceptance, autonomy, personal growth, positive relationships, environmental mastery, and purpose in life (ryff, 2014). self-acceptance describes a person’s attitudes towards themselves and their ability to accept both good and bad qualities. autonomy is a measure of self-determination, independence, and the ability to resist societal pressure to think for oneself. personal growth is a person’s feeling of continued development and openness to new experiences. positive relationships describe a person’s warm, satisfying, and trusting relationship with peers or family as well as the capacity to extend empathy to others. environmental mastery measures a person’s sense of mastery and competence in utilizing external activities and opportunities. lastly, purpose in life gauges a person’s direction in life and longand short-term goals (ryff, 2014). college students many studies have explored different aspects of psychological well-being in college students to identify specific internal or external factors that affect students’ well-being. a study conducted by ludban in 2015, based on ryff’s categories, measured the psychological well-being of a sample of college students to understand the positive and negative factors that influence their psychological health. the results of this study suggest gender, age, support, and financial welfare are the primary aspects that predict psychological well-being in college students. receiving support from family or friends, especially in specific circumstances for non-traditional students, is a significant factor in lowering stress and maintaining emotional mastery (ludban, 2015). researchers have also examined the relationship between psychological instability and the propensity for developing psychological issues such as depression in an undergraduate sample (gable & nezlek, 1998). students reported on facets of their psychological health such as anxiety, self-esteem, and causal uncertainty. results indicated students who reported lower levels of psychological well-being were at a higher risk for depression. additionally, while the relationship between daily adjustment and depression risk is complex, day-to-day instability should be considered to fully understand the trajectory of depression (gable & nezlek, 1998). specific lifestyle aspects of psychological well-being have also been examined (ozpolat et al., 2012). the researchers utilized a lifestyle inventory to measure and categorize students’ lifestyles into five sub-dimensions: control, perfectionism, pleasing, self-esteem, and expectations. findings indicated students with low self-esteem and need-to-please lifestyles are at a greater risk of negative psychological wellbeing outcomes, compared to students who are expectation-oriented. students who fit this lifestyle criteria may still maintain positive relationships with others but may do so at the cost of their own desires and well-being (ozpolat et al., 2012). additional findings indicated that students who engaged in task-oriented coping strategies also self-reported higher levels of psychological well-being (punia & malaviya, 2015). academic performance studies examining the relationship between psychological well-being and college students’ academic performance have been mixed. for example, the connection between the academic performance of firstyear undergraduate students and their psychological well-being was examined (topham & moller, 2011). results did not indicate an association between psychological well-being and academic performance at the end of the first year, but students with clinical levels of personal concerns may still be at risk for developing psychological health problems (topham & moller, 2011). a similar study conducted in 2015 by punia and malaviya also examined the relationship between college students’ academic performance and psychological well-being. the results indicated that while most of the participants self-reported medium levels of well-being and average academic performance, those who reported medium or high levels of academic performance also reported higher levels of psychological well-being. in general, psychological well-being can affect both broad and specific areas of a college student’s academic performance. although igd symptoms may make it difficult for an individual to prioritize school responsibilities over gaming, research examining the effects of video game usage on academic performance has varied results. an early study from 2007 attempted to explore the correlation between academic performance and overall time spent on gaming. anand’s study utilized sat scores and overall gpa as a gauge of academic 77 ramifications of video game playing in college performance. the results of anand’s analysis showed that extensive gaming habits had a negative impact on both gpa and sat scores. however, anand emphasizes that sat scores only represent a single instance of academic performance and extrapolating conclusions may be difficult (anand, 2007). a 2014 study conducted by drummond and sauer examined collected data from adolescents to view the effect size of video game usage on academic achievement in science, mathematics, and reading. across the data, differences in academic performance were negligible although the researcher noted that reading performance did show a noticeable decline but did not reach the cutoff level (drummond & sauer, 2014). a longitudinal german study from 2018 also examined the long-term effects of extensive gaming time on a sample of adolescents. gnambs et al. (2018) specifically looked at the effects of the amount of time students spent playing computer games on their overall grade performance and competencies in math and reading. the study results indicated that students who played games most frequently would have a decline in grades in the proceeding years, but they did not show marked decreases in math and reading competencies (gnambs et al., 2018). a few studies found that moderate video game use may be beneficial for skills related to academic development. one study from 2013 explored the effects of strategic games (i.e., specifically strategy or rpgs) on students’ self-reported problem-solving skills over time. adachi and willoughby (2013) found students who played strategy games predicted higher levels of problem-solving skills. the researchers also noted that higher problem-solving skills were associated with higher levels of academic achievement in students (adachi & willoughby, 2013). another study by przybylski and mishkin (2016) examined the difference in effects of overall game time on adolescents’ behavior, as well as comparing students who play cooperative games versus single-player games. students in the sample who played for less than an hour a day had lower levels of conduct issues and hyperactivity, but students who played for more than three hours a day had higher levels of behavioral issues. additionally, students who primarily played single-player games had lower levels of behavioral problems and higher levels of academic achievement; students who played cooperative or competitive games were more emotionally stable and reported better relationships with their peers (przybylski & mishkin, 2016). ventura et al.’s online study from 2013 compared the levels of persistence with tasks exhibited by gamers compared to non-gamers. during the study, persistence was measured using anagram or riddle tasks, which were correlated with a self-reported measure of persistence and examined alongside self-reported levels of gaming time. individuals who reported higher levels of gaming time spent longer time persisting on tasks (ventura et al., 2013). further research has examined the link between psychological well-being and aspects of school performance. for example, the exploration of the concept of belongingness at a university, and how it is affected by students’ values, university norms, health, and academic outcomes have been examined (suhlmann et al., 2018). findings indicate that a sense of belongingness at a university contributes to overall psychological well-being and reduces dropout intention. furthermore, a dignity self-construct is a major aspect of the relationship between student belongingness and the norms and values of the university (suhlmann et al., 2018). in addition to university retention, psychological well-being also affects the way students are involved in classroom participation (carton & goodboy, 2015). carton and goodboy’s (2015) study examine how psychological issues such as depression, stress, and anxiety affect interaction involvement, and how these results could extrapolate to a classroom setting. the results indicated stress and depression were both negatively related to responsiveness and attentiveness, while anxiety was only related to attentiveness. it was concluded that these results could interfere with student class performance with symptomatology such as rumination, exhaustion, and poor sleep quality (carton & goodboy, 2015). problematic technology usage psychological health can be greatly affected by different forms of technology usage. emerging literature has coined the phenomenon of technostress, which describes the struggles associated with adapting or coping with technologies in a healthy manner (la torre et al., 2019). while emerging studies primarily focus on technostress because of workplace stress, technostress can be considered in other aspects of life. specific forms of non-work-related technostress primarily stem from excessive usage of social networking services (sns) and include issues such as communication or social interaction overload, internet multitasking, and compulsive 78 camaganacan usage of smartphones. in a professional environment, technostress can lead to issues with psychological well-being such as worry, self-criticism, and a negative self-view (la torre et al., 2019). non-work-related technostress can result in conflicts between family and technology or work and technology. furthermore, perceived stress stemming from technostress can lead to burnout, depression, or anxiety (la torre et al., 2019). while current research on technostress is largely focused on work-related contingencies, non-work-related technostress is also important to consider given the major psychological effects of technostress symptoms. personality and developmental trends while not explicitly labeled under the technostress definition, many studies have examined the psychological effects of technology dependency and personal factors that may be related to problematic technology usage. a study conducted by montag et al. (2014) explored how personality factors may affect smartphone usage in college students. the researchers measured phone usage within their sample as well as participants’ personality factors based on the big five personality traits (i.e., openness, conscientiousness, extraversion, agreeableness, and neuroticism). the results of the study indicated extraversion was highly associated with higher levels of phone usage (montag et al., 2014). a similar study conducted by hsiao (2017) also explored the correlates of technology usage with the big five personality traits. however, this study also included traits such as materialism and external locus of control, and technology usage was specified as compulsive usage of sns and mobile game applications. findings indicated that neuroticism, materialism, extraversion, and locus of control increase compulsive usage of sns apps, while agreeableness, materialism, and locus of control influence the usage of game apps (hsiao, 2017). similarly, researchers have also examined phone usage in a young adult sample to understand individual differences in personality traits as it pertains to smartphone usage (harari et al., 2019). once again, extraversion was associated with higher levels of social behaviors, and thus more technology usage. results showed openness to be associated with higher levels of social behaviors (harari et al., 2019). tams et al. (2018) explored issues of locus of control in the context of technology dependency. in particular, the study describes the issue of nomophobia, or the fear of not being able to access one’s smartphone, and correlations with technostress. in a work setting, technostress can lead to phone dependency, which in turn may result in nomophobia and additional stress. however, when situational certainty is established, the effects of nomophobia may decrease (tams et al., 2018). the effects of technology usage on adolescent psychological well-being has garnered much attention in recent years. for example, twenge et al. (2018) measured self-reported levels of technology usage in multiple domains such as television viewing habits and new media screen activities and compared these usage levels to measures such as psychological well-being and levels of in-person interaction. results indicated psychological well-being decreased as adolescent technology usage increased during the four-year period. additionally, non-technology-based activities, such as using print media or sports and exercise that were associated with higher levels of psychological well-being declined over time (twenge et al., 2018). several studies have noted the issues of problematic technology use in college students. de leo and wulfert (2013) explored the tenants of problematic internet use (piu) and how piu relates to other externalizing negative behaviors such as illicit drug use or risky sex in a college student sample. the researchers found that piu was not highly correlated with other forms of externalizing behaviors, and furthermore did not increase antisocial behaviors or affect academic performance. however, piu behaviors were suggested to be risky for students who are experiencing socially anxious or withdrawn behaviors and may lead to interferences in daily functioning (de leo & wulfert, 2013). beranuy et al. (2009) explored correlates between problematic internet and phone use with perceived emotional intelligence and psychological distress. findings indicated students who display higher levels of psychological distress also engage in higher levels of problematic technology use. additionally, higher levels of attention to emotion, a component of emotional intelligence, were also associated with higher levels of maladaptive technology usage (beranuy et al., 2009). specific fields of study may put students at risk for experiencing more symptoms of technostress. for instance, students in more technology-heavy fields of study, such as journalism and broadcasting, report higher levels of maladaptive technology usage, and female students show more consequences of maladaptive technology use than male students 79 ramifications of video game playing in college (beranuy et al., 2009). bjornsen and archer (2015) further explored the relationship between academic performance and problematic technology usage. their study examined the in-class phone usage of a sample of college students and how the usage correlated with students’ test scores. results indicated phone usage was significantly negatively correlated with test scores and using a phone during class for social networking purposes was the activity most associated with lower test scores (bjornsen & archer, 2015). similarly, leep et al. (2014) examined the relationship between college students’ cell phone usage and their quality of life, and how gpa and anxiety mediate the relationship. the study found students with higher levels of cell phone usage had lower gpas, higher levels of anxiety, and overall lower levels of perceived quality of life. the researchers noted at the end of their study that recognizing the relationship between quality of life and cell phone usage is important for high-usage students to reflect on their habits (lepp et al., 2014). in general, college students with poor mental health are more likely to engage in maladaptive technology-use behaviors, which may also affect their academic performance. the current study the purpose of this study is to examine the relationship between gaming, psychological well-being, and gpa in a college student sample. previous research indicates that video games have the potential to improve psychological well-being, but a poor relationship with technology may have negative psychological and academic consequences. the researcher is interested in seeing if students who play video games casually (cvgs) report higher levels of psychological well-being compared to non-gamers (ngs) and gamers meeting the criteria for internet gaming disorder (ags). additionally, the researcher seeks to compare academic performance via gpas between the three groups. lastly, the researcher wishes to see if ags also have more issues with technology boundary management compared to casual gamers and nongamers. this research adds to the existing literature about the relationship between psychological health, academic performance, and video game use as well as video games as a factor contributing to technostress. hypotheses 1. is there a relationship between gaming and subjective well-being in college students? h1: cvgs will report higher personal well-being compared with ags and ngs. h2: ngs will report higher subjective well-being than ags. 2. is there a relationship between gpa and game usage among college students? h1: ngs will have a higher gpa compared with ags and cvgs. h2: cvgs will have a higher gpa compared with ags. 3. is there a relationship between technology boundary management and gaming? h1: ngs will have lower levels of boundary management problems compared with ags and cvgs. h2: cvgs will have lower levels of boundary management problems compared with ags. methods data was collected from a sample of undergraduate students attending texas woman’s university. the survey was published online using the psychdata survey program after obtaining approval by the institutional review board. the survey was used to collect self-reported data from students. the survey protocol included psychometric instruments as well as demographic measures. participants electronically provided informed consent before participating in the survey and received sona credits as an incentive to participate. the inclusion criteria required participants to be 18 years or older and currently enrolled in classes for the semester. participants who did not meet the minimal age range were excluded. the data were examined using ibm’s statistical package for social sciences (spss). demographics of interest included age, gender, ethnicity, current number of credit hours, current gpa, types of video games played, specific genres of games played, whether the student plays games online or not, and number of hours played in a week. groups were defined as ngs, ags, and cvgs. ngs (non-gamers) are students who did not report playing video games at all. ags (addicted gamers) are students who reported playing video games and met the minimum criteria for internet gaming disorder based on their responses. lastly, cvgs (casual gamers) are students who reported playing video games but did not meet the criteria for internet gaming disorder. the sample consisted mostly of hispanic and latino students (33.5%) followed by white (25.7%), black and african american (20.4%), and other 8080 camaganacan ethnicities (20.4%). the mean age of students in the sample was 19.4 years (sd = 1.7). the gender ratio of the sample was 93.2% female, 6.5% male, and 0.3% non-binary or other. on average, students reported taking 13.8 credit hours (sd = 2.3) and had 3.3 gpas (sd = 0.7). students played 2.4 hours of video games a week on average (sd = 1.0). measures the degree of gaming addiction in the sample was measured with the internet gaming disorder scale (igd scale). the igd scale (lemmens et al., 2015) is a 27-item measure with a yes/no dichotomous scale. the igd scale is used to measure behaviors consistent with internet gaming disorder, such as overt preoccupation or persistence with gaming. the dichotomous version of the scale is internally consistent and possesses good criterion-related validity, with a cronbach’s alpha of .93 (lemmens et al., 2015). more yes answers indicate more symptoms of igd. an example of an item on the igd scale is “during the last year, have you been feeling tense or restless when you were unable to play games?” the dsm-5 notes that, while the igd diagnosis usually involves behaviors related to specific internet games, it can involve non-internet games (apa, 2013). additionally, the dsm-5 recognizes nine criteria for igd: preoccupation, tolerance, withdrawal, persistence, escape, problems, deception, displacement, and conflict, as defined in table 1 below. the dsm-5 recommends a minimal threshold of experiencing five or more criteria for diagnostic purposes. as a result, addicted gamers, or ags, are defined as gamers who meet this minimal threshold. perceived well-being will be measured with the psychological wellbeing scale (pwb scale; ryff & keyes, 1995). the shortened version of the pwb scale was utilized and consists of 18 items on a seven-point likert-type scale with anchors ranging from one (strongly agree) to seven(strongly disagree). this version of the pwb scale has lower internal consistency but higher factorial validity; the scale has a cronbach’s reliability over .88 (lee et al., 2019). the pwb scale is used to gauge psychological well-being in adults across multiple subscales including relationships with others and personal growth. we used all scales of the measure to determine how students perceive their psychological well-being. higher scores indicate lower levels of perceived psychological well-being. an example of an item is “when i look at the story of my life, i am pleased with how things have turned out so far.” the boundary management subscale (asbury et al., 2018) is a nine-item measure with a three-point likert-type scale with anchors ranging from one (never) to three (always). the boundary management subscale has convergent reliability and internal consistency with a cronbach’s alpha over .70 (asbury et al., 2018). the boundary management scale is used to measure boundary management behaviors related to technology use. higher scores indicate more issues with boundary management. an example of an item is “when i go online, i lose track of time.” results data cleaning before conducting our analysis, the data was screened for outliers and missing data. eight students were removed who were under the minimum age range or missing demographic information, 32 for missing significant portions of the pwb or bm surveys, and an additional 129 duplicate responses. a total of 169 responses were removed from the data set, and the final total sample was 382. data met all assumptions regarding normality. overall, app games made up 34.4% of usage, gaming consoles represented 35%, and pc gaming at 30.7%. most students who participated preferred one gaming platform type (42.6%), with 38.3% using two types, and 18.9% stated they played all three. the reported favored game genre within the sample was casual multi-player (46.4%) followed by causal single-player (30.1%), sports (4.9%), and rpg (4.6%). the full spread of demographics can be seen in table 2 below. data analysis an anova was conducted to test each of the hypotheses. the three gaming groups served as the independent variables, while psychological well-being, gpa, and boundary management served as the dependent variables. this analysis was used to examine potential differences between gaming usage and the dependent variables of psychological well-being, gpa, and boundary management respectively. after running the anovas, group means were compared by running post-hoc tests. a tukey hsd test was utilized as a conservative post hoc test for identifying significant main effects and interactions. eta squared was also used to calculate the effect sizes between our means and measure the relationship between our variables. 81 ramifications of video game playing in college a one-way between-subjects anova was conducted to compare subjective well-being between non-gamers, addicted gamers, and casual gamers. there was a significant main effect of gaming time on personal well-being [f(2, 370) = 3.69, p = 0.03)]. post-hoc comparisons using the tukey hsd test indicated that the mean well-being score for ags (m = 92.45, sd = 13.57, n = 202) was significantly different than the scores for cvgs (m = 96.14, sd = 13.32, n = 141). however, ngs’ scores did not significantly differ from either ags or cvgs (m = 91.13, sd = 14.34, n = 30). taken together, these results indicate that gamers who met the criteria for addiction were more likely to report overall lower levels of subjective well-being compared to casual gamers. nongamers do not appear to report significantly better well-being than addicted gamers or casual gamers. a second one-way anova was conducted to compare gpa between ngs (m = 3.31, sd = 0.55, n = 28), ags (m = 3.25, sd = 0.68, n = 203), and cvgs (m = 3.38, sd = 0.62, n = 138). there was no significant main effect of gaming on gpa [f(2, 366) = 1.54, p = 0.22]. as a result, gaming habits were not found to affect a student’s gpa. the final one-way anova was conducted to compare boundary management levels between gamer types. there was a significant main effect of gaming on boundary management [f(2, 379) = 8.97, p = 0.00]. post-hoc comparisons using the tukey hsd test indicated that the mean boundary management score for ags (m = 1.99, sd = 0.32, n = 208), was significantly different than boundary management scores for cvgs (m = 1.84, sd = 0.31, n = 142). ngs’ scores (m = 1.95, sd = 0.33, n = 32) did not significantly differ from either ags or cvgs. these results indicate that gamers who met the criteria for addiction are more likely to self-report more problems with technology boundary management than casual gamers. the results of my anovas can be seen below in table 3. discussion the current study examined the relationship between gaming, psychological well-being, gpa, and technology boundary management. the researcher hypothesized addicted gamers would report lower levels of well-being, lower gpas, and more struggles with technology boundary management compared to non-gamers and casual gamers. the researcher also hypothesized nongamers would report higher levels of well-being, higher gpas, and fewer struggles with boundary management compared to casual gamers and addicted gamers. the analyses supported two of the three hypotheses. definite conclusions could not be drawn about the ngs in the sample because of the few responses from ngs. however, the results suggest differences in psychological well-being and boundary management between the ags and cvgs. the researcher expected gpa to also be significantly different between ags and cvgs, but gaming did not appear to be a factor related to grades in college. the non-significant findings between gpa and gaming tendencies may be due to the sample. texas woman’s university has a primarily female student population, and previous research on gender and gpa performance notes that women in general tend to have higher gpas than men (keiser et al., 2016). in turn, perhaps there is a ceiling effect in the sample where women’s higher gpa may be due to increased abilities to self-discipline for academia (duckworth & seligman, 2006). the predominantly female sample may be useful to emerging research, as current studies on igd seem to focus on male samples, and being male is often concluded to be a significant predictor of the disorder (carlisle et al., 2019; männikkö et al., 2019). a 2020 study compared a sample of male and female gamers and problematic technology usage towards video games or social media usage. the study found that female gamers tended to engage in problematic social media usage, while males were more likely to have problematic gaming tendencies (cudo et al., 2020). an attempt at re-running the anovas sans male participants (n = 26) resulted in no significant changes in outcomes. as igd is still an emerging disorder, with little research focused on female-exclusive samples thus far, the researcher would caution against the generalization of the findings related to academic performance and igd. however, future research on igd in female samples may want to continue focusing on the overlap between igd and problematic technology usage, particularly with social media. current findings do support the literature suggesting igd is often comorbid with other psychological issues and problematic technology use 82 is associated with worse psychological outcomes. a longitudinal study on adolescents’ pathological game usage noted that students with initially moderate symptoms were at a higher risk of developing increasing symptoms over time, including specific issues such as anxiety, depression, and problematic phone usage (coyne et al., 2020). another study noted additional correlations between addicted technology usage and psychological disorders, with men being more vulnerable to video game addiction and women to problematic social media usage (andreassen et al., 2016). recognizing the overlap between igd and technology boundary management is also an important step in research, as recognizing symptoms and related effects for both areas is still limited (zajac et al., 2017). the preference towards game consoles within the sample is curious, as current research on gaming addiction is primarily centered around online gaming. online games are in constant development, which encourages players to play often and play for long periods of time. furthermore, online games offer prolonged opportunities to interact with other people online. both factors may contribute to addictive gaming tendencies (yildiz, 2019). additionally, greater concerns are being levied about mobile game addiction. one study theorizes that mobile gaming addiction may be the result of phubbing, a phenomenon that results from individuals using phones at the behest of in-person social interaction (yam & i̇lhan, 2020). this study also notes phubbing refers to the overlapping effects of mobile gaming, social media, internet, and phone addiction, which ties back to some of the previously discussed issues with technostress. considering the preferred console of choice may be a point of interest in future igd research. also, of interest within the sample is the high number of respondents who identified as hispanic or latino. texas woman’s university has a high population of latino and hispanic students, estimated to be around 28.3% of the total student population ([twu], 2020). again, while current igd research is limited, the few ethnocentric studies have primarily focused on asian countries such as china or korea due to extreme cases of game addiction leading to the death of an individual (chen et al., 2018). according to the national alliance on mental illness (nami), hispanics and latinos seek out mental health services less than the rest of the adult population. delays in seeking treatment often lead to worse psychological health outcomes. additionally, common psychological issues within these communities include generalized anxiety disorder, depression, post-traumatic stress disorder, and substance abuse (nami, 2020). understanding the inherent mental illness risks within the hispanic and latino communities may be useful for clinicians in treating igd within the population. another area of focus to consider is the reason why students may be motivated to play video games. broader research points to a variety of factors that contribute to player enjoyment such as the pleasure and satisfaction from executing a behavior, entertainment, and the ability to socialize with others (hsu & lu, 2004). video games can also empower individuals, particularly if an individual lives in an uncertain environment (king & delfabbro, 2009). additionally, personality and motivational factors can account for individual engagement in gaming (king & delfabbro, 2009). lastly, gaming may be used as a coping strategy for stress or other forms of psychological issues, though inherent disorders may put an individual at risk for gaming addiction (chang et al., 2019; kircaburun et al., 2019). gaming motivation often differs between individuals but may account for the likelihood of addiction. limitations this study is subject to several limitations. data collected for the study was self-reported and subjected to response bias. additionally, the study was quasi-experimental and causality cannot be inferred. social desirability bias may have affected participant responses to the survey. this study also has limited generalizability because the sample primarily consists of hispanic and latino female college students. due to the nature of the study, few ngs participated, which made it difficult to draw conclusions about ngs compared to ags and cvgs. future research future research should address the design limitations by expanding to college populations from other geographic regions to see how the model generalizes to other college students outside of the southern united states area. additionally, further research should include more comparison data taken from nongamers, as well as more male and non-binary gamers and gamers of other ethnicities. a longitudinal study should be considered to understand the long-term effects of gaming on gpa and well-being to better permit camaganacan 83 causal inferences to be made. it may also be of interest to expand the research population beyond college students and examine working adults’ usage of video games, and how usage relates to technology boundary management and affects perceived wellbeing. conclusion the study underscores the effects of igd in the lives of students and provides insight into how igd correlates with perceived psychological well-being and technology boundary management. both psychological well-being and boundary management significantly correlate with gaming. although the study does not fully address igd psychological issues, the study offers valuable insight into understanding igd and its related effects on mental health. despite limitations, 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(2017). treatments for internet gaming disorder and internet addiction: a systematic review. psychology of addictive behaviors, 31(8), 979. https://doi.org/10.1037/ adb0000315 camaganacan 87 table 1 nine criteria for internet gaming disorder from the dsm-5 note. dsm-5 = diagnostic and statistical manual of mental disorders (5th ed.; american psychiatric association, 2013). adapted from “the internet gaming disorder scale by lemmens, j. s., valkenburg, p. m., & gentile, d. a., 2015, psychological assessment, 27, p. 567. ramifications of video game playing in college 88 table 2 demographics of sample camaganacan 89 table 3 one-way anova results for dvs by gaming group (n = 382) ramifications of video game playing in college 90 appendix a twenty-seven items for the internet gaming disorder scale preoccupation during the last year... . . . have there been periods when you were constantly thinking about a game while at school or work? . . . have there been periods when all you could think of was the moment that you could play a game? . . . have there been periods when you were constantly fretting about a game? tolerance during the last year... . . . have you felt the need to continue playing for longer periods of time? . . . have you felt the need to play more often? . . . have you felt unsatisfied because you wanted to play more? withdrawal during the last year... . . . have you been feeling tense or restless when you were unable to play games? . . . have you been feeling angry or frustrated when you were unable to play games? . . . have you been feeling miserable when you were unable to play a game? persistence during the last year... . . . did you want to play less, but couldn’t? . . . did you try to play less, but couldn’t? . . . were you unable to reduce your time playing games, after others had repeatedly told you to play less? escape during the last year... . . . have you played games to forget about your problems? . . . have you played games so that you would not have to think about annoying things? . . . have you played games to escape negative feelings? problems during the last year... . . . have you skipped work or school so that you could play games? . . . have you played throughout the night, or almost the whole night? . . . have you had arguments with others about the consequences of your gaming behavior? deception during the last year... . . . have you lied to your parents or partner about the time you spent playing games? . . . have you hidden the time you spend on games from others? . . . have you played games secretively? displacement during the last year... . . . have you been spending less time with friends, partner or family to play games? . . . have you lost interest in hobbies or other activities because gaming is all you wanted to do? . . . have you neglected other activities (e.g., hanging out with friends, hobbies or sports) so that you could play games? conflict during the last year... . . . have you experienced serious problems at work or school because of gaming? . . . have you experienced serious conflicts with family, friends or partner because of gaming? . . . have you lost or jeopardized an important friendship or relationship because of gaming? camaganacan 91 appendix b psychological wellbeing scale 1. “i like most parts of my personality.” 2. “when i look at the story of my life, i am pleased with how things have turned out so far.” 3. “some people wander aimlessly through life, but i am not one of them.” 4. “the demands of everyday life often get me down.” 5. “in many ways i feel disappointed about my achievements in life.” 6. “maintaining close relationships has been difficult and frustrating for me.” 7. “i live life one day at a time and don't really think about the future.” 8. “in general, i feel i am in charge of the situation in which i live.” 9. “i am good at managing the responsibilities of daily life.” 10. “i sometimes feel as if i've done all there is to do in life.” 11. “for me, life has been a continuous process of learning, changing, and growth.” 12. “i think it is important to have new experiences that challenge how i think about myself and the world.” 13. “people would describe me as a giving person, willing to share my time with others.” 14. “i gave up trying to make big improvements or changes in my life a long time ago” 15. “i tend to be influenced by people with strong opinions” 16. “i have not experienced many warm and trusting relationships with others.” 17. “i have confidence in my own opinions, even if they are different from the way most other people think.” 18. “i judge myself by what i think is important, not by the values of what others think is important.” ramifications of video game playing in college 92 appendix c boundary management subscale • i am on my cell phone while watching tv i am on my cell phone while driving • others get mad at me because i am on my cell phone frequently • i leave my cell phone on and place it close to my bed when i go to sleep i am on my cell phone during dinner, even when dining with others when i go online, i lose track of time • the time i spend online interferes with my personal relationships • i neglect things that need to get done due to the time i spend online i get extremely anxious when i cannot use my cell phone camaganacan 99 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university objective measurement and insight assessment of muscle dysmorphia austin b. lowe, m.a., frederick g. grieve, ph.d., and amy brausch, ph.d. western kentucky university muscle dysmorphia is a relatively new psychological disorder primarily affecting men. the main diagnostic criterion is an obsession with the idea that the body is not sufficiently lean or muscular when compared to others. as a muscular physique is so important to their self-worth, individuals with muscle dysmorphia may have little insight into how their behaviors are affecting their lives and may be less likely to seek psychological treatment. the purpose of this study was to measure factors related to exercise and muscle dysmorphia and examine their relationship to insight and recognition of criteria for muscle dysmorphia. participants (n = 85) completed a series of questionnaires to assess the independent variables and were then administered two questionnaires designed to assess insight to any criteria of muscle dysmorphia participants might be experiencing as well as their recognition of criteria in a case vignette. a series of multiple regression analyses were conducted using feeling of obligatory exercise, exercise motivation, reasons for exercise, athletic identity, and symptoms of muscle dysmorphia as predictor variables for awareness of diagnostic criteria of muscle dysmorphia and self-reported symptoms of muscle dysmorphia. results indicated that participants with higher athletic identity and greater symptoms of muscle dysmorphia had a higher insight into their own dysmorphia than participants with low athletic identity and fewer symptoms of muscle dysmorphia. at the same time, individuals with more symptoms of muscle dysmorphia had a lower recognition of muscle dysmorphia in others than those with fewer symptoms. historically, psychological research addressing body image concerns has focused predominately on women, as dissatisfaction with the body was primarily seen in women (brownell & rodin, 1994). the rationale behind this was that their bodies were seen as the major form of social capital for women (crandall, 1994). however, more recent research (grieve, wann, henson, & ford, 2006) indicates that men, too, have begun to be dissatisfied with their bodies. while women generally want to lose weight and be thinner (thompson & stice, 2001), men desire to either lose weight or gain weight, with a focus on increased muscularity rather than adiposity (ridgeway & tylka, 2005). the focus on increasing muscularity can lead to pathological behaviors; the syndrome that results from these pathological behaviors has been termed muscle dysmorphia (pope, gruber, choi, olivardia, & phillips, 1997). in the most recent version of the diagnostic and statistical manual of mental disorders (dsm5; american psychological association, 2013), muscle dysmorphia is listed as a subtype of body dysmorphic disorder. the key symptom of muscle dysmorphia is that an individual believes that his or her body is not as muscular as he or she wishes it would be, even though the individual is usually more muscular than the majority of the population (olivardia, 2001). obsessions with muscularity lead individuals to frequently miss social or occupational functions because they are overly committed to their exercise routines. whereas a woman with an eating disorder will generally be seen compulsively exercising to improve her lower body, a man with muscle dysmorphia may exercise just as frequently, but focus on his upper body muscles instead (thompson & stice, 2001; ridgeway & tylka, 2005). despite obsessive commitments to exercise, individuals with muscle dysmorphia have varying degrees of insight into their preoccupation with their body size. a study by olivardia, pope, and hudson (2000), revealed that of the 24 male weightlifters that met three of the specific criteria for muscle dysmorphia, 10 (42%) participants reported “excellent” or “good” insight into recognizing that their impressions of their body size override (hidden running head text): lowe, grieve, brausch muscle dysmorphia keywords: muscle dysmorphia; motivation; athletic identity; insight; awareness please address correspondence regarding this article to: rohgcnslr1219@outlook.com 100 lowe, grieve, brausch was mistaken; 12 (50%) of participants reported “fair” or “poor” insight. the remaining two participants (8%) lacked any insight and refused to accept that they were not “small” (olivardia, pope, & hudson, 2000). additionally, individuals with muscle dysmorphia feel intense anxiety when their bodies are exposed in public and go to extreme lengths to avoid such situations (apa, 2013). even though they are distressed by others seeing their bodies, individuals with muscle dysmorphia frequently check their appearance in the mirror to look for any changes in physique. finally, individuals with muscle dysmorphia have strict diets comprised of high protein and low amounts of carbohydrates and fats. they often use performance-enhancing substances, such as anabolic-androgenic steroids, despite the risk to their health (olivardia, 2001; grieve, truba, & bowersox, 2009). one of the greatest concerns regarding muscle dysmorphia is that even though individuals may be concerned about the effects their behavior has on their lives, the fear of becoming less muscular is greater (olivardia, 2001). even when individuals do seek out treatment, it is often for depression, anxiety, eating or steroid abuse, rather than issues surrounding muscle dysmorphia. in the previously mentioned study by olivardia, pope, and hudson (2000), a clinical interview revealed that of the 24 participants, 29% had a history of an eating disorder, 58% reported a history of a mood disorder, and 29% had a lifelong history of an anxiety disorder (olivardia et al., 2000). despite these findings, little research has been done to assess what factors contribute to an individual seeking treatment other than receiving encouragement from others. there are some barriers to therapy for individuals with muscle dysmorphia (grieve et al., 2009). individuals with muscle dysmorphia find the symptoms ego-syntonic: that is, the symptoms do not cause distress. in fact, working out and dieting to increase muscle mass decreases the anxiety that they experience because they believe they are too small. individuals with muscle dysmorphia do not consider therapy necessary for improving their lives, and they skip sessions with their therapists because the sessions conflict with their scheduled gym times, using this as a form of self-medication (olivardia et al., 2000). currently, the only information regarding prevalence of muscle dysmorphia is limited to specific populations (olivardia, 2001). studies have proposed that 5% to 10% of weightlifters and 9% of men diagnosed with body dysmorphic disorder have muscle dysmorphia (cafri et al., 2005; olivardia, 2001). this is most likely an underestimate of the true prevalence rate as it is difficult to provide an estimate of the population. many men do not see the symptoms of muscle dysmorphia as indicating a problem—in fact, they view the symptoms as eliminating a problem (see olivardia, 2001)—so they do not present for treatment. the mean age of onset for symptoms is 19.4 years (olivardia et al., 2000), which means that it generally begins in college as young men begin to adopt the social ideal body image. as muscle dysmorphia is associated with anabolic steroid use (olivardia, 2001), it is important to note that the rate of anabolic steroid use in young men is similar to the rate of bulimia nervosa in young women (schooler & ward, 2006); that is, approximately 2 million males of all ages in the united states have used anabolic steroids at some point in their lives (pope, phillips, & olivardia, 2000). grieve (2007) proposed a conceptual model for the etiology of muscle dysmorphia that included four categories of variables, each with contributing factors: socioenvironmental, emotional, psychological, and physiological. while limited research has been done in all of these areas (see grieve, 2007), socioenvironmental factors have been shown to be the most influential in individuals who develop muscle dysmorphia. these factors convey muscular ideals through an individual’s social environment, such as family, peers, athletics, and mass media. mass media has been regarded as the most influential of all pressures (grieve, 2007). mass media, predominately in western societies, promotes individuals with physiques that are generally impossible to attain without the use of anabolic steroids (baghurst & kissinger, 2009). the western social ideal male body includes a muscular build, with a broad chest and thin waist; this is often considered a “v” shape (ridgeway & tylka, 2005). studies have shown that media presentations of the male body (i.e., magazine models, action toys, and celebrities) influence body image ideals through contrast effects (grieve, 2007). even though social comparison theory has been shown to help others by increasing selfesteem through contrasting with others considered to be of lower status (dijkstra, gibbons, & buunk, 2010), the opposite effect has been shown to result from 101 muscle dysmorphia contrasting with individuals with a perceived higher status. in the case of muscle dysmorphia, comparing oneself to overly muscular individuals can decrease self-esteem. exposure to muscular male models in the media has been associated with lower levels of body satisfaction and self-esteem (leit, gray, & pope, 2002). as these messages have previously led females to adopt exercise and dietary strategies to attain thinness, it is reasonable to guess that they can equally lead males to engage in similar strategies to gain and improve muscular physiques (cafri et al., 2005). men with body image concerns can overutilize exercise; in fact, this excessive exercise can become “addictive” and sometimes is referred to as anorexia athleticism (strother, lemberg, stanford, & turberville, 2012). in addition to exercising in order to improve muscularity, several other motivations have been identified as factors in determining why individuals complete exercise, how often they exercise, and how long they exercise. self-determination theory (sdt; deci & ryan, 1985) has been suggested as a means of exploring motivations in order to gain a greater understanding of the motives underlying exercising (duncan, hall, wilson, & jenny, 2010). sdt proposes that motivations for exercising can be broken down into two categories: intrinsic motivations and extrinsic motivations. intrinsic motivations are focused on personal interests, with specific motivations being enjoyment, improving abilities, or social affiliation. on the other hand, extrinsic motivations are concerned with achievement or recognition, and include weight loss or appearance (markland & ingledew, 1997). further research into motivations for exercise has found that there are differences in motivation based on gender. in a study conducted by kilpatrick, hebert, and bartholomew (2005), male and female college students were administered the exercise motivations inventory-2 (emi-2; markland & ingledew, 1997) to distinguish differences in extrinsic and intrinsic motivations between genders; the emi-2 is comprised of various subscales, each reflecting a different motivation regarding why people think they should exercise. an analysis of the results revealed that men rated the motives of competition, challenge, social recognition, and strength and endurance higher than women; weight management was the only motive that women rated higher than men. given that the motivations rated highest by men are frequently seen in individuals exhibiting criteria of muscle dysmorphia, as well as the sample being comprised of college students that have been primarily used in previous studies, there is a greater need for understanding of exercise and individual motivations (kilpatrick et al., 2005). exercising should be distinguished from sport and athletic participation. although both are classified as forms of physical activity, there are benefits and motivations related to athletic involvement beyond the physiological aspects of just exercising (kilpatrick, bartholomew, & riemer, 2003). exercise has normally been defined as participating in physical activity to gain or maintain fitness; on the other hand, sport is defined as engaging in physical activity for recreational purposes. individuals participating in sport derive benefits such as higher self-esteem, more positive body image, greater social development, and greater social status than non-participating individuals (cafri et al., 2005). furthermore, individuals participating in athletics often develop skills that carry over into their personal lives, such as abstaining from alcohol and illicit drugs, accepting and overcoming failures and difficult situations, as well as having a wider range of educational and career opportunities. kilpatrick, hebert, and bartholomew (2005) examined the differences in exercise behaviors and motivation for exercise between engaging in exercise and engaging in sports. results indicated that participants engaged in exercise more frequently and at a higher intensity than they engaged in sports, but there were no significant differences in ratings of duration or adherence to activity. additionally, analyses revealed a mix of intrinsic and extrinsic motivations for each form of physical activity; participants rated appearance, strength and endurance, stress management, health pressures, ill-health avoidance, and positive health motives higher when they engaged in exercise, but rated affiliation, challenge, competition, enjoyment, and social recognition motivations higher when participating in sport (kilpatrick et al., 2005). sport participation also carries associated risks. the most salient set of risks for the present study involve body image issues. athletes participating in sports such as bodybuilding and football, where greater muscle mass and body size are valued are at risk for developing steroid abuse or muscle dysmorphia (grieve, 2007). 102 lowe, grieve, brausch on the contrary, sports with weight restrictions, such as wrestling, boxing, swimming, or gymnastics, inspire participants to avoid gaining weight in an effort to stay lean; as a result, these individuals have a high risk of developing eating disorders or abuse of diuretics and laxatives (cafri et al., 2005; murray, rieger, karlov, & touyz, 2013). athletic identity is defined as the degree to which an individual considers himor herself an athlete (chen, snyder, & magner, 2010). athletic identity has been found to correlate with: athletic appearance; the importance of exercise, sport, and physical activity; perceptions of competence; and encouragement from others to be an athlete. benefits associated with higher levels of athletic identity include an improved sense of self, perceived improved social life, and higher levels of confidence. a strong athletic identity can also improve athletic performance by providing an individual with a more focused approach to training. finally, individuals who strongly identify themselves as athletes exercise more frequently and engage in more exercise behaviors than those with lower athletic identities. in a study by chen, snyder and magner (2010), athletic identity, commitment to sports, and sports participation were examined in relation to possible benefits on personal and social life. a sample comprised of 163 student-athletes and 112 non-athlete students were administered a series of questionnaires to assess the previously mentioned factors. an analysis of the results showed that student athletes reported that their athletic involvement had improved their overall health, development, and meeting new friends. interestingly, the researchers noted that athletes who were involved in team sports (i.e., football, basketball, volleyball, etc.), rated personal role, personal attributes, core benefits, social relationship, and special behaviors higher than athletes involved with more individual sports (i.e., track and field, tennis, etc.); the athletes involved with the individualized sports reported placing a greater importance of sports in their lives and expectations of others higher than team sport athletes (chen, snyder, & magner, 2010). however, there are also costs that arise with the adoption of a stronger athletic identity. individuals with a strong athletic identity run the risk of neglecting areas of their life unrelated to athletics, such as work or friendships outside of sport. also, because they often lack other sources of self-worth, individuals with a high sense of athletic identity are more vulnerable to depression when faced with role-disrupting life events (brewer, 1993). for example, after sustaining an injury, individuals with a high degree of athletic identity are likely to interpret it as inhibiting their ability to exercise or participate in competitions; this in turn decreases mood and self-esteem (brewer, van raalte, & linder, 1993). present study the purpose of the current study was to examine patterns of and motivations for participants’ exercising and their awareness for any personal evidence of muscle dysmorphia. we predicted that participants score on the exercise and md questionnaires will be negatively related to personal insight of diagnostic criteria for muscle dysmorphia in themselves. we also predicted that participants score on the exercise and md questionnaires will be positively related to identification of diagnostic criteria via a case vignette. the independent variables were chosen to assess the degree of factors related to exercise, importance of exercise, and typical behaviors of muscle dysmorphia in participants. these variables were considered important to assess in relation to muscle dysmorphia because the majority of studies have not examined frequency of exercise in participants, considered alternative motivations for exercise aside from improving musculature, or have used samples comprised of professional athletes without assessing the importance that their participation in athletics is to their self-concept. method participants participants were 85 men all over the age of 18 who were recruited via two methods. approximately one-third (27 participants; 31.8%) were students attending university; participants were recruited through the department of psychology’s online participant pool and were awarded course credit for their participation. the remainder of the participants (58, 68.2%) were recruited through the amazon mechanical turk website and were awarded a monetary payment upon completion; these participants were awarded either $0.20 (initially) or $0.50 (later) for their participation. 103 muscle dysmorphia the average age of participants was 32.73 (sd = 13.42), with ages ranging from 18 to 65. participants were comprised of 8 (9.3%) high school graduates, 13 (15.1%) freshmen in college, 9 (10.5%) sophomores, 6 (7.0%) juniors, 19 (22.1%) seniors, 13 (15.1%) graduate students, and 17 (19.8%) college graduates. participants included 58 (68.2%) caucasians, 17 (20.0%) asians, 5 (5.9%) african americans, 2 (2.4%) american indian/alaskan natives, 2 (2.4%) participants who did not indicate their race/ethnicity, and 1 (1.2%) hispanic (see table 1). body mass index (bmi) was calculated for participants by using their reported height and weight. the mean height of participants was 70.24 inches (sd = 3.51), with heights ranging from 60 to 76 inches. the mean weight of participants was 184.47 pounds (sd = 45.26), ranging from 70 to 310 pounds. the mean bmi of participants was 26.17 (sd = 5.73), ranging from 11.30 to 44.09; this average falls outside the range of what is considered a healthy bmi (18.5 to 24.9) into the overweight range (25 to 29.9). of the 85 participants, 39 reported currently participating in one or more sports. at least one participant reported engaging in the following sports: baseball, basketball, bowling, boxing, cheerleading, chess, cricket, cross fit, cycling, dance, dodge ball, fishing, football, frisbee, golf, hiking, hockey, powerlifting, racing, soccer, softball, table tennis, skipping rope, swimming, tae kwon do, tennis/badminton, track/running, volleyball, weightlifting. materials and procedure demographics. participants completed a demographic questionnaire that included questions regarding age, race/ethnicity, education level, current sport participation, height, and weight. the response option to the question regarding sport participation was an open response to allow participants to define sport participation in their own manner. obligatory exercise questionnaire. this measure was used to assess fixation, frequency, and commitment to exercising (oeq; pasman & thompson, 1988). the oeq is composed of 20 questions designed to gather information on individual attitudes and habits in exercise; responses are on a four-point likert-type scale, from 1 (never) to 4 (always). an example question on the oeq is “if i miss a planned workout, i attempt to make up for it the next day.” the oeq is scored by summing the responses for each question (reverse scoring two questions). higher scores indicate a greater sense of obligation to exercise. the oeq has excellent internal consistency (cronbach’s α = .96; pasman & thompson, 1988). exercise motivations inventory – 2. this measure (emi-2; markland & ingledew, 1997) was used to determine overall motivation behind exercise participation. the emi-2 contains a total of 51 questions that are designed to assess fitness and health-related reasons for exercising among exercisers and non-exercisers; for this study, participants responded to each reason on a scale from 1 (not at all true for me) to 5 (very true for me). table 1 demographics of participants characteristic n % gender male 85 100 age 11–20 14 16.4 21–30 33 38.9 31–40 14 16.6 41–50 7 8.4 51–60 10 11.9 61–70 4 4.8 n/a 3 3.5 ethnicity caucasian 58 68.2 asian 17 20.0 african american 5 5.9 american indian/alaskan native 2 2.4 other 2 2.4 hispanic 1 1.2 education high school graduate 8 9.3 college freshmen 13 15.1 college sophomore 9 0.5 college junior 6 7.0 college senior 19 22.1 college graduate 17 19.8 graduate student 13 15.1 104 lowe, grieve, brausch a sample motivation for exercising question is “to stay slim.” the emi-2 total score was obtained by summing the scores of all items. in addition, scores for each of the subscales (stress management, revitalisation, enjoyment, challenge, social recognition, affiliation, competition, health pressures, ill-health avoidance, positive health, weight management, appearance, strength & endurance, and nimbleness) was obtained by summing the items associated with each. the emi-2 is applicable to exercisers and non-exercisers, and has acceptable internal consistency across subscales, with cronbach’s alpha ranging from .69 to .92 (markland & ingledew, 1997). reasons for exercise inventory. this measure (rei; silberstein, striegel-moore, timko & rodin, 1988) assessed how important specific reasons for exercise were for participants. the rei contains a total of 24 reasons for exercising and asks participants to rate how important each reason is, with responses ranging from 1 (not at all important) to 7 (extremely important). an example reason for exercising on the questionnaire is “to cope with stress, anxiety.” the rei has six subscales: weight control, attractiveness, mood, fitness, health concerns, enjoyment, and tone. each subscale score consisted of the sum of the items associated with the subscale. the rei assesses participants’ reasons for exercising in contrast to reasons why they believe they should exercise. furthermore, the subscales have reported good internal consistency, averaging between .70 and .81 (crawford & eklund, 1994). athletic identity measurement scale. this measure (aims; brewer & cornelius, 2001) was used to measure participants’ athletic identity. it is made up of three factors: exclusivity, social identity, and negative affectivity (groff & zabriskie, 2006). the aims consists of seven questions with responses ranging from 1 (strongly disagree) to 7 (strongly agree). the aims is scored by summing the scores for each of the subscales. the aims has high internal consistency (coefficient alpha = .81; brewer & cornelius, 2001) and test-retest reliability (r = .89, p < .01; brewer, 1993). muscle dysmorphia questionnaire. this measure (mdq; grieve et al., 2014) was used to measure symptoms of muscle dysmorphia. the mdq is made up of 34 questions with responses ranging from 1 (strongly disagree) to 6 (strongly agree). a sample question from this inventory is “i am inclined to continue to work out when i am sick.” the mdq is scored by summing the scores (reverse scoring three items). the mdq has a high internal consistency (cronbach’s α = .86; grieve et al., 2014). symptom insight assessment. the sia was designed by the experimenter by using the criteria for muscle dysmorphia (olivardia, 2001) as a guideline. participants were instructed to rate to what degree they believed they exhibited each of the criteria for muscle dysmorphia. participants rated each criterion on a scale from 1 (not at all true for me) to 6 (very true for me). this measure was used to assess participant knowledge and awareness of any personal symptoms of muscle dysmorphia. criteria awareness assessment. participants read a vignette describing an individual who exhibited each of the criteria of muscle dysmorphia; they were then asked to rate how much they believed the patient described met the criteria for muscle dysmorphia on a scale from 1 (not at all true for jim) to 6 (very true for jim). both this measure and the vignette were designed by the experimenter by using the criteria for muscle dysmorphia (olivardia, 2001) and a case history reported in a previous study (mosley, 2009) as a guide. this measure was used to assess identification of the symptoms of muscle dysmorphia. procedure prior to study commencement, institutional review board approval was obtained. in-person participants were given an informed consent document that indicated that completing the survey implied consent; on-line participants were given the same document with a link that indicated consent and took participants to the actual survey. after agreeing to participate, participants completed the demographics questionnaire. participants then completed the oeq, the emi-2, the rei, the aims, and the mdq in this order. after completing the above questionnaires, participants were asked to rate themselves on each of the diagnostic criteria for muscle dysmorphia. participants read the vignette and indicated to what extent they believed the individual in the vignette met each of the diagnostic criteria for muscle dysmorphia. upon completing the study, participants were debriefed about the aim of the study, the purpose of each questionnaire, the hypotheses, and contact information for any 105 muscle dysmorphia questions regarding their participation; participants were then guided to the final page and instructed to close the browser window. amazon mechanical turk participants were provided a code at the end of the survey and were paid when they used that code in the recruitment website. the mean amount of time that it took participants to complete the study was 23.87 minutes (sd = 28.09), with times ranging from 7 to 172 minutes. in order to ensure that participants from amazon mechanical turk were paying attention to item content, five manipulation check questions were spread throughout the survey to ensure that participants were reading the items. although participants were excluded from the data set if they missed even one manipulation check question, the amazon mechanical turk participants were only denied payment if they missed more than three manipulation check questions. results preliminary analyses the items from each of the questionnaires were summed to create a total score for each scale (see table 2 for means and standard deviation). cronbach’s alpha was calculated for each of the scales to determine internal consistency; each scale was shown to have high internal consistency, with coefficients ranging from .81 to .96. pearson product-moment correlation coefficients were conducted to assess the relationship between each of the variables; results were varied with the two strongest correlations between the emi-2 and the rei (r = .84, p < .001) and between the mdq and sia (r = .870, p < .001) (see table 3 for full results). hypothesis testing a multiple regression analysis was conducted to predict scores on the symptom insight and criteria awareness from scores on the oeq, emi-2, rei, aims, and mdq. hypothesis 1 proposed that high scores on the oeq, emi-2, rei, aims, and mdq would be associated with low scores on the sia. the overall model was significant, f (5, 79) = 57.19, p < .005, r2 = .78; however, only the aims (t = 3.064, p = .003) and mdq (t = 13.864, p = .000) were statistically significant predictors of symptom identification in participants. hypothesis 2 proposed that high scores on the oeq, emi-2, rei, aims, and mdq would be associated with high scores on the caa. the overall model was significant f (5, 79) = 3.88, p < .005, r2 = .20, but in this analysis, only the mdq was a significant predictor of criteria awareness for muscle dysmorphia in the presented case vignette (t = -2.280, p = .025). see table 4 for the full results. to determine if sports participation was a factor in participants’ responses, a second, separate set of regression analyses were run where participants were split into one of two groups based on whether they answered ‘yes’ or ‘no’ to participating in sports; 39 participants reported that they currently participated in sports, while 46 participants denied current sports participation. results were similar to the total sample analysis for the sia for both groups; overall, the independent table 2 descriptive statistics for each of the measures used in the study variable m sd range alpha (α) oeq 45.95 10.52 26–76 .89 emi-2 159.74 37.06 69–242 .96 rei 112.54 25.55 39–168 .92 aims 20.73 12.10 7–49 .94 mdq 94.13 26.77 47–147 .92 sia 14.44 6.64 6–30 .83 caa 30.40 5.27 15–36 .81 note. the above statistics were obtained for the following measures: obligatory exercise questionnaire (oeq); exercise motivations inventory – 2nd edition (emi-2); reasons for exercise inventory (rei); athletic identity measurement scale (aims); muscle dysmorphic questionnaire (mdq); symptom insight assessment (sia); criteria awareness assessment (caa). 106 lowe, grieve, brausch variables statistically significantly predicted scores, but only the aims and mdq were statistically significant predictors; sport participation group: f (5, 33) = 19.25, p < .005, r2 = .75; no sports participation group: f (5, 40) = 33.68, p < .005, r2 = .81. however, neither groups’ scores on the independent variables were statistically significant in predicting caa scores; sport participation group: f (5, 33) = 1.90, p > .05, r2 = .22; no sport group: f (5, 40) = 1.36, p > .05, r2 = .15. see tables 5 and 6 for full results. discussion muscle dysmorphia is a fairly new clinical diagnosis that is primarily shown in adolescent and adult males. the primary symptom is that an individual believes that he or she is not sufficiently lean or muscular, even though the individual may already be overly muscular (pope et al., 1997). these symptoms and beliefs are often derived from individuals comparing themselves to others they encounter or a desire to conform to specific body types promoted by mass media (baghurst & kissinger, 2009; grieve, 2007). to compensate, individuals engage in behaviors to increase muscularity that include frequent weightlifting and strict eating behaviors, often taking away time from social or occupational activities (american psychiatric association, 2013; olivardia, 2001). as the compulsion to attain a certain body shape becomes central to their self-concept, individuals with muscle dysmorphia may be unwilling to admit that their behaviors are negatively affecting their lives and may be unwilling to seek treatment because it would take away from their time exercising (grieve, truba, & bowersox, 2009; olivardia, pope, & hudson, 2000). table 3 correlations among variables variable oeq emi rei aims mdq sia caa pearson correlation 1 .663** .547** .610** .542** .452** -.272* oeq sig. (2-tailed) .000 .000 .000 .000 .000 .012 n 85 85 85 85 85 85 85 pearson correlation .663** 1 .840** .680** .443** .375** -.199 emi-2 sig. (2-tailed) .000 .000 .000 .000 .000 .068 n 85 85 85 85 85 85 85 pearson correlation .547** .840** 1 .502** .405** .330** -.055 rei sig. (2-tailed) .000 .000 .000 .000 .002 .618 n 85 85 85 85 85 85 85 pearson correlation .610** .680** .502** 1 .397** .450** -.317** aims sig. (2-tailed) .000 .000 .000 .000 .000 .003 n 85 85 85 85 85 85 85 pearson correlation .542** .443** .405** .397** 1 .870** -.335** mdq sig. (2-tailed) .000 .000 .000 .000 .000 .002 n 85 85 85 85 85 85 85 pearson correlation .452** .375** .330** .450** .870** 1 -.325** sia sig. (2-tailed) .000 .000 .002 .000 .000 .002 n 85 85 85 85 85 85 85 pearson correlation -.272* -.199 -.055 -.317** -.335** -.325** 1 caa sig. (2-tailed) .012 .068 .618 .003 .002 .002 n 85 85 85 85 85 85 85** *correlation is significant at the 0.05 level (2-tailed); **correlation is significant at the 0.01 level (2-tailed). 107 muscle dysmorphia the purpose of the current study was to assess participant insight to the diagnostic criteria that they might have and to determine whether they recognize diagnostic criteria in a case vignette. the predictor variables used were obligation to exercise (oeq), motivations and reasons for exercise (emi-2 and rei, respectively), athletic identity (aims), and symptoms of muscle dysmorphia (mdq). it was hypothesized that individuals with high scores for each of the predictor variables would have a low insight score, but would have a high score on recognizing symptoms in the vignette. the first hypothesis was that individuals with high obligation, motivation, and reason for exercise, athletic identity, and muscle dysmorphia behavior would report low symptom insight and recognition. an analysis of the results indicated a statistically significant increase in symptom insight as athletic identity and muscle dysmorphia behavior increased. of the six criteria listed, the ones that participants rated the highest were: (1) you are hung-up on the idea that your body is not sufficiently lean or muscular; (2) you avoid situations where your body is exposed to others, or endure such situations with distress or anxiety; and (3) you have feelings about the inadequacy about your body size and musculature that causes distress and impairment in your social, occupational, or other important areas of functioning. these results are somewhat similar to olivardia, pope, and hudson (2000). of the 24 men with muscle dysmorphia interviewed, less than half had accurate insight that their body perception was distorted. this lack of insight could be due to the nature of muscle dysmorphia symptoms. the symptoms are egosyntonic; that is, excessive weight lifting relieves anxiety that people have about their bodies so the symptoms table 4 regression examining predictor variables for symptom insight assessment and criteria awareness assessment, overall sia caa variable b se b β p b se b β p oeq -.059 .049 -.093 .237 -.028 .075 -.055 .713 emi-2 -.020 .021 -.111 .356 -.026 .033 -.186 .421 rei .000 .026 .002 .987 .074 .039 .358 .062 aims .128 .042 .232 .003 -.098 .064 -.226 .126 mdq .217 .016 .876 .000 -.055 .024 -.277 .025 note. the above statistics were obtained for the following measures: obligatory exercise questionnaire (oeq); exercise motivations inventory – 2nd edition (emi-2); reasons for exercise inventory (rei); athletic identity measurement scale (aims); muscle dysmorphia questionnaire (mdq); symptom insight assessment (sia); criteria awareness assessment (caa). table 5 regression examining predictor variables for symptom insight assessment and criteria awareness assessment, sport participants (n = 39) sia caa variable b se b β p b se b β p oeq -.136 .084 -.230 .116 -.087 .122 -.177 .481 emi-2 -.003 .045 -.013 .946 -.099 .065 -.506 .137 rei -.035 .053 -.105 .513 .125 .076 .455 .110 aims .177 .085 .269 .045 .051 .123 .093 .681 mdq .227 .026 .919 .000 -.046 .038 -.222 .243 note. the above statistics were obtained for the following measures: obligatory exercise questionnaire (oeq); exercise motivations inventory – 2nd edition (emi-2); reasons for exercise inventory (rei); athletic identity measurement scale (aims); muscle dysmorphia questionnaire (mdq); symptom insight assessment (sia); criteria awareness assessment (caa). 108 lowe, grieve, brausch are seen in a positive light (grieve, 2007; grieve et al., 2009). therefore, many times people who exhibit the symptoms do not see them as problematic. the second hypothesis proposed that, after reading the vignette of an individual exhibiting symptoms of muscle dysmorphia, participants with high obligatory exercise, motivation and reason to exercise, athletic identity, and muscle dysmorphia behavior would have high recognition of symptoms in the described individual. analyses showed a significant decrease in recognizing symptoms in the vignette as participants’ behaviors of muscle dysmorphia (mdq) increased. these results show some relation to the concept of identification in social comparison theory. as noted by dijkstra et al. (2010), when an individual identifies with a comparison target, those who view the target as doing worse off themselves, make downward comparisons between themselves and the target, provoking feelings of anxiety or fear (dijkstra et al., 2010). in this study, it is likely that participants saw something of themselves in the description in the vignette and reported low symptomology as a means of defending their own self-image. in addition, the relationship between insight and athletic identity can be attributed to the behaviors associated with athletic involvement. participation in athletics already requires a significant time commitment. athletes generally obtain and maintain a particular body shape through exercise and diet as part of this participation (brewer, van raalte, & linder, 1993). therefore, it is possible that individuals with high levels of athletic identity recognize the criteria for muscle dysmorphia because of the experience of being an athlete rather than because of experiencing mental illness. these results also hold clinical implications. the results suggest that the mdq and sia may be beneficial in a treatment setting to measure the specific behaviors of muscle dysmorphia and patient insight about the preoccupation with improving body image. taking this one further step, a readiness to change survey could also be administered to patients to determine how willing they are to change their behavior, what therapy might be most effective, and possible treatment outcome. thus, insight into problem behaviors can be used as a motivational tool, such as within motivational interviewing (miller & rollnick, 2013). there are several limitations to the results of this study. first, even though the sia and caa are based on the established criteria for muscle dysmorphia (american psychiatric association, 2013; olivardia, 2001), they were specifically designed for this study, and therefore may have questionable validity. additionally, the vignette was also written for this study and was not tested in advance; therefore, it is possible that the vignette does not sufficiently or accurately describe the criteria for muscle dysmorphia. second, there is the possibility that because participants were allowed to complete the survey outside of a research environment for their own convenience, some participants may have misunderstood the questions. third, the sia and caa were administered at the end of the study; even though there is a decreased likelihood of this affecting table 6 regression examining predictor variables for symptom insight assessment and criteria awareness assessment, no sport group (n = 46) sia caa variable b se b β p b se b β p oeq .042 .069 .052 .543 .127 .104 .219 .229 emi-2 -.035 .023 -.211 .130 .009 .035 .072 .803 rei .018 .028 .081 .524 .030 .042 .190 .478 aims .120 .057 .169 .042 -.052 .087 -.103 .549 mdq .208 .020 .855 .000 -.054 .030 -.309 .079 note. the above statistics were obtained for the following measures: obligatory exercise questionnaire (oeq); exercise motivations inventory – 2nd edition (emi-2); reasons for exercise inventory (rei); athletic identity measurement scale (aims); muscle dysmorphia questionnaire (mdq); symptom insight assessment (sia); criteria awareness assessment (caa). 109 muscle dysmorphia the caa, administering the sia at the beginning of the study could have made it less likely to be influenced by response bias. future research should focus on assessing differences in muscle dysmorphia symptoms and behaviors based on ethnicity, sport, and gender. including measures of self-esteem, depression, or anxiety could also be useful in a treatment setting to determine patient overall mood state and gain a greater understanding of psychological well-being for individuals with muscle dysmorphia. in conclusion, individuals have difficulty recognizing symptoms of muscle dysmorphia in others. however, those with a strong athletic identity or high rates of behaviors appear to have greater insight to any possible symptoms that they themselves might be experiencing, which may be useful in treatment. references american psychiatric association. 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(2001). thin-ideal internalization: mounting evidence for a new risk factor for body-image disturbance and eating pathology. current directions in psychological science, 10, 181–183. microsoft word manuscript 4_12.12.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 maltreatment by fathers and externalizing behavior problem: the effect of child personality lilian ayiro maseno university, kenya this study examined the relation between maltreatment by fathers and externalizing behavior in children. it assessed the moderating role of child personality characteristics in this association. a totalof155 biological father-child dyads participated. children were 7 to 10 years old (m = 8.6, sd = 1.11) from bungoma county in kenya. the findings indicated that there was no significant difference in physical and psychological maltreatment, and neglect of boys and girls by fathers. there was also no significant difference between the big five personality factors: agreeableness, extraversion, neuroticism, conscientiousness and openness of boys and girls. in addition, no significant difference emerged in externalizing behavior between boys and girls. maltreatment by fathers was associated with externalizing behavior problems in children. openness and extraversion moderated this association. children who are more open and more extraverted were more susceptible to externalizing behavior when maltreated by fathers than those who were less open and less extraverted. this study adds to existing knowledge on child maltreatment and behavior problems and the role of fathers, an area that has least been explored in kenyan research on parenting. it provides insight into the development of inclusive parent training programs on positive parenting that include fathers. the training should focus on promoting father-child relationship by equipping fathers with knowledge on how to respond to the needs of children with different personality traits and behavior. this study recommends that prevention and treatment programs should target both boys and girls. keywords: behavior, father’s parenting, maltreatment, personality, moderating research on fathers’ involvement in childrearing has increased substantially in western industrialized countries (bakermans-kranenburg et al., 2019). studies indicate that relationships with fathers affect children from childhood and into adulthood. high quality father involvement during childhood promotes healthier relationships and other favorable life qualities in adulthood (jessee & adamson, 2018). paternal involvement in child-care is beneficial for positive social behavior, emotional regulation, and linguistic development in children (cabrera et al., 2018). in addition, children who enjoy a secure attachment with their fathers are less likely to exhibit antisocial behavior than those with an insecure relationship with their fathers (marcus & betzer, 1996). it is commonly believed that father involvement is associated with positive outcomes for children (schneider, 2014). this might not be the case at all times – what matters is the quality of the relationship. children with a strained relationship with their fathers may be better off if their fathers are less or uninvolved with them (marcus & betzer, 1996). this is attributed to the fact that stressful father-child associations may be more detrimental than not having a father figure. it is worth pointing out that a lot has been documented on father’s influence on children’s development in westernized, industrialized countries. studies on the © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology, 18, pp-pp. graduate student journal of psychology ayiro caregiving role of fathers in the african context remain scarce (abubakar et al., 2013). this could be a contributing factor to less active involvement of fathers in training programs on positive parenting (bakermans-kranenburg et al., 2019). studying the influence fathers have on children in african families is important because the families are undergoing rapid social changes which include increased numbers of single fatherhood, working mothers, and non-working fathers (mwenda, 2012). the changes are likely to make fathers in these family settings take up more child caring roles than in the past. in kenya, there has been an evolving construction of fatherhood due to western influence which has likely changed the role of contemporary kenyan fathers from being somewhat distant and patriarchal to fathers who are actively involved in child socialization (wandede et al., 2014). the current study addresses the paucity of research of paternal childcare and maltreatment in an african, non-industrialized country, where male dominance has been highly respected (mulindi, 2015). this may add to existing and growing literature on fathers from industrialized countries (bakermans-kranenburg et al., 2019). as fathers get involved with their children, there is a likelihood of maltreatment. this is because maltreatment of children has been existing in almost every culture and society (stoltenberg et al., 2013). child maltreatment has been described as all forms of physical and emotional ill-treatment, or neglect, resulting in actual or potential harm to a child (holden, 2010, p. 284). globally, it has been estimated that over half of all children, equivalent to almost one billion children, aged 2-17 years, have experienced violence (hillis et al., 2016). in the united states of america, 80% of child maltreatment cases have been caused by parents (world health organization [who], 2006). in ireland, 67% of parents perceived smacking of their children aged 0-18 years as not being harmful, 59.6% believed they had a right to smack if they wished and only (28.4%) felt that it was wrong to smack children (halpenny et al., 2010). in asia, africa, and northern america, it was estimated that at least 50% of children experienced past-year violence (hillis et al., 2016). mothers and fathers have been the most common perpetrators of child maltreatment in kenya (united nations children’s fund [unicef], 2010). between 2014 and 2016, 54% of physical maltreatment, 47% of emotional maltreatment and 75% of child neglect were perpetuated by immediate family members. in bungoma county, kenya, 82% of children aged 1-14 years have been subjected to at least one form of psychological aggression or physical punishment by household members and 65% of the parents believe physical punishment is necessary part of child rearing in bungoma county (kenya national bureau of statistics [knbs] and united nation children education fund [unicef], 2016). notably, studies on child maltreatment have focused primarily on american and european societies, and much less on african societies (stoltenberg et al., 2013). in addition, literature specifically on maltreatment by fathers is scarce worldwide as well as in developing countries. the current study explores maltreatment of children by fathers in an african culture and the findings may add to a scarce literature on this topic. middle childhood is a developmental period of particular interest to understanding parenting, child behavior, and psychological adjustment (lansford et al., 2010). this developmental stage may be a period of both opportunities and challenges to children (charlesworth et al., 2007). although a child’s social world expands as they enter school, they are likely to be exposed to maltreatment and behavior problems; especially due to decreases in parental monitoring, school inequalities, learning challenges, and common family violence (cheevers et al., 2010; yaros et al., 2016). maltreatment by fathers and externalizing behavior problem during middle childhood, there is considerable change in children’s physical, cognitive, social, and emotional development (holden, 2010, p. 184). this change may make them to question adult guidelines and expectations as they strive to achieve autonomy (charlesworth et al., 2007). the common externalizing behaviors during middle childhood are disobedience, anger, fighting, frustration, and screaming (holden, 2010, p.193). although there is likely to be confrontation in meeting the child’s needs and parental demands in middle childhood, little is documented on the association between harsh or maltreating parenting of children in middle childhood and their behavior problems in africa. this made it a developmental period of special interest for this study. maltreatment, externalizing behavior and personality factors of boys and girls cultural expectations related to gender and developmental stages could influence child maltreatment; at certain ages of growth and development, children are expected to have acquired certain socially acceptable competences and failure of which could lead to child maltreatment, such as ridicule or physical abuse by the parents (kane, 2005). unlike other developmental stages, during middle childhood, boys and girls seem to follow different gender role developments where boys’ identification with masculine roles attribute increases, while girls’ identification with feminine roles attribute decreases (sravanti & kommu, 2020). these can likely lead to cross gender behavior in girls and boys, which may be perceived differently in different cultural contexts. externalizing behavior problems have also been reported to be common in boys and internalizing behaviors in girls (slobodskaya & akhmetova, 2010). notably in kenyan communities, social-cultural gender norms socialize girls and boys differently; thus, girls are generally expected to be submissive and more nurturing than boys who are expected to be aggressive, outgoing, and hardy (namulundah, 2011). in addition, levels of control and demand of parents for girls and boys may differ due to different expectations and attitudes regarding behavior and discipline of boys and girls (lansford & deater-deckard, 2012). this suggests that levels and types of maltreatment of boys and girls may differ too. nonetheless, a majority of previous researchers have used ex post facto designs in researching childhood maltreatment which may pose a challenge for memory of incidences of abuse by the respondents, hence, reducing reliability of the data. the big five personality factors (barbaranelli et al., 2003) include extraversion or surgency (talkative, assertive, energetic, sociable, assertive, forceful); agreeableness or social adaptability (warm, good natured, kind, affectionate, cooperative, trustful, nurturance, and friendliness in order to avoid conflict); conscientiousness or dependable (orderly, efficient, responsible, thorough); neuroticism or emotional instability (easily upset, anxiety, depression, irritability, self-conscious and nervous); openness or intellect was described as curiosity, appreciating other cultures, openness to experience-intellectual independence (haslam et al., 2017). studies in the united states of america and european individualistic culture samples suggest that women score higher on neuroticism and agreeableness than men and there are no gender differences in openness and conscientiousness. the gender differences in neuroticism and agreeableness were however not replicated in eastern and collective cultures (weisberg et al., 2011). here, we study the big five personality dimensions as moderators of the association between child maltreatment by fathers and externalizing behaviors of boys and girls in middle childhood, a topic that has least been studied in africa. graduate student journal of psychology graduate student journal of psychology ayiro relation between maltreatment, child personality and externalizing behavior there has been increasing number of studies conducted to explain the link between childhood maltreatment and behavior outcomes from childhood through adolescence to adulthood (rodriguez & eden, 2007; smith & thornberry, 1995). maltreatment could be linked to psychopathology in youths (mcgee et al., 1997). it may also be associated with anti-social, avoidant, and depressive behaviors in early adulthood (johnson et al., 1999). maltreatment can also compromise personality development and heighten psychopathology thus influencing adjustment problems in adulthood (higgins & mccabe, 2000). nonetheless, most of the studies have assessed mother-child relationships which could be different from the father-child relationship. the current study explored the father-child relationship that has been interpreted as a more complex, dynamic, and more contextually sensitive than the mother-child relationship (jessee & adamson, 2018). the findings will add to existing literature on parenting in a non-western culture. externalizing are behaviors that are directed outwards to other people while internalizing behaviors are directed inwards to the self (tandon et al., 2009). it should be noted that fathers might be less important for the development of internalizing behaviors (connell & goodman, 2002). in addition, detecting externalizing behaviors in young children is easier compared to internalizing behavior problems, because internalizing behavior are characterized by quiet internal distress, and externalizing is portrayed as socially negative or disruptive behavior (schneider, 2014). notably, most studies have examined the link between childhood maltreatment and behavior outcomes in adolescents and adults and not children in middle childhood who are also at risk. the fact that symptoms of externalizing behavior can be easily detected made it possible for fathers to report on the externalizing behavior of their children in the current study. studies in kenya have indicated contradicting findings on the association between childhood maltreatment and behavior outcomes. one of the studies showed that more frequent use of physical discipline was normative and had less impact on children (lansford et al., 2005). the other study that compared the association among adults in kenya, zambia, and the netherlands, indicated a significant association between child neglect and negative psychological outcomes including externalizing behavior problems in the kenyan sample (mbagaya et al., 2013). the inconsistency in the findings and the fact that most parents in bungoma believe physical punishment is necessary part of child rearing (knbs & unicef, 2016), prompted the current study to interrogate further the association between child maltreatment and child behavior outcomes in kenya. research indicates that child personality characteristics may affect the association between parenting and child behavior (higgins & mccabe, 2000; mcgee et al., 1997). some children’s temperamental or personality features, such as high irritability, might trigger maltreating behavior more easily (lee et al., 2013; warrier et al., 2021). low conscientiousness, agreeableness, neuroticism and high levels of extraversion have been associated with high levels of externalizing behavior (slobodskaya & akmetova, 2010). in addition, maltreatment may be linked to different personality traits and some genetic variations may be associated with different susceptibility to environmental influence (rogosh & cicchetti, 2012; warrier et al., 2021). however, most studies assessing personality attributes in children have over relied on temperament as a maltreatment by fathers and externalizing behavior problem measure of personality in childhood, under the assumption that personality traits were not well developed in children (oshri et al., 2013). the current study therefore used the big five personality factors, (barbaranelli et al., 2003) and the vulnerable population hypothesis (zachar, 2009). according to the vulnerable population hypothesis, certain individuals may be particularly vulnerable to psychological problems, perhaps because of environmental and social conditions, perhaps because of their personality or temperamental problems, perhaps because of physiological factors or combination of all these risk factors. using the two theories we assessed the moderating role of child personality in the association between maltreatment and externalizing behavior in children. we thus investigated whether some personality factors explain why some children were more vulnerable to develop externalizing behavior problems when maltreated by fathers than others. in the current study, fathers reported the day-to-day incidences of maltreatment of children in middle childhood. we assessed whether there were differences in maltreatment of boys and girls. we also examined the moderating role of the five personality traits in the association between maltreatment by fathers and child externalizing behavior to ascertain whether some personality factors made some children more susceptible to externalizing behavior when maltreated by their fathers. we expected that children who scored high on neuroticism and on extraversion scales would score high on maltreatment and high on the externalizing behavior scales. we also presumed that those who scored high on conscientiousness, agreeableness and openness would score low on maltreatment and externalizing behavior scales. method procedure this study assessed the association between maltreatment by fathers and externalizing behavior problems among children in middle childhood. we also investigated whether there were significant differences in the big five personality factors, externalizing behavior, and maltreatment of boys and girls in middle childhood by their fathers. we targeted children and their biological fathers out of the total population of 226,165 children aged 5-10 years who were residents of bungoma county, kenya in the year 2016 (kenya national bureau of statistics economic survey, 2016). children in middle childhood were targeted because they were found to be most maltreated (child line kenya, 2017). in addition, it has been estimated that 82% of children in bungoma county are subjected to at least one form of psychological aggression or physical punishment by household members (knbs & unicef, 2016). this gave the impetus to carry out the study on maltreatment of children in middle childhood in bungoma county, kenya. sample and sampling this was part of a larger study on fathers and mothers parenting style, child maltreatment and behavior problems. for this paper, the target sample was n = 384 father-child dyads and was deemed appropriate for a study population of 100,000 and above, at 95% confidence level, 5% margin error and 50% population percentage of variability (tahredoost, 2017). cluster sampling technique was used to select participants across 7 sub counties in bungoma county. given that most children in this age bracket were in primary schools, the schools formed primary cluster units. this method was most appropriate because the children covered a large geographical population. two schools were randomly selected per sub-county from the 7 sub counties for equal representation in the county. only children aged between 7-10 years were selected using information found in the class registers. stratified and random sampling techniques were then used to select the participants. admission numbers for the graduate student journal of psychology graduate student journal of psychology ayiro children were written on equal sized cards. the cards were put in containers that were arranged based on gender (male and female) and age (7 years, 8 years, 9 years, and 10 years old), respectively. the cards were shuffled in the containers and picked randomly until the target of 384 children was reached. ethics review committee of maseno university in kenya evaluated and declared that the procedures had no potential risk or negative consequences or discomfort to children. after obtaining approval from the committee, maseno university school of graduate studies and bungoma education county director permitted the data collection exercise. in this study, schools were the primary cluster, and the selection procedure of the children was done in the schools. there was the requirement for the children’s gatekeepers to consent. visits were made to the sampled schools to meet the respective head teachers and class teachers of grades 1-3. the head teachers were important because they controlled the access to the schools. the class teachers played a key role in the recruitment of participants in this study by providing the information about the age of the children as documented in the class registers. the cooperation of the head teacher and class teachers was, therefore, important for the success of the study. children who were above 10 years or not staying with their biological fathers were excluded from the study sample. the selected children were informed about the study and were given the opportunity to give or refuse to give verbal assent to participation. those who gave verbal assent to participate in the study were asked to avail their parents’ telephone numbers to enable the researcher to seek the parents’ consent. the parents were given the required information and adequate time to help them understand the study and decide on the consent. either mothers of the children in consultation with fathers, or fathers alone, gave the consent of participation and the most appropriate day and time for data collection. decision of parents who were not willing to participate was respected unconditionally. in order to get reports of as many fathers of children in middle childhood, we targeted only one child per household participating as possible. a case where two children from the same family were selected, the father was given an opportunity to choose to report about only one of the children. fathers who agreed to participate were assured that their identities, and that of their children, would be concealed and the information they would provide would be kept confidential and solely used for the study. they were also assigned alpha numeric codes as a way of protecting their identities. participants were asked to provide true information and would not be victimized for the information they would provide. fathers of the children responded to the questionnaires on agreed dates and time at a place convenient to them and the researcher, mostly at home of the children. the participants agreed on an incentive of 500 kenya shillings (approximately $5) for their time upon responding to the questionnaires. fathers who were not able to read and write were assisted by the researcher and research assistant. measures it has been found that parents’ educational level, income and gender of child may affect quality of parenting and externalizing behavior in children. a study on mothers’ parenting showed that mothers with less education display more controlling and physical discipline and those with higher education knew about child development and used inductive reasoning with their children (durgel et al., 2013). mothers’ higher levels of income was associated with lower externalizing behavior in african american youths aged 11-17 years (anton et al., 2015). in the current study, a background information maltreatment by fathers and externalizing behavior problem form was used to gather information about the age and gender of the children, fathers’ education level and monthly earnings from salaries, casual labor or self-employment. maltreatment by fathers was assessed by parent-child conflict tactics scale (merbert, & straus, 2002). the scale was considered suitable because it measures parenting practices associated with physical assault (13 items), child neglect (4 items), and psychological maltreatment (5 items) and has been used in previous studies in a kenyan sample (mbagaya et al., 2013). fathers responded how often they had used a certain disciplinary strategy when their children did something wrong. they indicated their responses on a 5-point scale ranging from 1 = never to 5 = every time. examples of the items included, “when my child does something wrong, i shake him/her” (physical maltreatment), “when my child does something wrong, i yell, scream or shout at him/her” (psychological maltreatment), and “i fail to ensure my child gets food” (neglect). the big five personality traits were measured by the big five personality questionnaire for children (barbaranelli et al., 2003). the scale was appropriate for this study because it can be used as a self-report for children, and for ratings by teachers and parents of the children. in addition, there is satisfactory internal consistency reliability for each factor (barbaranelli et al., 2003). fathers evaluated how well the items fitted their children’s personality attributes related to the big five personality factors: openness, extraversion, neuroticism, conscientiousness and agreeability on a 5-point scale ranging from 1= never to 5= always. example of the items were, “make friends easily” (extraversion), “trust others” (agreeableness), “respect follow rules” (conscientiousness), “nervous” (neuroticism), and “like to learn new things” (openness). the child behavior checklist (achenbach, 1991) was used to assess child externalizing behavior. the instrument was appropriate because it has been found to be reliable and used in previous studies among kenyans (skinner et al., 2014). in addition, the questionnaire has also been translated into kiswahili which is a national language of kenya and is used by kenyans across different social-economic and education backgrounds. the questionnaire consisted of 28 items on a 3-point scale. fathers evaluated how well the descriptions fitted their children’s behavior ranging from 0 = not true to 2 = very true. the items consisted of the delinquent (11 items) and aggression (19 items) subscales. the items on the delinquent subscale were: “not guilty when misbehave,” “hang with trouble people,” “lying, run away from home,” “set fires,” “steals at home,” “steals outside home,” “use obscene language,” “truancy,” “use drugs,” and “vandalism.” the aggression subscale had the following items: “argues,” “brags,” “cruel to others,” “demand a lot of attention,” “destroy own things,” “destroy others’ things,” “disobedient at home,” “disobedient at school,” “jealous,” “get into many fights,” “attack people,” “screams,” “shows off,” “stubborn,” “mood changes,” “talks too much,” “teases,” “temper tantrums,” “threaten people,” and “loud.” apart from the child behavior checklist, which is available in kiswahili, the parent-child conflict tactics scale and the big five personality questionnaire for children were forward and backward translated into kiswahili language. content and face validity of the instruments were determined before the start of the actual research. the systematic examination of contents of the instruments was done by experts and scholars with long term experience in the field of child research. the instruments were found to cover the behavior domains which they were supposed to measure. in addition, a pilot study was carried out to establish clarity and adaptability of instructions of the questionnaires to some of the fathers who were of low educational levels. graduate student journal of psychology graduate student journal of psychology ayiro a small sample of in total 38 father-child dyads which represented 10% of the final sample participated in the pilot study. the internal consistency cronbach’s alphas of the subscales were computed. the measures were found to have reliable internal consistency. for the big five questionnaire for children, the internal consistency alpha for the sub scales were: extraversion (α =.79), agreeableness (α =.79), conscientiousness (α =.84), neuroticism (α =.63) and openness (α =.74). the internal consistency alpha levels for the sub scales of the parent-child conflict tactics scale were: physical assault/maltreatment (α =.74) psychological aggression subscale (α =.66) and neglect subscale (α =.52). straus et al. (1998), also found low internal consistency for the neglect scale (α =.22) and attributed it to the diverse behavior included in the measure such that parents who engaged in one of the acts did not engage in the others. low internal consistency for the neglect scale in the current study could have been attributed to the varied behaviors included in the measure. the externalizing behavior had internal consistency of α =.77. analytic strategy data was coded and organized for analysis using ibm spss version 25. background information data was analyzed using descriptive statistics. a dimensional approach was used to classify subscales of maltreatment, personality factors and externalizing behavior variables in the study. using this approach, the degree to which a characteristic is present was assessed and lower scores equated to lower levels and higher scores to higher levels (hagan et al., 2014). in the current study, higher scores on maltreatment scales signified that the frequency of physical, psychological, and neglectful behavior by fathers was more prevalent, thus, higher level of maltreatment. higher scores on a personality factor scale suggested higher levels of the personality attribute while higher scores on child externalizing behavior problems scale corresponded to greater symptoms of the behavior problems. the approach was suitable for this study because it indicated the degree of maltreatment, personality and behavior along continuous dimensions and enabled comparing the children along the different levels and to use correlational and regression analyses. forms of child maltreatment, physical assault, psychological aggression, and neglect, were computed by summing up scores of individual items of the subscales and means derived for each type of maltreatment. later, a composite score (total maltreatment) was computed by summing up the types of maltreatment. scores of 30 items assessing externalizing behavior on the child behavior checklist, assessing delinquent behavior (11 items) and aggression (19 items), were also summed to constitute the externalizing behavior scale. for the big five personality factors, scores of items assessing each personality factor were computed and summed to constitute the variables for the agreeableness, openness, extraversion, neuroticism and conscientiousness. independent sample t-test was computed to determine mean differences in maltreatment, personality characteristics and externalizing behavior problems of boys and girls by fathers. this test was suitable for comparing means obtained from two groups (boys and girls) to ascertain whether there were significant differences in their levels of extraversion, agreeableness, neuroticism, openness and conscientiousness as well as maltreatment and externalizing behavior. pearson’s correlation was used to determine whether there were significant linear bivariate relations between child maltreatment, the big five factors in children, and externalizing behavior problems. this helped in understanding which variables were associated with lower or higher scores on externalizing behavior. the bivariate findings were complemented with a multivariate regression analysis. graduate student journal of psychology maltreatment by fathers and externalizing behavior problem hierarchical regression analysis was computed to predict of child externalizing behavior from maltreatment. the method was used because it allowed for controlling potentially confounding factors such as gender of children, fathers’ monthly income, and education level that have been found in previous studies to have an effect on maltreatment and externalizing behavior problems. controlling these variables was important in understanding the association between maltreatment by fathers and child externalizing behavior. we evaluated the effects of the personality characteristics as moderators using process tool (hayes, 2018). to avoid potentially problematic high multicollinearity with the interaction terms and to ease the interpretation of the outcome, variables were centered (standardized) before conducting the regression analyses (aiken & west, 1991). a moderating effect was detected when the relation between outcome variable and the interaction of predictor and moderator variables was significant (baron & kenny, 1986). in this study, moderation occurred when the interaction between maltreatment and personality characteristics was a significant predictor of externalizing behavior problems. this indicated that the level of the child personality factor influenced the relation between maltreatment by fathers and externalizing behavior problems in children by either strengthening or weakening the relation. the process tool plotted simple regression equations at 1 standard deviation below the mean to illustrate moderation at a low level of the moderator; at the mean to illustrate moderation at mean level of the moderator; and 1 standard deviation above the mean to illustrate moderation at high level of the moderator (field, 2018). the level of significance for the statistical tests conducted in this study was set at α < 0.05. results descriptive statistics of the participants a total of 155 biological fathers of 155 children (boys, n = 85 and girls, n = 70), aged 7-10 years (mean age, 8.5 years) participated in this study. a majority of the fathers had attended primary education, n = 84 (54%), a total of n = 57 (37%) had secondary and n = 11 (7%) had college education. only n = 3 (2%) had never attended school. eight children (5%) were staying with single fathers. the rest, n = 147 (95%) were staying with both their fathers and mothers. comparison of maltreatment, personality factors, and externalizing behavior of boys and girls we computed an independent sample t-test to ascertain whether there were significant differences in maltreatment by fathers, personality factors, and externalizing behavior of boys and girls aged 7-10 years. results indicated that there was no significant difference in mean in extraversion personality factor between boys (m = 2.89, sd = .57) and girls (m = 2.72, sd = .76), t = 1.55, p > .05. there was also no significant difference in agreeableness between boys (m = 2.79, sd = .56) and girls (m = 2.81, sd = .73), t = -.15, p > .05 and conscientiousness between boys (m = 3.08, sd = .60) and girls (m = 3.04, sd = .79), t = .32, p > .05. likewise, there was no significant differences in neuroticism between boys (m = 1.23, sd = .77) and girls (m = 1.15, sd = .80), t = .64, p > .05. no significance differences were also found in openness between boys (m = 2.91, sd = .66) and girls (m = 2.82, sd = .83), t = .79, p > .05. see table 1. ayiro graduate student journal of psychology table 1 independent sample t-test for maltreatment, personality characteristics, and externalizing behaviors of boys and girls questionnaire subscales mean sd t df p boys girls boys girls personality factors extroversion 2.89 2.72 .57 .76 1.55 153 .12 agreeableness 2.79 2.81 .56 .73 -.15 153 .89 conscientiousness 3.08 3.04 .60 .79 .32 153 .75 neuroticism 1.23 1.15 .77 .80 .64 153 .52 openness 2.91 2.82 .66 .83 .79 153 .43 problem behavior externalizing .30 .24 .20 .21 1.71 153 .09 child maltreatment physical assault .57 .50 .39 .40 1.12 153 .27 psychological .92 .77 .80 .70 1.22 153 .23 neglect .34 .47 .33 .58 .16 153 .88 we found that there was no significant difference in physical assault of boys (m = .57, sd = .39) and girls (m = .50, sd = .40), t = 1.12, p > .05, by fathers. there was also no significant difference in psychological maltreatment of boys (m = .92, sd = .80) and girls (m = .77, sd = .70), t = 1.22, p > .05 and neglect of boys (m = .34, sd = .33) and girls (m = .47, sd = .58), t = .16, p > .05) of boys and girls by their fathers. in addition, no significant difference in externalizing behavior problems between boys (m = .30, sd = .20) and girls (m = .24, sd = .21) t = 1.71, p > .05. see table 1. this suggested that boys and girls did not differ significantly in their levels of externalizing behavior problems, nor personality factors, and were not maltreated differently by their fathers. relation between maltreatment, child personality characteristics, and behavior problems as a preliminary step, bivariate correlations were conducted to examine whether significant linear relations existed between, child maltreatment, personality characteristics, and externalizing behavior. findings indicated a positive, significant relation between maltreatment by fathers and child externalizing behavior problem (r = .33, p < 0.01). there was a positive significant association between maltreatment and neuroticism (r = .25, p < 0.01). we did not find significant association between maltreatment and agreeableness (r = -.12, p = 0.135), conscientiousness (r = -06, p = .426), extraversion (r = .01, p = .840) and openness (r = -14, p = .088). there was significant, negative association between externalizing behavior and agreeableness (r = -.18, p < 0.05), conscientiousness (r = 19, p < 0.05) and openness personality characteristics (r = -21, p < 0.05). the relation between externalizing behavior problems maltreatment by fathers and externalizing behavior problem and neuroticism was positive and significant (r = .36, p < 0.01). however, the relation between extraversion and externalizing behavior was not significant (r = .06, p =.432). see table 2. table 2 relation between maltreatment by fathers, child personality characteristics, and behavior construct 1 2 3 4 5 6 7 child malt extern behavior .33** extraversion .02 .06 agreeableness -.12 -.18* .69** conscientiousness -.06 -.19* .67** .77** neuroticism .36** .16* -.03 -.09 openness -.21* .69** .70** .76** -.02 **p ≤ 0.01; *p ≤ 0.05 the findings implied that externalizing behavior problems increased with a decrease in agreeableness, conscientiousness and openness. in contrast, there was a positive significant association between neuroticism and externalizing behavior problems suggesting that an increase in neuroticism was associated with an increase in externalizing behavior problems. given the statistically significant linear relation between the predictor variable (child maltreatment) and outcome variable (child externalizing behavior), we conducted linear regression analysis. as expected, the association between father’s reported maltreatment of children, and externalizing behavior problems, was statistically significant, even after controlling for gender of children and monthly income of fathers as possible covariates (β = .33, p < 0.01). the findings suggested that maltreatment by fathers was a risk factor to child externalizing behavior problems. moderating effects of the big five personality characteristics on the relations between maltreatment by fathers and externalizing behavior problems in children we assessed whether child personality factors moderated the association between maltreatment by fathers and child externalizing behavior using process tool. models for each personality factor were computed separately. the moderating effect was only ascertained when the interaction between maltreatment and level of personality factors (agreeableness, conscientiousness, neuroticism, openness or extraversion) was a significant predictor of externalizing behavior. the results showed that interaction between maltreatment by fathers and extraversion of the child was a positive significant predictor of child externalizing behavior (β = .175, 95% ci [.066, .283], t = 3.176, p <.001). in addition, interaction of maltreatment by fathers and openness was a positively associated with child externalizing behavior (β = .108, 95% ci [-.006, .210], t = 2.092, p = .038). the interaction between maltreatment and neuroticism was not a significant predictor of externalizing behavior problems in children (β = -.066, 95% ci [-.010, -.141], t = 1.711, p = .081). the interaction between maltreatment by fathers and conscientiousness was also not a significant predictor of child externalizing behavior (β = 0.078, 95% ci [-.044, .199], t = 1.265, p = .208). further, the interaction between agreeableness and child maltreatment was not a significant predictor of externalizing behavior problems (β = 0.064, 95% ci [-.059, .187], t = 1.034, p = .303). given that moderation occurs when the interaction between maltreatment and personality characteristics is a significant predictor of graduate student journal of psychology graduate student journal of psychology ayiro externalizing behavior problems, openness and extraversion characteristics in children were the only moderators of the association between maltreatment by fathers and child externalizing behavior. in light of the foregoing, we plotted regression lines using the process tool to assess how openness and extraversion affected the relation between maltreatment by fathers and child externalizing behavior. the regression lines represented three levels of openness and extraversion (high, mean, and low). we conducted slope analyses to examine how maltreatment of children and externalizing behavior changed at the three levels. findings indicated that when openness was low, there was a non-significant association between maltreatment by fathers and child externalizing behavior (β = 0.068, 95% ci [-0.035, 0.171], t = 1.305, p = 0.193). at the mean value of openness, there was a significant positive relation between maltreatment by fathers and child externalizing behavior (β = 0.165, 95% ci [0.091, 0.239], t = 4.393, p < 0.001). when openness was high, there was a significant positive relationship between maltreatment by fathers and child externalizing behavior (β = 0.225, 95% ci [0.122, 0.328], t = 4.31, p < 0.001). the significant association between externalizing behavior and the interaction between maltreatment by fathers at mean and high level of openness and not at low level, suggested that the association was stronger in children with average and higher levels of openness. see figure 1. figure 1 model depicting the moderating role of the openness personality factor in children on the relation between child maltreatment by fathers and child externalizing behavior problems regarding the moderating effect of extraversion on the relation between maltreatment by fathers and child externalizing behavior, results indicated that when extraversion was low, there was a non-significant association between maltreatment by fathers and child externalizing behavior (β = 0.023, 95% ci [-0.086, 0.133], t = 0.419, p = 0.66). at the mean value of extraversion, there was a significant positive relationship between maltreatment by fathers and child externalizing behavior (β = 0.144, 95% ci [0.072, 0.216], t = 3.976, p < .001). when extraversion was high, there was a significant positive maltreatment by fathers and externalizing behavior problem relationship between maltreatment by fathers and child externalizing behavior (β = 0.252, 95% ci [0.160, 0.344], t = 5.395, p < 0.001). see figure 2. figure 2 model depicting the moderating role of extraversion personality factor on the relation between child maltreatment by fathers and externalizing behavior discussion the current study found no significant difference in maltreatment, externalizing behavior problems, nor personality characteristics of boys and girls aged 7-10 years. the finding that there was no difference in maltreatment of boys and girls is similar to a study among boys and girls in middle childhood in cambodia, kenya, tanzania, and swaziland. (ravi & ahluwalia, 2017). it seems likely that fathers perceived boys and girls in middle childhood as children who are yet to assume gender roles which brings about differences between boys and girls in african societies. this finding suggest that different treatment of boys and girls does not occur between age 7-10 years. in most societies in kenya, boys are initiated into manhood and assigned to male related roles at 15 years (mulindi, 2015). it is possible that before circumcision of boys, both boys and girls are regarded as children and therefore treated equally. the finding of no significant difference in externalizing behavior of boys and girls differs with a previous study which indicated that child maltreatment predicted juvenile delinquency in males and not females (topitzes et al., 2011). the divergent findings could have been attributed to sample characteristics and measurements (topitzes et al., 2011). incidences of child maltreatment by fathers in this current study is a key contribution to data on cases of child maltreatment that has been predominantly derived from mother-child association. the study also offers valuable insight about prevention and treatment programs which should target both boys and girls. in this study, there was a positive association between maltreatment by fathers and externalizing behavior among children. this suggested that children who were maltreated by fathers were likely to exhibit externalizing behavior problems. previous studies have reported similar associations using maternal data. a study among children in primary school in tehran found significant association between child maltreatment by mothers and child externalizing behavior (alizadeh et al., 2011). a different study among 88 emerging adults aged 18-22 years in south western university in the united states, also found a positive significant relation between childhood maltreatment by mothers and externalizing behavior problems (hagan et al., 2014). a study of 140 children in elementary school children in minnesota also showed that physical abuse graduate student journal of psychology graduate student journal of psychology ayiro predicted early onset of externalizing behavior (egeland et al., 2002). based on the previous findings on association between maltreatment by mothers and current study on fathers, it can be concluded that regardless of gender of the parent, maltreatment of children can have an effect on their externalizing behavior. the current study, therefore, supports the available literature on the association between child maltreatment and behavior problems by fathers that has been under-explored. in addition, this study is unlike previous research on maltreatment and behavior problems that have mainly evaluated documented files on incidences of childhood maltreatment, which are prone to under reporting of cases that have potential harm to the child (johnson et al., 1999). this study provides valuable data on current situation of the association between fathers and children in middle childhood in kenya. concerning the moderating effect of the big five child personality factors, this study found that the strength of the relation between maltreatment by fathers and child externalizing behavior weakened as the level of openness and extraversion decreased. the significant association at the mean and higher level on openness and extraversion suggested that the association was stronger externalizing behavior emerged in children with average or greater levels of openness and extraversion personality characteristics. thus, children who are more open and are more extraverted are more susceptible to externalizing behavior when maltreated by fathers than those who are less open and less extraverted. the study findings suggest that the association between big five personality factors and maltreatment by mothers could be different from fathers. whereas a previous study, see rogosh & cicchetti, 2004, indicated that children who are maltreated by mothers exhibited lower openness to experience, the current study did not find such a significant association between maltreatment by fathers and openness to experience of children. it rather showed that maltreatment by fathers and average to high openness to experience put children at higher risk of exhibiting externalizing behavior problems. this is an essential refinement of findings in previous studies that maltreatment would predict externalizing in all children. nonetheless, this study confirms the suggestion that child personality factors are likely to influence the parent-child relationship (meunier et al., 2011). specifically, the findings offer valuable insights about the underlying processes in father child relationship. the findings support the vulnerability hypothesis that some population can be more vulnerable than others because of factors such as their personality attributes. in the current study, it appears that child behaviors associated with high level of extraversion (talkative, assertive, energetic, sociable, assertive, forceful) and high level of openness (curiosity, intellect, and openness to experience) when maltreated by fathers, are likely to exhibit externalizing behavior than those who are less extraverted and less open to experience. this study indicates that maltreatment by fathers is a risk factor to externalizing behavior problems in children. the study provides knowledge on the importance of father-child relationship that is least documented in kenyan literature on parenting and child behavior. the findings may be an eye opener on the neglected role played by fathers in behavior development of their children in kenya. the study therefore forms a basis for further research on paternal influences on child development in addition to the almost exclusive focus on mothers in kenya and africa. the findings also add to literature on the big five personality factors. it shows that the big five personality factors of children may moderate the association between paternal parenting practices and child behavior problems. specifically, the study highlights that children with high levels of openness (curiosity, appreciating other cultures, openness to experiencegraduate student journal of psychology maltreatment by fathers and externalizing behavior problem intellectual independence) and extraversion (talkative, assertive, energetic, sociable, forceful) are likely to be more vulnerable to externalizing behavior when maltreated by fathers. limitations and future directions the present study has several limitations that should be addressed in future research. first, the cross-sectional design used did not explore causal relations between maltreatment by fathers, personality factors and behavior problems. longitudinal studies should be conducted to explain the links. second, we assumed that child personality factors would moderate the associations, yet it could be mediating, future studies should explore potential mediating role of the big five personality characteristic in the association between child maltreatment by fathers and behavior problems. in addition, the findings are basically on fathers as they are the neglected parents in research, but future studies may add comparisons with mothers to create a more complete picture of the family. lastly, given the sensitivity of data of this study, participants may have responded in a socially desirable manner to impress the researcher using the self-reports and the information they provided may not be perfectly reliable. future studies could utilize multiple informants and add child’s or spouse’s reports on maltreatment practices. implications this study suggests that father involvement is not always associated with positive outcomes in children and boys and girls are maltreated by fathers equally and are at equal risk of externalizing problem behaviors. the study confirms the vulnerability hypothesis that some people are more vulnerable to psychological problems due to factors such as personality problems. these findings may offer a valuable insight in developing an inclusive parenting program for both fathers and mothers, for boys and girls on sensitive parenting, and child personality factors in case of african parents. the programs need to factor in topics on child personality to enable fathers understand that parental practices, such as maltreatment and certain personality factors, may make children more vulnerable to externalizing behavior problems. using this knowledge, fathers may be motivated to develop more sensitive parenting strategies to children, especially to those who perceive that their children are high on the openness and extraversion personality factors. this may help reduce the incidence of maltreatment by fathers and hence externalizing behavior among the children. acknowledgements the author acknowledge dr. catherine mbagaya, professor lucas othuon and professor marinus van ijzendoorn for their assistance in designing and all other aspects of the study. special thanks to professor marinus van ijzendoorn for editing the manuscript. this work was supported by lolle nauta foundation and issbd/jacobs foundation. references abubakar, a., van baar, a., fishe, r., gona, j. k., bomu, g., & newton, c. r. j. c. 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(2009). psychiatric comorbidity: more than a kuhnian anomaly. philosophy, psychiatry, & psychology, 16(1), 13–22. https://doi.org/10.1353/ppp.0.0212 gsjp volume 16 final 38 graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 38 a framework for understanding msm and down-low sexuality among cultural minority men anna l. halliday teachers college, columbia university the practice of “down low” sexuality in african american and latino american cultures is a pattern in which a pdq�lghqwlàhv�dv�vwudljkw�\hw�hqjdjhv�lq�vh[xdo�dfwv�zlwk�rwkhu�phq��7klv�sdshu�h[dplqhv�wkh�irufhv�wkdw�fdxvh�phq� who have sex with men (msm) to reject a queer identity in favor of a closeted one. a framework for understanding grzq�orz�vh[xdolw\�dprqj�hwkqlf�plqrulw\�phq�lv�sursrvhg�edvhg�rq�wkh�suhplvh�wkdw�hwkqlf�060�duh�lqáxhqfhg� by a trifecta of cultural pressures unique to their minority status and not experienced similarly by white msm. this premise rests on research suggesting that ethnic minority men are expected to achieve different standards of masculinity, experience compounded stigmas associated with minority status, and are more frequently involved in an interdependent family model when compared to white msm. this complicates effective identity managephqw�dprqj�hwkqlf�plqrulw\�060��7klv�iudphzrun�lv�xvhixo�wr�shrsoh�zrunlqj�lq�wkh�phqwdo�khdowk�àhog�ehfdxvh� deepening our understanding of the cultural processes behind down-low sexuality as a sexual identity can help counselors work with this population from an informed standpoint of increased competence. discourse about why some ethnic minority msm may opt for a down low identity rather than being openly queer is important when the jrdo�lv�wr�sudfwlfh�fxowxudoo\�frpshwhqw��lghqwlw\�diàupdwlyh�frxqvholqj��1rwh��7kh�whup�´fxowxuhµ�zloo�iuhtxhqwo\� be used in place of race because culture is an observable product of the undeniably existent racialization process. introduction to down-low sexuality “down low” is a sexual identity comprised of men who identify as straight yet secretly or discreetly engage in homosexual behaviors with other men. 7klv�h[suhvvlrq�àuvw�durvh�zlwklq�$iulfdq�$phulfdq� vernacular to mean any behavior done with discretion and was subsequently adopted by some ethnic communities as an identity label referring to men with closeted sexual practices (sandfort & dodge, 2008). 7khvh�phq�duh�dovr�riwhq� whuphg�vwudljkw�lghqwlàhg� phq�zkr� kdyh� vh[�zlwk�phq�� ru� vwudljkw�lghqwlàhg� msm, especially among researchers of the subject. msm is used in place of other terminology such as homosexual or bisexual, which do not aptly apply since the fundamental characteristic of men on the down low is that they testify to having heterosexual orientations. thus, msm is a behavioral marker used to diswlqjxlvk�ehwzhhq�vhoi�lghqwlàfdwlrq�dqg�dfwxdo�dfwlrqv� this phenomenon came to broader public awareness in 2008 when author j. l. king appeared on oprah to promote his book, on the down low: a journey into the lives of ‘straight’ black men who sleep with men, which tells his story of being a black man married to a woman while maintaining covert sexxdo� diidluv� zlwk�phq� iru� wzhqw\�àyh� \hduv� xqwlo� wkh� h[wudpdulwdo� uhodwlrqvklsv�àqdoo\� hqghg�klv�pduuldjh� (sandfort & dodge, 2008). the down low has been written about, both before and after king’s appearance, for nearly two decades by other writers including best-selling novelist e. lynn harris, hip hop star terrance dean, and keith boykin, author of the 2005 book “beyond the down low: sex, lies and denial in black america”. boykin cautions that the grzq� orz� lv� qrw� vshflàf� wr� fxowxudo�plqrulwlhv� dqg� that these closeted minorities are now being unjustly blamed for the spread of hiv/aids as a result of down low discourse (phillips, 2005). this paper does qrw�dvvhuw�wkdw�wkh�grzq�orz�lv�vshflàf�wr�hwkqlf�plnorities. rather, this paper proposes that down low identities are more common among cultural minorities than among white men, and seeks an explanation for this by delving into the unique cultural challenges some minority populations face in being open about engaging in sexual activities with other men. existing research suggests that down-low sexuality is more prevalent among ethnic minority msm than among white msm. one survey-based study conducted by pathela, hajat, schillinger, blank, sell, and mostashari (2006) collected detailed sexual histories from a population-based sample of 4,193 men anna l. halliday, mental health counseling, teachers college, columbia university contact:alh2183@tc.columbia.edu 39 aged 18 and older. they categorized the men by sexual identity and actual sexual behavior according to vhoi�uhsruwv�� &dwhjrulhv� lqfoxghg� vwudljkw�lghqwlàhg� men who have sex only with women, straight-identiàhg�phq�zkr�kdyh�vh[�rqo\�zlwk�phq��vwudljkw�lghqwlàhg�phq�zkr�kdyh�vh[�zlwk�phq�dqg�zrphq��elvh[xdoo\�lghqwlàhg�phq�zkr�kdyh�vh[�rqo\�zlwk�phq�� jd\�lghqwlàhg�phq�zkr�kdyh�vh[�rqo\�zlwk�phq��hwf�� 7kh�uhvhdufkhuv�irxqg�wkdw�����ri �vwudljkw�lghqwlàhg� msm belonged to ethnic minorities groups wheredv�rqo\�����ri �jd\�lghqwlàhg�060�zhuh�hwkqlf�plqrulwlhv��7kh�vwxg\�dovr�irxqg�wkdw�vwudljkw�lghqwlàhg� 060�zhuh�vljqlàfdqwo\�pruh�olnho\�wkdq�jd\�lghqwlàhg� men to have been born in a foreign country populated primarily by black and latino people. among the iruhljq�eruq��vwudljkw�lghqwlàhg�phq������zhuh�iurp� latin america and 30% were from the caribbean. other studies reiterate the high prevalence rates of down-low sexuality among minority men in that some ethnic groups are more likely to engage in msm behavior but less likely to openly adopt non-heterosexual identities. a meta-analysis by millett, malebranche, mason, and spikes (2005) found that black msm are more likely to be bisexually active or identiàhg�wkdq�dq\�rwkhu�hwkqlf�jurxs��)xuwkhupruh��zkhq� compared to white msm, black msm were demonstrated to be less likely to disclose their non-heterosexual identity to others (millett, et al., 2005). a comparative evaluation of 208 black msm and 142 white msm found that 75% of black men compared to 36% of white men concealed their homosexual behaviors from their female partners (stokes et al., 1996). an additional study found that white men were vljqlàfdqwo\�pruh� olnho\� wkdq�eodfn�phq� wr�glvforvh� their bisexual or gay identity to family (62% versus 46%), heterosexual friends (59% versus 35%), healthcare providers (48% versus 29%), church members (32% versus 12%) and other people (kennamer et al., �������7khvh�àqglqjv�vxjjhvw�wkdw�grzq�orz�vh[xdolw\� is more common among some groups of ethnic men, particularly black msm, than among white msm. based on this demographic research, it thus follows that ethnic minority msm are more likely to remain on the down low when compared to white msm. explaining the forces behind this trend is relevant to increasing cultural competency for clinicians. this sdshu�sursrvhv�wkh�lqáxhqfh�ri �wkuhh�lqwhuzryhq�vrcial pressures particular to cultural minority groups in the u.s. which act in collaboration to make it more gliàfxow�iru�wkhvh�phq�wr�lghqwli\�rshqo\�dv�vh[xdoo\� queer, or non-heterosexual. these processes include differing constructions of masculinity among white and ethnic men, compounded stigmas associated with belonging to a minority group and owning a queer identity, and an interdependent family model emphasizing familial interdependence, or the tendenf\�lghqwlàhg�e\�vrfldo�vflhqwlvwv�iru�vrph�fxowxuhv�wr� place great value on family ties to inform individual decisions. these facets complicate identity management among ethnic minority msm in that disclosing a non-heterosexual identity causes may be perceived as an abandonment of certain cultural values. masculinity the premise of this section as it relates to down-low sexuality is that separate ethnic groups face unequal social pressures affecting the expression of their sexual identity according to ethnically or culturally differential standards of masculinity. :lwk� uhvwulfwhg�dffhvv� wr�àqdqfldo� dqg� vrfldo� vwdwxv�� males from some minority cultures become particularly invested in macho masculinity as a source of identity. when compared to white msm masculine standards, the masculinity of many ethnic minority groups appears macho or hyper-masculinized, as these men present in overtly masculine ways in order to compensate for a lack of power or social status afforded more easily to white men (acker, 2006, hooks, 1992). for this reason, ethnic minority msm may be reluctant to forfeit their culturally valued macho masculinity and thus are more likely to remain on the down low to preserve this valued trait. accordingly, an underrepresentation of ethnic minority msm within the mainstream gay culture, which lv� glvsursruwlrqdwho\� uhsuhvhqwhg� e\� diáxhqw� zklwh� males, discourages ethnic minority msm from openly identifying as non-heterosexual since they may not identify with aspects of queer, white cultural values. masculinity consists of a set of physical and behavioral traits related to being born biologically male (acker, 2006). these traits comprise a gender performance expectation that usually stands in contradiction halliday 40 to the gender performance associated with females, femininity. masculinity can be conceived of as a guideline for how men should behave, including how to have sex and with whom. society teaches boys from a young age that correct gender expression in the form of enacting masculinity is inherent to personal growth and eventual success (acker, 2006). this is especially relevant in the united states, where masculine gender performance is largely based on achieving economic success (acker, 2004; acker 2006). achievement of masculinity can occur in a variety of forms but overall this gender performance serves to legitimize men as separate from women in many arenas of life including work and home (acker, 2004; acker 2006). similarly, differing expectations of masculinity also effect identities across ethnic groups, particularly the expression of sexual orientation. hegemonic masculinity, or what is commonly known as traditional masculinity, refers to the ideal form of masculinity promoted by mainstream culture which men are encouraged to achieve (acker, 2004). american fxowxuh�hvvhqwldoo\�surprwhv�ehlqj�dq�diáxhqw��zklwh� man as the ideal form of masculine achievement (acker, 2004; acker, 2006; hooks, 1992). since hejhprqlf�pdvfxolqh� lghdov�duh�klvwrulfdoo\�ghàqhg�e\� groups of people in the highest positions of power lq�$phulfd�� wkh�diáxhqw�zklwh�pdoh��zklwh�hwkqlflw\� and social class are intrinsic elements of hegemonic masculinity (acker, 2006; hooks, 1992). this is problematic for ethnic minority men in that satiating traditionally sought after standards of masculinity is prevented by a lack of white privilege necessary to achieve hegemonic masculinity. acker (2006) and hooks (1992) detail the extent to which hegemonic masculinity is ingrained in american culture and how this is problematic for minorities. acker writes, ´khjhprqlf�pdvfxolqlw\� fdq� eh� ghàqhg� dv� wkh� wdnen-for-granted, generally accepted form” of masculinity, and that it “legitimates the power of those who embody it” (2004, p. 82). hegemonic ideals thus maintain and promote a system of power and oppression based on standards of ethnicity and social class. excluded from hegemonic ideals, some ethnic groups responded by carving out their own standards of masculinity separate from traditional expectations. this resulted in promoting forms of hypermasculinity, or macho masculinity, among groups of ethnic minority men (katz, 1999). though traditionally ethqlf�plqrulwlhv�frxog�qrw� uhds�vrph�ehqhàwv�diiruged by hegemony to white males, such as a stake in capitalism, other demonstrations of masculinity including sexual prowess and physical domination were accessible means for achieving masculinity. these overt expressions of masculinity may serve to compensate for the systematic lack of power associated with cultural or class-based disadvantages (hooks, 1992). a common pattern is for ethnic minorities to place great emphasis on sexuality as a source of masculinity to compensate for features acting against them (i.e. skin color and social class) in the attainment of masculine ideals or the power associated with masculinity (hooks, 1992, nesvig, 2001). in wklv�zd\�� vh[xdo� lghqwlàfdwlrq� ehfrphv� d� vrxufh� ri � achieving masculinity among ethnic minority men and may cause identifying as queer to further threaten the precarious standing of their masculinity. for example, hooks (1992) discusses in detail how achieving black masculinity often tends to rely upon phallocentrism, or the notion that masculinity can be achieved by what a man does with his penis as opposed to how well he provides for his family. this type of masculinity is a direct response to hegemonic oppression, which has a history of making lw�gliàfxow�iru�plqrulwlhv�wr�vxffhhg�lq�wkh�zrunirufh� (acker, 2004). hooks describes how phallocentrism is “rooted in physical domination and sexual possession of women” (hooks, 1992, p. 94). indeed, the black phallocentric masculinities hooks enlists, such as the wandering “playboy,” the man with many women, and the woman-hating type embodied by eddie murphy’s character in harlem nights seem to be overly dramatic takes on hegemonic masculinity which rely on sexual power relations between the sexes. hooks notes that these efforts to assert masculinity are well-received because they are viewed as attempts wr�frpshqvdwh�iru�d�vruw�ri �lqkhuhqw�ghàflhqf\�wkdw� becomes internalized by minorities (hooks, 1992). if within aspects of black culture a man’s use of his penis, especially through the domination of women, becomes critical to achieving masculinity (hooks, 1992) it thus follows that gay mainstream culture contains connotations of submission which msm and down-low sexuality 41 are unsuitable to the hyper-masculine ideal valued by ethnic men. under these prescriptions of gender expression, submitting to another man sexually or using one’s penis in the wrong way to have sex with another man rather than a woman could potentially threaten masculinity and affect social standing. identifying as queer could cause a man of color to forfeit some of his masculine qualities, a compromise many of these men may feel they cannot afford to make. hooks (1992) voices the relationship of black masculinity’s phallocentric dependence to coming out as queer when she writes, “challenging black male phallocentrism would also make a space for critical discussion of homosexuality in black communities” (p. 112). this drives home the point that phallocentricism is a barrier standing in the way of developing openly non-heterosexual identities for groups of black men. nesvig (2001) argues that the very same conundrum also affects latino men. this researcher asserts that some latino cultures similarly construe sexual masculinity based on penetration. he explains that “these models assume that latin american homosexuality is based on a rigid male-female, active-passive, dominant-submissive dichotomy… the insertive, active partner is rendered ‘male,’ and the receptive, penetrated partner is considered to be subservient and plays the role of ‘female’” (p. 692). nesvig (2001) presumes that, as with the emphasis on phallocentrism among african american culture, this paradigm was a reaction to feelings of powerlessness. when spain colonized latin america, people were stripped of many of their personal freedoms (nesvig, 2001). according to nesvig (2001), sexual domination, or penetration, was a way to conquer another person and regain some symbolic semblance of power. conquering a man might be seen as more gliàfxow� wkdq� dvvhuwlqj� srzhu� ryhu� d� zrpdq�� dqg� thus more admirable. but because of strict anti-sodomy laws based in religion coupled with a weighty emphasis on machismo principles, sex with other men came with profuse social risks (nesvig, 2001). thus, the penetration model in which one man zdv�ghprudol]hg�zkloh�wkh�rwkhu�uhdiàuphg�klv�pdvculinity arose to satiate a perceived lack of manly power among colonized groups in latin america. while nesvig (2001) cautions that this is a highly general description of latin american sexual practices, contemporary remnants of this model continually operate today. fear of being emasculated by receiving penetration may contribute to latino msm assuming a down-low sexuality. additionally, under this penetrative paradigm, latino sexuality cannot be adequately interpreted using the common categorizations of heterosexual or homosexual at all since sexuality rests on the sexual act rather than the sex of the partner (nesvig, 2001). sexual practices are an integral part of how men achieve masculinity. since ethnic minority men are not afforded the masculine privileges associated with being included in hegemonic ideals, achieving masculinity through sexuality becomes crucial for these groups. deviation from masculine standards surrounding sexuality entails great risk, and cultural conceptions of masculinity among ethnic groups contradict the adoption of a queer identity. the situation is very different for the white msm. the privilege associated with their race allows white msm more freedom to deviate openly from heterosexist values. their symbolic power (race) and subvwdqwldwhg�srzhu��àqdqfldo�phdqv��doorzv�zklwh�060� greater room for the expression of unconventional sexual identities. thus, mainstream queer culture seems to be designed around the needs and attributes of the white gay man, and it is a culture with disproportionately lower representation of ethnic minority msm. popular culture provides ample illustration of this point. though pop culture is at best a distorted mirror of reality, media representations of queer masculinity can be a window into how gay people live their lives and can demonstrate how masculinity informs queer lifestyles. cam and mitchell, a gay couple on abc’s popular television show “modern )dplo\µ��duh�d�txlqwhvvhqwldo�h[dpsoh�ri �wkh�diáxhqw�� white, gay male couple. mitchell, who works as a law\hu�� hduqv� vxiàflhqw�prqh\� wr�doorz�&dp� wr� vwd\�dw� home raising their adopted daughter, lily. they live in a large suburban house adorned with ornate, expensive belongings. in many ways, their household closely resembles the idyllic heterosexual mold in that one man acts as the provider and his partner is the stay-at-home nurturer. at the same time, other aspects of this lifestyle are stereotypical conceptions of how mainstream gay men should behave. while they halliday 42 ixoàoo�vrph�ihdwxuhv�ri �khjhprqlf�pdvfxolqlw\��vxfk� as delineating the roles of provider/nurturer, these characters are not the stoic, emotionally disinterested hegemonic prototype of masculinity. nor are they, dv�wzr�diáxhqw�zklwh�pdohv��h[dpsohv�ri �hwkqlf�k\permasculinity. cam and mitchell talk openly about their feelings and are emotionally expressive, traits that are more frequently associated with femininity and discouraged by masculinity as being inappropriate for men. it thus becomes evident that one substantial facet of mainstream gay culture which deviates from normative expectations of masculinity is the idea that the gay man can be effeminate without completely jeopardizing his position of power. in relation to how masculinity informs queer identity, it can be deduced that this departure from hegemony is permissible because the people whom the characters ri �&dp�dqg�0lwfkhoo�duh�edvhg�rq��diáxhqw�zklwh�jd\� males, retain more freedom of gender expression. conversely, there are few explicit representations of minority queers within pop culture. perhaps the most comprehensive examples in the current media duh� wkh� àfwlrqdo� fkdudfwhuv� ri � /d)d\hwwh� dqg� -hvxv� from “true blood”. lafayette, a black male, and jesus, a latino male, are a gay couple featured on season 3 of hbo’s vampire series. besides their queer sexuality, lafayette and jesus are the antithesis of cam and mitchell in terms of masculine expression. these phq�duh�qrw�diáxhqw��wkh\�duh�zrunlqj�fodvv��/d)d\ette works as a diner cook, drug dealer, and prostitute and jesus is an orderly at a mental hospital. furthermore, they do not exhibit effeminate behaviors such as emotional expression and physical restraint. though lafayette wears make-up and jewelry, these characters are macho or hypermasculine. they present as the extreme representations of masculine ideals that arise when ethnic minority men do not fulàoo�zklwh��khjhprqlf� lghdov��7kh\�kdyh�kdug�erglhv� dqg�txlfn�àvwv� dqg� duh�pruh� olnho\� wr�àjkw� wkdq� wr� cry. while the story lines of cam and mitchell are consumed with play dates and pre-school choices in the suburbs, lafayette and jesus are combating prejudice in their rural louisiana town. this may or may not be an accurate portrayal of minority homosexuals and the daily challenges they face when deviating from masculine norms. it is not, however, the queer world most media chooses to focus on. accordingly, if mainstream queer culture is built durxqg�dqg� lv�pruh� uhfhswlyh�ri � wkh� diáxhqw�zklwh� pdoh��lw�lv�pruh�gliàfxow�iru�hwkqlf�plqrulwlhv�wr�lghqtify within this structure because their cultural values are not fully represented. it has been noted that ethnic plqrulw\�060�àqg�lw�gliàfxow�wr�uhodwh�wr�pdlqvwuhdp� gay culture because they view it as primarily white and feminine (sandfort & dodge, 2008). besides ascribing to a sense of secrecy, down-low sexuality is also characterized by a markedly masculine sexual prowess in accordance with some ethnic cultural values (layli, 2005; sandfort & dodge, 2008). minority males may feel as though they have to exaggerate masculine attributes in order to compensate for a lack of privilege that comes with not being white. to men who are not afforded hegemonic privilege at birth as is the diáxhqw�zklwh�pdoh��ryhuw�glvsod\v�ri �sk\vlfdo�pdvculinity may be perceived as a route through which masculine status can be earned. masculinity is relevant to the framework for understanding down low identity since ethnic minority msm may be less likely to disclose their queer behaviors because they are faced with stricter expectations of how men should exhibit masculinity based on their ethnicities. thus, they are underrepresented in mainstream gay culture. the complex interplay of race, power and competing visions of masculinity is challenging to msm from ethnic minorities attempting to forge an identity within mainstream queer culture. firstly, there are aspects of black and latino masculinity acting to discourage them from adopting queer identities. secondly, queer culture is primarily represented e\� wkh� diáxhqw�zklwh�pdq� dqg�rplwv� fxowxudo� lghdov� of ethnic minority msm. adopting a queer identity may reduce an ethnic msm’s perceived sense of masculinity, which is intrinsic to maintaining his social standing where privilege is already lacking. therefore, ethnically differential expectations of pdvfxolqlw\�zlhog�dq�hqruprxv�lqáxhqfh�ryhu�pdq\� ethnic msm’s choice to remain on the down low. compounded stigmas since both minorities and gay men challenge the expectations of hegemony, that white, heterosexual males are the ideal, they are stereotyped as msm and down-low sexuality 43 ehlqj� ghyldqw� ru� ghàflw� �5lwwhu� � 7huqguxs�� ������� this creates stigma affecting the daily lives of people. stigma affects the stigmatized by “limiting them socially and disempowering them psychologically (ritter & terndrup, 2002, p. 16)” and allows for discrimination. being of both of a queer identity and of a minority culture makes a person vulnerable to compounded stigma because their sexuality and race deviate from privileged groups. avoiding compounded stigma may be a motivation for remaining on the down low. in the current state of racial and sexual relations, perhaps the down low can be conceived of as a way to preserve one’s mental health and physical safety in the face of compounded stigma. research supports the supposition that choosing wr�uhpdlq�rq�wkh�grzq�orz�lv� lqáxhqfhg�e\�hiiruwv� to avoid possible stigma associated with coming out, a possibility that is increased by being a queer ethnic minority as opposed to a queer white msm. miguel 0xxr]�/der\�� d� surplqhqw� uhvhdufkhu� lq� wkh� àhog� of down-low sexuality, has argued that, “implicit in the notion of the ‘down low’ is the idea of avoiding the cultural stigma attached to non-heterosexual identities and for this reason keeping non-heteronormative sexual matters private” (2008, p. 774). being private about sexual matters is therefore a function of the down low identity, likely because being openly queer causes ethnic minorities to be further vulnerable to discrimination resulting from stigmatization. managing two or more outlying identities, in this case ethnic minority status and queer sexual orientation, can be a struggle for these populations. “ethnic gay men and lesbians need to live within three riglgo\�ghàqhg�dqg�vwurqjo\�lqghshqghqw�frppxqlwlhv�� the gay and lesbian community, the ethnic minority community, and the society at large. while each community provides fundamental needs, serious consequences emerge if such communities were to be visibly integrated and merged” (morales, 1989). on one side of the coin, msm members of minority cultures fear homophobia and threats of physical violence within their ethnic communities (fullilove & fullilove; 1999; nesvig, 2001; ward, 2005). additionally, ethnic men are also concerned with being confronted by racism within the gay community (han, 2008). a vwxg\�ri � wkh�phqwdo�khdowk�ri �rshqo\� lghqwlàhg�jd\� and bisexual latino men in miami, los angeles, and new york found that coming out was associated with a relatively high frequency of symptoms of psychological distress, low self-esteem, and social isolation resulting from experiences of social discrimination (diaz, ayala, bein, henne, & marin, 2001). thus, remaining on the down low may serve to protect ethnic minority msm from further discrimination. � $�vshflàf�lqvwdqfh�ri �krz�vwljpd�lpshghv�lghqtity formation is the stigma of hiv/aids. hiv/ aids infection has long been associated with both msm and ethnic minorities. when the disease was àuvw�uhsruwhg�rq�lq�wkh�hduo\�����·v��lw�zdv�iuhtxhqwo\� shjjhg� wkh� ´jd\� sodjxhµ�� ´7kh�$,'6� vwru\� kdg�ànally made its way from the science section and the back pages of the news, but it was still reported almost exclusively as a gay disease (kinsella, 1989, p. 75). in recent years, hiv/aids prevention has become a major concern for ethnic communities (fullilove & fullilove, 1999; millett et. al., 2005; muñozlaboy, 2008). figures 1 and 2 summarize infection rates per year by ethnicity and mode of transmission. figure 2: estimated new hiv infections, 2010, by transmission category abbreviations msm men who have sex with men idu injection drug user figure 1: new hiv infections in the united states, 2010, by ethnicity halliday 44 rates of infection for these groups are disproportionately high when compared to other fractions of the population. figure 1 demonstrates that black american males as a group accounted for the highest rates of new hiv infection in 2010 followed by latino males (center for disease control and prevention, 2012). figure 2 shows that msm, whether vwudljkw�� ru� jd\�lghqwlàhg�� frqvwlwxwhg� ryhu� kdoi � ri � all new hiv infection cases in the same year (center iru�'lvhdvh�&rqwuro�dqg�3uhyhqwlrq���������7khvh�àjxuhv�vhuyh�wr�vxssruw�wkh�àqglqj�wkdw�hwkqlf�plqrulw\� males form black and latino backgrounds as well as msm have the highest rates of new hiv infections. furthermore, men on the down low are often blamed publicly for spreading the hiv/aids virus to women. though this claim remains largely unfounded (sandfort & dodge, 2008), it contributes to the stigma experienced by ethnic minority msm who have disclosed that they sleep with men, especially considering that the rates of new hiv infection are indeed highest among these groups. openly gay and bisexual hiv-positive msm face greater risk of experiencing symptoms of psychological distress including anxiety and depression (diaz, et al., 2001). thus, the high hiv/aids infection rates among both ethnic minorities and msm create compounded stigmas about disclosing a non-heterosexual identity. ethnic minority msm may stand to face greater prejudice from societies who stigmatize hiv/aids by coming out as gay, since both ethnic minority groups and msm have the highest rates of hiv/aids infection. what is risked when ethnic minority msm befrph�yxoqhudeoh�wr�frpsrxqghg�vwljpdv"��0hq�zkr� choose to stay on the down low may be protecting their mental health since identity management is profoundly affected by compounded stigmas (mondimore, 1996). as a minority of a minority, ethnic queers “bear the additional task of integrating two major aspects of their identity when both are conspicuously devalued” (greene, 1994, p. 248). thus, there is a tendency among queer minorities to feel forced to choose between a cultural versus a queer identity since the weight of compounded stigmas is so burdensome (sandfort & dodge, 2008). it can be assumed that this compounded stigma affects identity management by causing queer minorities to remain on the down low for fear of facing further discrimination. familialism in the interdependent family model the interdependent family model is a collectivist style of social relating which is exhibited in higher frequency among ethnic cultures than among white culture (greene, 1994; muñoz-laboy, 2008). due to the interdependent family model adhered to most often by ethnic people and less so by whites, minority msm are more likely to desire inclusion within their culture and therefore to downplay their sexuality. this model is characterized by the tremendous emphasis placed on families being dependent upon one another for support, emotional connectedness, honor, loyalty, and solidarity, often referred to as “familialism” (muñoz-laboy, 2008). as muñoz-laboy explains, “in cultures where collectivism is a predominant value, the sexual orientation of individuals is no longer an individual issue, but rather a struggle between placing an individual’s orientation over apparent collective social order” (2008, p. 776). interdependent family members are expected to forgo personal opinion in favor of shared beliefs and attitudes and are in return rewarded with a sense of belonging. since cultural minorities depend on family extensively for their psychological and often physical wellbeing, it logically follows that when faced with an identity dilemma they choose to remain faithful to their cultural identity. this means that minority msm might assume a down-low sexuality in order to avoid possible familial rejection induced by homophobia. muñoz-laboy’s research leads to the hypothesis that interdependent communities characterized by faploldolvp�lqáxhqfhv�khdowk�sudfwlfhv�dprqjvw�/dwlqr� msm because individuals with high degrees of familialism are less likely to engage in risky behaviors (muñoz-laboy, 2008). with the stigmas attached to hiv/aids, homosexual behaviors are considered risky among latino americans. muñoz-laboy (2008) performed an analysis of several case studies of bisexually active latino men. he found two common characteristics: 1) the desire to procreate in order to protect familial honor, and 2) a compartmentalization of sexual identity as separate and hidden from culturdo�diàoldwlrq��,q�rughu�wr�surfuhdwh�xqghu�wkhvh�whupv�� msm and down-low sexuality 45 sex with men would be discouraged, which could contribute to the compartmentalization of a queer identity and, thus, down-low sexuality. this body of research demonstrates that values associated with interdependent familialism wield control over sexual identity among ethnic minorities and complicate identity management strategies. familialism as part of an interdependent family model affects the choice to remain on the down low because family opinion, approval, and support are greatly valued among ethnic minorities, and disclosure could compromise this system by causing the msm to be ostracized. clinical implications and directions for future research the research included throughout this paper serves to provide insight into the down low identity. this is relevant when working with msm populations because research on down-low sexuality is currently limited. the three-pronged framework presented here can be used as a tentative guideline for future research on the topic by identifying areas in need or further investigation and support. understanding why ethnic msm may be more inclined than white msm to choose a down low identity rather than adopting an openly queer one is important for clinicians working with these populations. because research on queer populations suggests that disclosure of one’s queer identity is correlated with better mental health (hill, 2009), many clinicians assume a pro-coming out stance, and in therapy will overtly or subtly encourage non-heterosexuals to disclose their true orientations. the potential problem with this assumption, as the bulk of the research cited throughout this work demonstrates, is that ethnic minorities face unique lghqwlw\� pdqdjhphqw� fkdoohqjhv� wkdw� pdnh� lw� gliàcult to openly join the mainstream queer culture. identity management among ethnic minority msm is complicated by pressures to conform to cultural standards of macho or hypermasculinity that may be compromised by having sex with men. successful identity management is also compromised by the need to avoid further discrimination by coming out as queer, such as being exposed to profound psychological distress and physical violence. the tendency of ethnic minorities to greatly value familial support in the decision to come out should also be acknowledged and respected when conducting therapy with these populations. clinicians are advised to be aware ri � wkhvh� lvvxhv�zkhq�sudfwlflqj� lghqwlw\� diàupdwlyh� counseling since there is a great deal at stake when ethnic minority msm begin disclosing their identities. the clinician and client may need to work togethhu� wr�ghwhuplqh�zkhwkhu� wkh�ehqhàwv�ri �dgrswlqj�d� queer identity outweigh the risks in order to ensure ehqhàfhqfh�dqg�plqlpl]h�kdup�grqh�gxulqj�wkhuds\��� conclusion research on down low identity points to the lqáxhqfh�ri �pdvfxolqlw\�� vwljpd� dqg� w\sh�ri � idplo\� model on the sexual identity of ethnic minority msm. these pressures are interconnected, and together create a situation in which identifying as queer is more gliàfxow� iru� fxowxudo�plqrulwlhv� wkdq� iru�zklwh�phq�� and in which down-low sexuality is common among minority msm. facets of hegemony prevent the absorption of minority men’s values into mainstream culture, thus impeding these men from candidly actualizing a queer identity of their own. in order to uhpdlq� fxowxudoo\� frpshwhqw� dqg� lghqwlw\� diàupdtive, the counseling profession must be aware of these factors when treating men belonging to racial and sexual minorities on the down low. this threepronged framework for understanding the choice to remain on the down low can be utilized for further research as well as for counseling these individuals. references acker, j. (2004). gender, capitalism and globalization. critical sociology, 30(1), 17-41. acker, j. (2006). is capitalism gendered and raciall]hg"�&odvv�4xhvwlrqv��)hplqlvw�$qvzhuv���������� /dqkdp��0'��5rzpdq� �/lwwohàhog�3xeolvkhuv�� inc. center for disease control and prevention (2012). [graph and chart illustrations of new incidences of hiv infections in 2010]. new hiv infection in the united states. retrieved from http:// halliday 46 www.cdc.gov/nchhstp/newsroom/docs/2012/ hiv-infections-2007-2010.pdf. díaz, r. m., ayala, g., bein, e., henne, j., & marin, b. v. (2001). the impact of homophobia, poverty, and racism on the mental health of gay and elvh[xdo�/dwlqr�phq��àqglqjv� iurp���86�flwlhv�� american journal of public health, 91(6), 927– 932. fullilove, m.t., & fullilove, r.e. (1999). stigma as an obstacle to aids action: the case of the african american community. american behavioral scientist, 42, 1117-1129. greene, b. 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(2006). discordance between sexual behavior and self-reported sexual identity: a population-based survey of new york city men. annals of internal medicine, 145, 416-425. phillips, layli (2005). deconstructing “down low” discourse: the politics of sexuality, gender, race, aids, and anxiety. journal of african american studies, 9(2), 3-15. ritter, k.y. and terndrup, a.i. (2002). heterosexism: $�)xqgdphqwdo�5hdolw\��+dqgerrn�ri �$iàupdtive psychotherapy with lesbians and gay men: 11-24. sandfort, t. & dodge, b. (2008). “…and then there was the down low”: introduction to black and latino male bisexualities. archive of sexual behavior, 37, 675-682. stokes j.p., mckirnan d.j., doll l., et al. (1996). female partners of bisexual men: what they don’t know might hurt them. psychology of women quarterly, 20, 267-284. ward, elijah g.(2005). homophobia, hypermasculinity and the us black church. culture, health & sexuality, 7(5), 493-504. msm and down-low sexuality gsjp volume 16 final graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 25 expanding the biopsychosocial model: the active reinforcement model of addiction annie hunt university of denver 7kh�frqwhpsrudu\�xqghuvwdqglqj�ri �dgglfwlrq�lv�h[sdqglqj�udslgo\�dv�uhvhdufk�dfurvv�vshfldo�àhogv�lqirupv�wuhdwment and intervention techniques. current prevention efforts work from the well-accepted biopsychosocial model and are aimed at identifying the underlying causes of addiction and attempting to block them from manifesting, primarily through educational methods. however, once an addiction has already emerged, intervention and treatment efforts should operate from a more comprehensive conceptualization of addiction that takes into account more than just underlying factors – these efforts must address how these factors are currently operating and reinforcing one another. the active reinforcement model proposed in this paper addresses the mechanisms of action that govern the relationships among three primary elements of addiction: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this model serves as a more comprehensive conceptualization of addiction as it accounts for each of the present factors and places them in an interdependent context. thus, while the biopsychosocial model effectively addresses the underlying causes of addiction, the proposed active reinforcement model addresses the mechanisms of existing addictions in a more comprehensive manner. a better description of the relationship between each element provides a deeper understanding of the full phenomenon of addiction, and may therefore be more effective in generating successful treatment outcomes than previous models. introduction to addiction medical, psychological, and social understandings of addiction have evolved rapidly over the past century, and contemporary addiction research and treatment is becoming increasingly interdisciplinary. addiction vwxglhv�� lqlwldoo\�edvhg�lq�wkh�àhog�ri �skdupdfrorj\�� now incorporate psychological, neurobiological, genetic, environmental, social, and spiritual considerations. furthermore, addiction is being studied in schools of social work, public health, medicine, and psychology. addiction has thus become a multi-disciplinary construct that necessitates a wide range of understanding from contemporary practitioners, and as this understanding expands, the professional obligation to maintain a consistent and regulated standard ri � sudfwlfh� ehfrphv� vljqlàfdqwo\�pruh� fkdoohqjlqj��� � 6wdqgdugl]hg� folqlfdo� sudfwlfhv� lq� wkh� àhog� ri � addiction are developed, tested, and disseminated through clinical research, and the myriad factors ináxhqflqj�wklv�àhog�suhvhqw�dq�lqwhuhvwlqj�fkdoohqjh�iru� researchers who must take them into consideration when designing and implementing studies. these studies are the mechanism for generating empirically edvhg�àqglqjv��zklfk�duh� wkh�qhfhvvdu\�suhuhtxlvlwh� in allowing new considerations to be incorporated into standardized treatment options. in order to increase evidence-based treatment options in response to the expanding conceptualization of addiction, rqh�pxvw� àuvw� ehjlq�zlwk� d� fohdu� xqghuvwdqglqj� ri � wkh�fxuuhqw� vwdwh�ri � wkh�àhog�� dqg� wkhq�sursrvh�dueas for further academic consideration and research. the starting point for this process is the diagnostic and statistical manual of mental disorders (dsm), ruljlqdoo\�sxeolvkhg�lq�������zklfk�vljqlàfdqwo\�lqáxences treatment options, research, insurance policies, public opinion, and social stigma. while the dsm dfnqrzohgjhv� wkdw� wkh� gldjqrvwlf� fodvvlàfdwlrq� surcess is a challenging one, and that there are no strict boundaries dividing one disorder from the others or from no mental disorder at all, it does offer a professional consensus about the categorization and idenwlàfdwlrq�ri �phqwdo�glvrughuv�dw�wkh�wlph�ri �lwv�sxelication (dsm-5; american psychiatric association, 2013). thus, it provides a reliable tool for establishing standards of diagnoses, terminology, and criteria iru�fodvvlàfdwlrq�zkloh�dw�wkh�vdph�wlph�hpskdvl]lqj� wkh� lpsruwdqfh� ri � áh[lelolw\�� dssursuldwh� wudlqlqj�� and cultural sensitivity during clinical application. addiction terminology. chemical and behavioral addictions have long been recognized as serious and prevalent psychological problems throughout history, so it is interesting that the most recent version ri � wkh�'60³wkh� )liwk�(glwlrq�� sxeolvkhg� lq�0d\� ����³grhv�qrw�dfwxdoo\�lqfoxgh�wkh�whup�́ dgglfwlrqµ� (apa, 2013). the category used in the dsm-5 to deannie hunt is doctoral student at the university of denver. correspondence concerning this article should be addressed to: anniehunt1@gmail.com 26 scribe the phenomenon colloquially referred to as chemical or substance addiction is titled “substance use disorder,” and it combines the former categories of substance abuse and substance dependence (from the dsm-iv) into a single disorder that is to be measured on a scale from mild to severe (apa, 2013). neither did the previous edition, the fourth edition, text revision, published in 2000 by the american psychological association, include the term “addiction,” as the term ‘dependence’ won out over ‘addiction’ by one vote during the last revision process (dsmiv-tr, apa, 2000; o’brien, volkow, & li, 2006). � 6shflàf� dqg� dffxudwh� whuplqrorj\� sod\v� dq� lpportant role in the conceptualization of this phenomenon. according to the national institute on drug abuse (nida), the term “dependence” indicates a physiological need or dependency on a substance. this is evidenced by a biological adaptation to the substance in which the body requires more of it to achieve an effect (the phenomenon of tolerance) and also manifests physical indicators if use is suddenly stopped (the phenomenon of withdrawal; nida, 2012). physical dependence, however, can occur with continued use of many different substances, including those taken as prescribed, and does not necessarily include the psychological or behavioral consequences that characterize an “addiction” or “disorder.” the term “disorder,” according to the apa (2012), includes the following: 1. a behavioral or psychological syndrome or pattern that occurs in an individual ��� 7kdw�uháhfwv�dq�xqghuo\lqj�sv\fkrelrorjlfdo� dysfunction 3. the consequences of which are clinically vljqlàfdqw�glvwuhvv�ru�glvdelolw\ 4. must not be merely an expectable response to common stressors and losses or a culturally sanctioned response to a particular event 5. that is not primarily a result of social devidqfh�ru�frqálfwv�zlwk�vrflhw\� thus, “disorder” indicates the presence of behavioral and psychological symptoms, but fails to clearly articulate the aspect of compulsory repetition that the terms “dependence” or “addiction” include in their ghàqlwlrqv� finally, the term “addiction,” according to the national institute on drug abuse, indicates compulsive use of a substance despite harmful convhtxhqfhv�� vxfk� dv� idloxuh� wr� ixoàoo� vrfldo�� zrun�� ru� family responsibilities, and an inability to stop using the substance of one’s own accord (2013). additionally, according to the apa website, addiction falls under the category of “mental health disorders/ ,vvxhv�µ� dqg� lv� ghàqhg� dv� ´d� fkurqlf� eudlq� glvhdvh� that causes compulsive substance use despite harmful consequences” (apa, 2012). arguably, the most frpsuhkhqvlyh� dqg� vshflàf� ghàqlwlrq� ri � dgglfwlrq� comes from the american society of addiction 0hglflqh��$6$0���������zkr�ghàqh�dq�dgglfwlrq�dv� a primary, chronic disease of brain reward, motivation, memory and related circuitry . . . [which] lv�uháhfwhg�lq�dq�lqglylgxdo�sdwkrorjlfdoo\�sxuvxing reward and/or relief by substance use and other behaviors. addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recogniwlrq� ri � vljqlàfdqw� sureohpv� zlwk� rqh·v� ehkdyiors and interpersonal relationships, and a dysfunctional emotional response (asam, 2010). it is interesting to compare the terms to identify differences as well as overlaps. according to the above ghàqlwlrqv�� ghshqghqfh� rq� d� vxevwdqfh� grhv� qrw� necessarily constitute an addiction, and an addiction does not necessarily involve physiological dependence (nida, 2012). furthermore, a disorder does not necessarily constitute an addiction. these terms therefore cannot be used interchangeably, as they each indicate the presence of different symptoms. it should be noted, however, that the dsm-5 does use the category of “addictive disorders” to describe pathological gambling as a behavioral addiction (apa, 2013). this is the only condition listed in this category, despite general clinical recognition of other non-chemical, behavioral addictions such as sex addiction, internet addiction, compulsive tanning, and compulsive shoplifting (e.g., grant, potenza, weinstein, & gorelick, 2010). neither the 1,'$� ghàqlwlrq� ri � glvrughu� qru� wkh� $3$� ghàqlhunt 27 tion of addiction include non-chemical addictions, despite the widespread social, medical, and cultural call for recognition and treatment of these particxodu� sureohpv� �*uliàwkv�� ������ :dqj� hw� do��� ������ this paper argues that one of the most critical aspects of active addiction treatment is addressing the phenomenon of being unable to stop certain substance use or behaviors solely of one’s own volition – namely, the compulsive aspect of the condition regardless of known negative consequences. as of the most current edition, the dsm still does not frpsuhkhqvlyho\�duwlfxodwh� wkh�suhvhqfh�dqg�vljqlàcance of this symptom. the continued exclusion of this component indicates that at this point in time, frqwhpsrudu\�uhvhdufk�kdv�vwloo�qrw�vxiàflhqwo\�slqpointed what exactly this phenomenon is, what it involves, how it operates, and how to address it. it is this phenomenon that the proposed active reinforcement model attempts to describe, validate, and address by drawing together parts of prior conceptualizations and constructing a more comprehensive model. this paper argues that once an addiction is manifest, it is actively reinforced by the relationships between three essential factors: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior, the combination of which results in the compulsive aspect of the phenomenon. understanding the relationship between these factors and how they actively reinforce addiction would offer a starting point for developing interventions aimed at disrupting these relationships. previous conceptualizations of addiction. addiction has previously been conceptualized using different models, with the most historically prominent being the “adaptive” and the “disease” models. the adaptive model preceded the disease model, dqg�vxjjhvwhg�wkdw�dgglfwlrqv�ghyhors�zkhq�vshflàf� psychological needs – such as acceptance, autonomy, frpshwhqfh�� ru� frqàghqfh�²� duh� qrw�phw�� wklv�zdv� also termed “integration failure” (alexander, 1990). the adaptive model argues that addictions develop wr�phhw�wkhvh�vshflàf�sv\fkrorjlfdo�qhhgv��dqg�wkdw� the addictive behavior provides a sense of support, reassurance, or meaning that individuals feel is missing in their lives. the disease model, also sometimes called the medical model, posited that addiction is neither an issue of failed willpower nor the result of conscious repeated habitual behavior, but is rather a chronic, progressive medical illness characterized by abnormalities or defects in brain functioning (sheehan & owen, 1999). silkworth (1939) was one of the pioneers of this model, originally applying it to alcohol dependence. in the primary text of the alcoholics anonymous program, he described alcoholism as an unusual or distorted behavioral response to alcohol consumption, and described problematic chronic drinking as a manifestation of a “physical allergy” to alcohol (alcoholics anonymous, 2001). sheehan and owen (1999) argue that the disease model represents a more comprehensive explanation of addiction through its depiction of neurological ghàflwv� dqg� deqrupdo� ehkdylrudo� uhvsrqvhv�� �7khvh� models offered initial foundations for the development of addiction studies and treatment, and they remained prominent until the emergence of george engel’s “biopsychosocial model” (engel, 1978). current conceptualization of addiction. the biopsychosocial model, which is used to describe many different mental disorders, is arguably the most prominent construct used to conceptualize addiction today (alonso, 2004). this model built upon the disease model by accepting that addiction involves abnormalities in brain functioning, but then expanded that model by integrating the subjective psychological experiences of individuals into the conceptualization of illness. it suggests that an understanding of the patient’s subjective experience is critical in developing accurate diagnoses and successful treatment options (borrel-carrio, suchman, & epstein, 2004). the biopsychosocial model thus seeks to explain suffering, disease, and illness as generated by multiple causes, including social, biological, and psychological factors. this inclusion of subjective psychological components into the disease model expands the concept of addiction to include individual experiences, perceptions, stressors, and perspectives as mediating factors in the expression of clinical illnesses and medical problems. thus, this model helps to bridge wkh�jds�ehwzhhq�wkh�phglfdo�dqg�sv\fkrorjlfdo�àhogv�� dqg� lv� h[whqvlyho\� dffhswhg� lq� wkh� àhog� ri � dgglfactive reinforcement model of addiction 28 tion studies and psychology today (alonso, 2004). drawing from the above-mentioned previous dqg� frqwhpsrudu\� ghàqlwlrqv� ri � dgglfwlrq�� wkuhh� fruh�hohphqwv�ri �dgglfwlrq�fdq�eh�lghqwlàhg�²�xqphw� psychological needs, impaired neurological mechanisms, and problematic behaviors. however, the dgdswlyh� dqg�glvhdvh�prghov�gr�qrw� vxiàflhqwo\�ghscribe the relationships involved in the phenomenon of addiction because they suggest simple linear causality between either coping and problematic behaviors or disease and problematic behaviors. this paper argues that the previous conceptualizations of addiction, including the biopsychosocial model, do identify wkh�fruh�hohphqwv�ri �dgglfwlrq��exw�idlo�wr�vxiàflhqwo\� demonstrate the reciprocal relationships among them. emerging research reveals evidence that unmet psychological needs, impaired neurological mechanisms, and problematic behaviors can act as both causes and effects in the construct of addiction (castellani, wedgeworth, wootton, & rugle, 1997; grant, brewer, & potenza, 2006; hyman & malenka, 2001). while the biopsychosocial model offers a more substantive argument for acknowledging the presence of combined psychological and biological/pharmacological factors in the development of addiction, and sduwldoo\�lghqwlàhv�vrph�ri �wkh�uhodwlrqvklsv�lqyroyhg� among these factors, it does not offer a comprehensive conceptualization of all of the relationships between these factors that contribute to active addiction and compulsive behaviors. it states that these different factors play a role in impacting outcomes, and that there is a relationship between biological/psychological elements and external functioning, but it makes xvh�ri �dq�hfohfwlf�dssurdfk�wkdw�grhv�qrw�vshflàfdoo\� or explicitly describe how that relationship functions and impacts addiction (ghaemi, 2009). furthermore, it fails to establish the impact that psychological factors have on neurobiological factors, the impact that neurobiological factors have on psychological factors, and the reverse impact that dysfunctional behaviors may have upon psychological and biological ixqfwlrqlqj³dq�lpsruwdqw�qhz�uhodwlrqvkls�wkdw�kdv� been demonstrated in emerging research (hyman & malenka, 2001). this paper will propose a new model that includes the critical elements of addiction and places them in an interdependent context that offers a more comprehensive understanding of how addictions function. it will also defend each ri �wkhvh�uhodwlrqvklsv�zlwk�uhfhqw�uhvhdufk�àqglqjv� proposed “active reinforcement model of addiction.” current research consistently indicates the presence of neurological, psychological, and external/behavioral components in the overall conceptualization of addiction, though each element may have varying degrees of intensity and causality (i.e., one element may be more powerful or have more lqáxhqfh� wkdq� rwkhuv�� ghshqglqj� rq� wkh� lqglylgxdo�� grant, brewer, & potenza, 2006). this paper argues that there is a cause-effect relationship between all three elements, meaning that each element both ináxhqfhv�dqg�lv�uhlqirufhg�e\�wkh�rwkhu�wzr�hohphqwv��� in light of this knowledge, a new model, entitled the “active reinforcement model of addiction” (figure 1), is proposed. from this conceptualization, the critical principle that emerges is not the imporwdqfh� ri � ghwhuplqlqj�zklfk� hohphqw� fdph� àuvw�� ru� àqglqj� dq�xqghuo\lqj� uhdvrq� iru�zk\� wkh� dgglfwlrq� emerged. rather, the focus is shifted to the importance of acknowledging how all three coexist and reinforce one another in an interdependent context once an addiction has become active. from there, an altered focus for treatment and interventions can be proposed, again shifting the focus of treatment techniques from why to how addictions function. prevention efforts generally focus on the question of why addictions develop and use education, risk protection techniques, and resilience training based on the proposed answers to this question, though there still is no consensus on exactly what fdxvhv�dgglfwlrq��6$0+6$����������7kh�àhog�lv�ixoo� of varying hypotheses and theories that attempt to explain addiction’s underlying causes in order to create successful prevention efforts and education programs aimed at stopping addiction before it starts. this paper, however, is not focused on prevention efforts, but rather proposes use of a different model to guide treatment of active addictions. prevention efforts are distinctive from treatment efforts, according to the american society of addiction medicine, though they may both be used concurrently in certain circumstances (asam, 2005). treatment, according to asam, is aimed at helping individhunt 29 active reinforcement model of addiction 11 � treatment, according to asam, is aimed at helping individuals currently suffering from an addiction. once addiction symptoms (according to either the dsm or apa criteria) are manifest, prevention models should be substituted for a working understanding of how the addiction is actively functioning. while research on preventive measures is valuable and will continue to hold its place in the field, this paper argues that addiction treatment and intervention should be based on a more comprehensive conceptual model of how addictions are actively sustained. figure 1: active reinforcement model of addiction. this figure illustrates the critical relationships that reinforce active addiction. as demonstrated by the figure above, the phenomenon of addiction is sustained by the presence of and relationship among three elements: a) impaired neurological mechanisms; b) � � ���������������� �� ��� � � ������������ �� ��� ���� ������� ��!����� ������ � ���� ��� � ���������� �� ���� ����� uals currently suffering from an addiction. once addiction symptoms (according to either the dsm or apa criteria) are manifest, prevention models should be substituted for a working understanding of how the addiction is actively functioning. while research on preventive measures is valuable and zloo� frqwlqxh� wr� krog� lwv� sodfh� lq� wkh� àhog�� wklv� sdper argues that addiction treatment and intervention should be based on a more comprehensive conceptual model of how addictions are actively sustained. � $v�looxvwudwhg�e\�wkh�àjxuh�deryh��wkh�skhqrphnon of addiction is sustained by the presence of and relationship among three elements: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this model serves as a comprehensive conceptualization of addiction that incorporates the main elements of addiction and places them in an interdependent context. it helps to organize the concept of active addiction into a strucwxuhg�phfkdqlvp�ghàqhg�e\�uhlqiruflqj�uhodwlrqvklsv�� which may allow studies and interventions to specifically focus on particular sections or relationships in the model. at the same time, it also offers a full depiction of the phenomenon, which may help to remind practitioners that each element and relationship must be attended to in treatment. this paper will describe how many existing theories and interventions àw�gluhfwo\�lqwr�wkh�dfwlyh�uhlqirufhphqw�prgho��dqg� will explain how each encompasses one or some of the six relationships described: a ȹ (causing) b, a ȹ c, b ȹ a, b ȹ c, c ȹ�b, and c ȹ�a. any element, standing alone or impacting only one of the other elements, does not necessarily lead to the emergence of an addiction. this model theorizes that all relationships must be present to some degree in order to constitute an active addiction. this paper will begin to justify this theory by examining the current worklqj�ghàqlwlrq�ri �zkdw� wkh� whup�´dgglfwlrqµ�phdqv� 'hàqlwlrq�ri �$gglfwlrq��d��e� �f� all people engage in self-regulatory behaviors in response to their biological, psychological, social, and spiritual wants and needs (bandura, adams, & beyer, 1977). many people use substances or engage in risky behaviors to meet these needs, and these do not always develop into disruptive or chronic patterns of use. the crossover from substance use or occasional dysfunctional behavior to the full manifestation of dgglfwlrq�lv�dpeljxrxv�dqg�gliàfxow�wr�ghàqh���2qh� must consider the motivations for, frequency and intensity of, and consequences of the substance use or dysfunctional behavior in order to determine whether it can be considered problematic (c). as noted previously, the dsm acknowledges that there are no absolute boundaries in diagnoses, and the vdph�áh[lelolw\�pxvw�eh�xwlol]hg�zkhq�dwwhpswlqj�wr� ghàqh�dgglfwlrq��$3$����������'hvslwh�wkh�fkdoohqjh� the phenomenon of addiction poses, it is still critical wr�ghyhors�d�jhqhudoo\�dffhswhg�zrunlqj�ghàqlwlrq�vr� that researchers and clinicians can work toward stangdugl]lqj�wkh�àhog��ghyhorslqj�ehvw�sudfwlfhv��dqg�uhjulating the associated treatment options for addiction. the american society of addiction medicine’s ghàqlwlrq� ri � dgglfwlrq�� suhylrxvo\� txrwhg� lq� wklv� paper, clearly supports the concept of a biological element in the reinforcement model of addiction, suggesting that neurological dysfunction (a) directly causes problematic psychological (b) and behavioral (c) manifestations (a ȹ b, a ȹ�c). it also indicates that the behavior (c) in turn can affect psychological and emotional components (b) of the individual’s life (c ȹ�e����,q�wkh�orqjhu�ghàqlwlrq��$6$0�jrhv�rq�wr�h[plain that brain “morphology, connectivity, and functioning are still in the process of maturation during development and young adulthood, and early expovxuh�wr�vxevwdqfh�xvh�lv�dqrwkhu�vljqlàfdqw�idfwru�lq� the development of addiction” (asam, 2011). this suggests that dysfunctional behaviors such as chemfigure 1: $fwlyh�5hlqirufhphqw�0rgho�ri �$gglfwlrq���7klv�àjxuh� illustrates the critical relationships that reinforce active addiction. active reinforcement model of addiction 30 ical abuse (c) also impact brain development (a) in a phenomenon known as “neuroadaptation” (c ȹ a; $6$0����������,w�lv�zruwkzkloh�wr�qrwh�wkdw�wklv�ghànition includes both “substance use and other behavlruvµ�lq�lwv�ghàqlwlrq��dqg�wkdw�wkh�lqfoxvlrq�ri �erwk� chemical and non-chemical addictions is a critical element to the reinforcement model, as will be discussed odwhu���7kxv��$6$0·v�ghàqlwlrq�ri �dgglfwlrq�àwv�lqwr� the proposed model, and supports some of the relationships it describes (a ȹ b, aȹ c, c ȹ a, c ȹ b). � $qrwkhu� zlgho\�uhfrjql]hg� ghàqlwlrq� of addiction came from the former president of the american society of addiction medicine, dr. michael miller, who stated: at its core, addiction isn’t just a social problem or a moral problem or a criminal problem. it’s a brain problem whose behaviors manifest in all these other areas . . . [the] disease is about brains, not drugs. it is about underlying neurology, not outward actions. (smith, 2011, p. 901) this statement also directly supports the reinforcephqw�prgho��dqg�ghprqvwudwhv�wkh�vljqlàfdqfh�ri �qhxrophysiology in affecting the full conceptualization of addiction (a ȹ�b, a ȹ c). goodman (1990) proposed d� vlploduo\� zhoo�dffhswhg� ghàqlwlrq� ri � dgglfwlrq� $gglfwlrq�pd\�eh�ghàqhg�dv�d�surfhvv�zkhuhe\� a behavior that can function to produce pleasure and provide relief from internal discomfort, [and] is employed as a pattern characterized by (1) recurrent failure to control the behavior (powerlessness) and (2) continuation of the behavior despite severe negative consequences (unmanageability). 7klv� ghàqlwlrq� kljkoljkwv� wkh� ehkdylrudo� hohphqw� lqfoxghg� lq� wkh� uhlqirufhphqw� prgho�� dqg� ghàqhv� what is meant by “dysfunctional” behavior (c) and psychological causes and consequences (b). while lw� grhv� qrw� vshflàfdoo\� phqwlrq� qrq�fkhplfdo� ehhaviors, it does not explicitly exclude them, and as such they too can be incorporated into this confhswxdol]dwlrq�� � )xuwkhupruh�� wklv� ghàqlwlrq� dgdresses the impact that these behaviors have on sv\fkrorjlfdo� ixqfwlrqlqj�� dqg� vxssruwv� dqg� àwv� into the reinforcement model (b ȹ c, c ȹ b). smith and seymour (2004) included the additional element of “compulsive use or engagement in the behavlruµ�wr�wklv�ghàqlwlrq��zklfk�vxjjhvwv�dq�xqghuo\lqj� biological urge (a ȹ c). moreover, they suggested that addictive behaviors (c) are used to gain either psychic (mood-related), recreational (social or activity-related), or instrumental achievement (performance-related) rewards (b). this also directly ties into the reinforcement model in that it explains the relationship that dysfunctional behaviors can have on psychological functioning and the attainment of needs (c ȹ b). application of the term “addiction” to both chemical and behavioral disorders. one critical theoretical consideration that supports the reinforcement model is the inclusion of non-chemical or behavioral dependencies (c) in the broader conceptualization of addiction. chemical dependencies alone are not necessarily considered dysfunctional, as many medical patients develop dependencies even when they take their medications as prescribed. these dependencies do not necessarily result in a compulsive or disruptive pursuit of chronic use. dependencies become dysfunctional only once they develop causal relationships with psychological and biological processes (c ȹ b, c ȹ a). additionally, certain behaviors, such as gambling, hand-washing, or exercising, are qrw� frqvlghuhg� g\vixqfwlrqdo� rq� wkhlu� rzq³wkhvh� behaviors only become dysfunctional when they disrupt psychological and biological processes (c ȹ b, c ȹ a), resulting in a non-chemical addiction. for example, hand-washing is a normal human behavior, but if it becomes a psychological obsession and an individual feels compelled to do it repetitively, then it has developed into an addiction (c ȹ a, c ȹ b). traditionally, the clinical terms “addiction” and “addictive behavior” have been applied exclusively to substance abuse and dependency, but there is growing empirical evidence of a related category of “non-chemical” addictive behaviors, “including gambling, eating disorders, and sexual behavior,” that have recently been included in the conceptualization of addiction (donovan & marlatt, 2005, p. 4). there are easily recognizable external patterns that are similar between chemical and behavioral addictions, including tolerance, withdrawal, repeated unsuccessful dwwhpswv�wr�vwrs��dqg�vljqlàfdqw�lpsdluphqw�lq�duhdv� of life functioning. however, the emerging recogqlwlrq� ri � elrorj\·v� lqáxhqfh� rq� dgglfwlrq� kdv� hqhunt 31 couraged researchers to explore whether behavioral addictions and substance addictions recruit similar biological processes (a ȹ c, c ȹ a; grant, brewer, & potenza, 2006). brain science and neural imaging have begun to validate food and sex addictions, compulsive shopping and gambling, and eating disorders, among others, as “process,” “non-chemical,” or “behavioral” addictions that can be included in the new, broader category of addiction disorders. emerging research indicates that dysfunctional behaviors can be powerful determinants of psychological functioning (c ȹ b) and can also cause neuroadaptation (c ȹ�a; lubman, yucel, & pantelis, 2004; hyman & malenka, 2001). it has also been demonstrated that dysfunctional behavior can be the direct uhvxow�ri �eudlq�ghàflwv�ru�pdodgdswlyh�sv\fkrorjlfdo� states (a ȹ�c, b ȹ�f���*udqw�hw�do�����������7khvh�àqgings support the incorporation of non-chemical addictions into the reinforcement model, as they follow the same relationship patterns of chemical addictions. this recognition greatly enhances the argument for the reinforcement model of addiction, as it helps to illuminate the interconnectedness of both internal and external factors involved in this phenomenon, regardless of the involvement of substances and chemicals. � 7kh������'60�uhylvlrqv� uháhfw� wklv� lqfuhdvlqj� awareness of the role of non-chemical dysfunctional behaviors in the construct of addictions through their inclusion of “gambling disorder” (apa, 2012). this movement to include a non-chemical addictive disorder demonstrates that researchers and practitioners are migrating toward the general understanding that both chemicals as well as behaviors can impact neuroadaptation within the brain’s reward system (c ȹ a). smith (2012) reinforced this by stating that addiction disrupts the areas of the brain responsible for regulating cognitive, emotional, and social behaviors, and marks suggested that “syndromes of behavioral addiction share [similar neurological] features with those of substance abuse . . . [including] obsessive-compulsive disorder, compulsive spending (including gambling), overeating, hypersexuality, kleptomania, and perhaps trichotillomania, tics, and the tourette syndrome” (c ȹ a, c ȹ b; marks, 1990, p. 1389). � $v� vxssruwhg� e\� wkhvh� àqglqjv�� erwk� fkhplfdo� and behavioral dependencies can be included in the reinforcement conceptualization of addiction. the emerging understanding of the ability of external bekdylruv�wr�lqáxhqfh�eudlq�fkhplvwu\��dv�zhoo�dv�wkh�uhfognition that brain chemistry affects external behaviors, demonstrates that these two factors are mutually lqáxhqwldo��dȹ c, c ȹ a). thus, including problematic and dysfunctional behaviors that do not include chemicals greatly supports the active reinforcement model, and further illuminates the extent to which external idfwruv� lqáxhqfh� lqwhuqdo� surfhvvhv� dqg� ylfh� yhuvd� three core components and six core relationships the psychological and behavioral components of addiction have been well established in contemporary research, so an extensive discussion of these elements is not necessary in this paper and they will be only eulhá\�phqwlrqhg�ehorz���5hvhdufk�rq�wkh�qhxurelrlogical components, however, is the more recent and emerging area that will be discussed in more detail. 3v\fkrorjlfdo�&rpsrqhqwv�ri �$gglfwlrq��e�ȹ a, bȹf� the active reinforcement model indicates a distinct relationship between psychological components (b), such as stressors, the effects of environmental lqáxhqfhv�� wkrxjkwv�� dqg� hprwlrqv�� xsrq� erwk� wkh� brain as well as behavior (b ȹ a, b ȹ c). there are numerous studies that support the causal relationship between unmet psychological needs and dysfunctional behaviors, as well as the impact of psychological stress on brain chemistry and neurological functioning (b ȹ c, b ȹ a) (castellani et al., 1997; whang, lee, & chang, 2003; young, boyd, & hubbel, 2000; sinha, 2001). these two relationships in the reinforcement model of addiction are well established, and a detailed discussion of these two mechanisms can be easily found in contemporary literature and is thus beyond the scope of this paper. one particularly good explanation of these relationships can be found in franken (2003), who explains the relationship between psychological urges and their impact upon neurological functioning and addictive behaviors. active reinforcement model of addiction 32 %hkdylrudo�&rpsrqhqwv�ri �$gglfwlrq��f�ȹ a, c ȹ�e� as previously mentioned, dysfunctional or risky behaviors alone do not comprise addiction. dysfunctional behavioral or chemical dependencies only become addictions when they develop relationships with the psychological and neurobiological elements of the active reinforcement model. this means that when a behavior or chemical use becomes a method of psychological coping to deal with stress, or when the individual feels compelled to engage in this behavior due to pressing internal impulses, the full relationship of these factors manifests as an active addiction (c ȹ a, c ȹ b). there are numerous studies that demonstrate the wide range of addictive behaviors, including both non-chemical and chemical dependencies, and a discussion of all of the behavioral elements associated with addiction is beyond the scope of this paper. for a more detailed discussion of these relationships, see smith (2012), smith and seymour (2004), marks (1990), or hyman and malenka (2001). 1hxurelrorjlfdo�&rpsrqhqwv�ri �$gglfwlrq��d� ȹ b, a ȹ�f� � :kloh�wkh�fxuuhqw�ghàqlwlrqv�ri �dgglfwlrq�h[sodlq� vrph�ri �wkh�qhxurorjlfdo�dqg�sv\fkrorjlfdo�lqáxhqfes on behavior (aȹ c, bȹ c), it is critical to also incorporate recent research that indicates that behaviors lqáxhqfh�qhxurorjlfdo�dqg�sv\fkrorjlfdo�ixqfwlrqlqj� (c ȹ a, c ȹ b). this research indicates that behaviors can contribute to neuroadaptation and psychological problems (lubman, yucel & pantelis, 2004). an individual may not necessarily have an underlying qhxurorjlfdo�ghàflw�wr�ehjlq�zlwk��exw�frxog�ghyhors� one as a result of engaging in dysfunctional behavior or encountering psychological stressors (lubman et al. 2004). thus, neurobiology is not necessarily the primary causative factor of this phenomenon. the active reinforcement model effectively demonstrates erwk�wkh�vljqlàfdqfh�dv�zhoo�dv�wkh�uhodwlrqvkls�ri �qhxrobiology to the overall conceptualization of addiction, instead of placing it as the primary causal factor. the active reinforcement model indicates that qhxurelrorj\� erwk� lqáxhqfhv� dqg�phgldwhv� wkh� uhlationship between dysfunctional behaviors and psychological issues, and in combination with these factors it can generate chemical or behavioral addictions. neuroimaging and neuropsychological studies have revealed clear differences in brain function between chronically addicted and non-addicted individuals, suggesting that addiction is indeed associated with alterations in brain functioning and neuropsychological changes (lubman, yucel, & patelis, 2004; a ȹ c, c ȹ a). the research they describe has been primarily focused on the brain’s reward pathways, which involve dopamine and serotonin receptors. dopamine and serotonin are neurotransmitters released by the brain as a result of certain actions and behaviors, and they are associated with the experience of pleasure and reinforcement and can function as ‘rewards’ in the brain. hyman and malenka (2001) report that the chemicals released as a direct result of engagement in addictive behaviors are both rewarding, or interpreted as intrinsically positive by the brain, as well as reinforcing, meaning that the behaviors involved with these rewards tend to be repeated (c ȹ a, a ȹ c). thus, substances and behaviors that produce these neurotransmitters can become very srzhuixo� uhlqirufhuv� wkdw� lqáxhqfh� ixwxuh� ehkdylru� and can result in inhibitory dysregulation (hyman & malenka, 2001). this means that individuals either develop lowered inhibitions against risky behavior or experience urges so strong that they overwhelm typical inhibitions (c ȹ a; lubman et al., 2004). tolerance. neurochemical changes in response to addiction often manifest in the development of tolhudqfh��ghàqhg�dv�d�ghfuhdvh�lq�wkh�hiihfw�ri �dq�dgdictive substance that often results in more frequent or intense engagement in addictive behavior (a ȹ c). individuals who develop these altered brain states pd\�ghprqvwudwh�wrohudqfh�dv�́ uhzdug�ghàflhqf\�v\qdrome, a hypothesized hypo-dopaminergenic state involving multiple genes and environmental stimuli that puts an individual at high risk for multiple addictive, impulsive, and compulsive behaviors” (a ȹ c; grant et al., 2006, p. 925). this hypo-dopaminergenic state is one of the proposed mechanisms of brain chemistry in addiction. lower levels of dopamine (or decreased activation of dopamine circuits and receptors) may result in an individual’s increased athunt 33 whpswv�wr�frpshqvdwh�iru�wkhvh�ghàflwv�wkurxjk�sduticular chemicals or behaviors (a ȹ c). higher levels of tolerance can promote increased and frequent use, which may then result in dependence (c ȹ a). sensitization. another result of chronic addiction is sensitization. this occurs through enhanced reward responses in the brain resulting from repeated administration of a substance or engagement in an addictive behavior (c ȹ�a; hyman & malenka, 2001). individuals who develop more sensitive brain states may experience a higher level of euphoria after engaging in behaviors that release dopamine or serotonin. due to the experience of more substantial ´uhzdugv�µ� wkh\�pd\� kdyh� juhdwhu� gliàfxow\� lq� frqtrolling impulses to engage in and continue addictive behavior (c ȹ a, a ȹ c). with chronic use of or engagement in these behaviors, adaptations at genetic, molecular, and cellular levels occur within distinct brain regions that counter acute drug effects in an attempt to maintain internal homeostasis (c ȹ a). when intake of the substance ceases, these neuroadaptations initially persist and act unopposed, resulting in a characteristic rebound syndrome, or “withdrawal” (lubman et al., 2004). hyman and malenka (2001) note that this response can develop beyond just a physical or psychological liking of one’s addictive behavior into the experience of intense urges or “wanting.” it is at that point that physical dependence can cross over to compulsive desire and pursuit as neurological systems become hypersensitive, zklfk�vljqlàfdqwo\�lqfuhdvhv�wkh�lqfhqwlyh�wr�vhhn�rxw� these stimuli (a ȹ c, c ȹ a; hyman & malenka, 2001). disrupting the relationships between the active elements of addiction as discussed, the active reinforcement model of addiction demonstrates six relationships between wkuhh�sulpdu\�hohphqwv�ri �dgglfwlrq��elrorjlfdo�ghàcits (a), unmet psychological needs (b), and dysfunctional behaviors (c); these relationships are described as a ȹ b, a ȹ c, b ȹ a, b ȹ c, c ȹ a, and c ȹ b. any of these elements in isolation do not necessarily indicate an addiction, and as such cannot be considered primary causal factors of this phenomenon. for example, an individual can engage in dysfunctional or risky behavior without it affecting their psychological or biological functioning. similarly, one may experience stress from unmet psychological needs but never turn to dysfunctional behavior as a coping mechanism, or may suffer from neurological ghàflwv�zlwkrxw� wkh�dgglwlrqdo�h[shulhqfh�ri �xqphw� psychological needs or attempting to compensate for wkhvh�ghàflwv�ehkdylrudoo\���5dwkhu��lw�lv�wkh�uhodwlrqships among these factors – not the factors themselves – that indicate an active addiction. therefore, this model suggests that addiction treatment research should be devoted to disrupting these mechanisms and developing interventions to block the relationships between the factors that combine to sustain addiction (indicated by the sign x). a comprehensive treatment plan must therefore involve interventions to disrupt these relationships (a x b, a x c, b x a, b x c, c x a, c x b). addressing and resolving one element can reduce the severity of the addictive behavior, but this paper argues that attention to all three factors and their respective relationships with one another is vital to successful, comprehensive addiction treatment. 7uhdwphqw�ri �%lrorjlfdo�)dfwruv��d�;�e��d�;�f� emergency care.�7kh�yhu\�àuvw� vwhs� lq�dgglftion treatment is to focus on the most urgent needs of the client (wallace, 2005). this typically involves meeting essential physiological requirements and ensuring that basic physical functioning is supported and maintained, as many clients cannot take action lq�dgguhvvlqj�sureohp�ehkdylruv�li �wkh\�duh�qrw�àuvw� stabilized (wallace, 2005). regardless of whether clients enter addiction treatment voluntarily or not, they can initially present in a state of shock, trauma, severe emotional disturbance, despair, depression, and other varying states of instability, and at that stage they may not be capable of identifying or attending to their basic needs. thus, prior to any psychological interventions, the client must be placed in a safe, calm environment without easy access to their addictive drug or behavior, and they must be thoroughly screened for any pressing physiological problems that can be immediately addressed (a x b, a x c). this includes any kind of treatment of overdose symptoms, medicine for management of withdrawal v\pswrpv� gxulqj� ghwr[làfdwlrq�� dgplqlvwudwlrq� ri � essential nutrients or electrolytes for severe cases of active reinforcement model of addiction 34 eating disorders, and other related medical treatment. pharmacological treatment. the use of prevfulswlrq�guxjv� wr� wuhdw� qhxurelrorjlfdo� ghàflwv� lv� d� critical component of addiction treatment. this has become the subject of extensive research as the conceptualization of addiction as a brain disease becomes more prevalent. while a full discussion of the pharmacological component of addiction treatment is beyond the scope of this paper, it is worth noting that the emerging trends of successful prescription drug use in the treatment of addiction often involve drugs associated with supporting or enhancing the serotonin or dopamine pathways of the brain (grant hw� do��� ������� �$oohyldwlqj� wkhvh� qhxurorjlfdo� ghàflwv� can directly promote psychological health and reduce engagement in dysfunctional behaviors as coping mechanisms (a x b, a x c; grant et al., 2006). 7uhdwphqw�ri �3v\fkrorjlfdo�)dfwruv��e�;�d��e�;� f� interdisciplinary approaches to addiction studies have allowed for more comprehensive incorporation of the psychological aspects of addiction. there have been several widely recognized movements wkdw� kdyh� ghàqhg� dqg� lqáxhqfhg� wkh� àhog� dv� lw� uhlates to addiction treatment, and while there are many different orientations to psychological counseling, one of the primary approaches – cognitive behavioral therapy – will be discussed here as an example of a psychological treatment that can be directly incorporated into the active reinforcement model. the cognitive-behavioral orientation is one of the main approaches used in addiction treatment today, and it purports that that human thoughts and behavior are driven by the conditioning and reinforcement that people experience throughout their lives (b ȹ c). dysfunctional thoughts and behavior, such as behavioral and chemical addictions, are considered to be the result of the development of inaccurate and unhealthy life schemas, which are the mental framework used to organize information about the self and the external world (b ȹ c) (alford & beck, 1997). the goals of cognitive-behavioral therapy are therefore to focus on individual problematic behaviors and thoughts, identify their orljlqv�dqg�lqáxhqfhv��dqg�fkdoohqjh�dqg�fkdqjh�wkhp� as needed to promote healthier psychological functioning and recovery (b x c). cognitive-behavioral therapy, or cbt, developed out of this psychological orientation and is prominent in addiction treatment programs today. it is a highly standardized therapeutic process that utilizes such techniques as identifying individual goals, focusing on present problems, exposure therapy, cognitive restructuring, behavior change, and psychoeducation (b x c). thus, while there are many approaches to the treatment of the psychological factors of addiction, cbt is one example of a well-established practice that is compatible with and supports the active reinforcement model. 7uhdwphqw�ri �%hkdylrudo�)dfwruv��f�;�d��f�;�e� � $� àqdo� fulwlfdo� frpsrqhqw� ri � wkh� dfwlyh� uhlqforcement model is the existence and relationship of dysfunctional behaviors and their impact on both psychological functioning and neurology. the most prominent treatment approach is the promotion and facilitation of abstinence or sobriety from dysfunctional behaviors or chemical dependencies as a way wr�glvuxsw� wkh�àqdo� uhodwlrqvklsv� lq� wklv�prgho� �f�;� a, c x b). other approaches, such as the harm-reduction model, emphasize the importance of moderation, self-regulation, honest and open self-reporting of engagement in problematic behaviors, and rwkhu� phdvxuhv� wr� vljqlàfdqwo\� uhgxfh� hqjdjhphqw� in disordered behavior (marlatt & tapert, 1993). one critical aspect of intervention efforts aimed at treatment of behavioral factors is the consideration of replacement behaviors that may be utilized in the absence of the typical addictive behavior, and the importance of providing the client with adaptive rather than harmful substitutes for these behaviors (shaffer et al., 2004). treatment of behavioral factors also involves a combination of the techniques used to treat the neurological and psychological aspects of addiction, and each of the interventions described above also work to disrupt the relationships between dysfunctional behaviors and psychological or neurological mechanisms (c x a, c x b). conclusion the working conceptualization of addiction hunt 35 continues to develop as emerging research across pxowlglvflsolqdu\� àhogv� lqirupv� wuhdwphqw� dqg� lqtervention techniques. while prevention efforts are often aimed at identifying the underlying causes of addiction, intervention and treatment should operate from a more comprehensive conceptualization of addiction that is focused on the mechanisms of action among three primary elements: a) impaired neurological mechanisms; b) unmet psychological needs; and c) dysfunctional behavior. this paper argues that all three must be present and involved in an active relationship with one another for an active addiction to be manifest. thus, the proposed active reinforcement model serves as a more comprehensive conceptualization of addiction that accounts for and incorporates all of the elements of addiction and places them in an interdependent context that may be more effective in generating successful addiction treatment outcomes than previous models. the next steps in validating the proposed model are to evaluate it using research studies and psychometric evaluations. one of the most critical aspects of this model is its comprehensive incorporation of multiple concepts of addiction, and demonstrating its effectiveness empirically could start with an evaluation of each of these elements and the six relationships described by the active reinforcement model. demonstrating the validity of these individual relationships empirically and introducing intervention efforts intended to disrupt them would support the relevance of this model and demonstrate the need for continued exploration of this conceptualization of addiction. once the individual relationships have been empirically validated, a treatment approach that addresses all components should be implemented, evaluated, and compared to models that operate from a less comprehensive conceptualization of addiction. in conclusion, the active reinforcement model serves as a more comprehensive conceptualization of addiction as it accounts for multiple interrelated factors. while the currently accepted biopsychosocial model effectively addresses the underlying causes of addiction, the proposed active reinforcement model addresses the mechanisms of existing addictions in a more comprehensive manner. a better description of the relationship between each element provides a deeper understanding of the full phenomenon of addiction, and may therefore be more effective in generating successful treatment outcomes. references alcoholics anonymous. 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(2000). prostitution, drug use, and coping with psychological distress. journal of drug issues, 3, 789–800. active reinforcement model of addiction microsoft word manuscript 7_12.12.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 raising a child of color with developmental disability: systematic review annahita d. modirrousta, b.a department of psychology, miami university yvette r. harris, ph.d department of psychology, miami university parenting a child of color with a developmental disability presents unique challenges for parents. we address those challenges in this review paper as they cohere around three major themes: the parental appraisal of their child's disability, social stigma, and lack of resources and help for their children. we conclude the review paper with suggestions on how researchers, educators, and practitioners might work with parents raising children of color with developmental disabilities. keywords: developmental disabilities, parents, children, race, ethnicity raising a child of color with a developmental disability: narrative review developmental disabilities consist of conditions that impair learning, language, physical traits, and behavior (holm, 1989). when it comes to parental experiences raising a child with a developmental disability, the literature explains advances in care for these children. parents of children with developmental disabilities have benefited from an increase in the number and quality of services for their children. the increased awareness and knowledge about developmental disabilities has helped them provide better care for their child (hodapp & ly, 2006). however, these benefits did not apply to children of color, who are non-white children in predominantly white countries (comas-díaz, 2000). there has been a clear pattern in examining the literature catered to parents of children of color with developmental disabilities. many parents have little knowledge about the disability, and as a result, they either fail to detect symptoms or assume their child would "grow" out of symptoms. this leads to parents not seeking help for their child (zuckerman et al., 2014). additionally, these parents fail to receive the necessary support from providers due to lack of access (nasser et al., 2017). in examining the existing literature, we found few articles detailing how parents experience raising a child of color with a developmental disability. this lack of research seems puzzling, given the statistics on children of color with a developmental disability. figure 1 (us department of education, 2012) demonstrates the rates of developmental disability among different races and ethnicities. non-white children, except for asian children, have higher rates of learning disability than white children, and asian children have disproportionately high rates of autism and language impairment. considering the high rate of developmental disability for children of color, the lack of research and resources regarding the experiences of parents raising children of color with developmental disabilities is a concern (klingner et al., 2007). the following review paper on parenting of children of color with developmental disabilities is necessary to bridge the gap in how race and ethnicity affect parenting. this gap exists because there has been a lack of research and concern on the topic (klingner et al., 2007). addressing this topic is crucial to help parents of children of color with © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. graduate student journal of psychology modirrousta & harris developmental disabilities, who are underrepresented in research, receive the needed help. this review paper aims to bring attention to parents' struggles raising children of color with developmental disabilities, which would help fill the gap. these parents experience stigma, defined by a trait that is viewed as unfavorable and thus are discriminated against in society (ahmedani, 2011). parents also experience a lack of help and resources available to them. in writing this review paper, we wanted to highlight parental variables and societal variables that influence the quality of medical assistance and treatment provided to children of color with developmental disabilities. using a positivist lens, we will therefore review the literature on different cultures and form conclusions on common themes within them. lastly, this paper will refer to "children of color.” still, we will warn that the research on different ethnicities does not generalize to all children of color. studies were done on a small sample, limiting generalizability. this paper also recognizes that adoption and interracial marriage might result in children of color who do not have parents of color. this paper merely examines multiple cultures to see how they experience a child with developmental disabilities. the term "children of color" is used as a blanket term for these cultures. we use the words "of color" rather than "minority" to emphasize that the children are non-white and are minorities in predominantly white countries. figure 1 percentage of 3-21-year-olds serving under the individuals with disabilities education act (idea) by type of disability and race/ethnicity methods this paper will examine first-world high-income countries predominantly. the countries chosen were the united states, ireland, and israel. this is to consider how countries of different cultures have different norms for parents of children with developmental disabilities. these parents will also be of an ethnic minority; an ethnic minority is someone of a race or ethnicity that is the minority in the country in which they reside (vega & rumbaut, 1991). the ethnicities chosen were latinos, african americans, asian americans, pakistanis, filipinos, and arabs. this is to capture the experience of being a minority group in a country that may not respond to their needs as efficiently as a majority group's needs (reichard et al., 2004). the developmental disabilities studied include autism spectrum disorder (asd), intellectual disability (id), down syndrome, raising a child of color with developmental disability and attention deficit hyperactivity disorder (adhd). the children studied were mid to high functioning. for this narrative review, one of the authors of this manuscript used psychinfo and google scholar to find empirical articles related to our topic. we entered five lines of related keywords with each word separated by or (and/or), and we separated each line by and. 1. child: child/children or elementary or kids we chose these keywords because we are researching elementary and kindergarten children around four to twelve years old. 2. developmental disabilities: developmental disorders or neurodevelopmental disorders or autism spectrum disorders or learning disorders or intellectual disorder we chose these keywords to examine different disabilities. we included neurodevelopmental disorders like asd or adhd, intellectual disorders like id, and other developmental disorders like down syndrome. we did not find much literature about learning disorders or other developmental disorders, but that would be a future research topic. 3. race/ethnicity: blacks or asians or latino/as or minority groups we included different races and ethnicities, such as black, asians, and latinos. we also used the blanket term "minority groups" to encompass other minority races and ethnicities, such as pakistanis and arabs. we did not find much information about different ethnicities, leading to future research. 4. parenting: parenting styles or skills or practices or attitudes considering this paper's topic examines the parenting of children of color with developmental disabilities, we searched for articles detailing parental practices. 5. parent-child relations: attachment or father/mother-child relations or child discipline or child-rearing practices or parental involvement we examined how parents raise their children and the relations between parents and their children. this is crucial because learning how parents discipline and involve themselves in their children's development can help understand how parents experience having a child with a developmental disability. from these keywords, we found 17 articles. we initially read the abstracts and picked the studies that best suited our paper. then, we read the full papers and used those studies' results in our review. we examined citations for each article based on their relevance to our paper and used new sources for this review, resulting in 45 articles and one figure. our inclusion criteria were studies that depicted parental involvement in raising children of color with a developmental disability. the children had to be a racial or ethnic minority in their country. we excluded studies of children with comorbid disorders and families who are the ethnic majority in their country (e.g., indian families in india). these articles revealed three themes regarding how parents experience raising a child of color with a developmental disability. by reading through the literature, it became evident that there were patterns of experiences across different cultures. the papers used in this study revealed many similarities in the parental raising of children of color with developmental disabilities, which fit into three themes. these themes are the way graduate student journal of psychology graduate student journal of psychology modirrousta & harris parents appraise their child's disability, the social stigma parents experience, and the lack of resources and help available for parents and their child. parental appraisal of disability although there are differences in how various ethnic groups appraise disability, there are some core similarities. for example, latino parents expect their child to reach developmental milestones such as recognizing faces and smiling later than other parents. due to this, they may fail to notice signs of a developmental disability and do not get help until much later. different milestones are expected for their child with developmental disabilities due to underlying cultural beliefs and child-rearing practices (pachter & dworkin, 1997). latino, african american, and asian parents are also more likely to attribute their child's symptoms to emotion or personality factors rather than disability and refuse to accept biological explanations for mental illness; this keeps parents from seeking help (yeh et al., 2004). some parents tend to attribute symptoms of disability to their unique child-rearing strategies. instead of understanding the cause of developmental disability, they believe the way they raise their children affects how they express these symptoms, rather than the disability itself. specific appraisals can lead to parents not trusting doctors and taking responsibility for their child's disability due to cultural norms. zuckerman et al. (2014) found that latino parents who watched vignettes of a parent and her child with asd attributed the child's symptoms to family issues and poor relationships among family members instead of asd. these parents believed that they could fix their child's problems through improving family interactions and only supported going to the doctor to seek family therapy resources rather than a diagnosis. as a result, parents concluded this might delay the child's diagnosis and treatment, which would keep the child from getting adequate help as soon as possible. furthermore, nasser et al. (2017) found that palestinian families in israel with a child with intellectual disability (id) viewed their child's diagnosis as evidence of abandonment and parental failure. they believed they had done something wrong as parents, causing their child to develop id. additionally, some parents of children of color with developmental disabilities believe that their child will eventually grow out of their symptoms. consequently, these parents are less likely to obtain a diagnosis and reject the doctors' assessment. this results in the child not getting the needed diagnosis to help the child. in zuckerman et al. (2014, p. x), latino parents determined that the child was exhibiting "bad toddler behavior" and would grow out of his problems. in contrast, other parents believed this was normal behavior of a child without siblings. this resulted in parents dismissing the pediatrician's advice and assuming that their child just needed more space and time. also, nasser et al. (2017) found that the parents resisted treatment initially and believed it was their role, not the doctor's, to treat their child with id. also, they believed that their child would improve and integrate into family life despite evidence to the contrary. finally, schuman (2000) revealed that mexican parents with a child with a developmental disability brought their child to a healthcare provider for assessment. still, parents often dismissed providers' input while having concerns that providers found irrelevant. mexican parents identified behavioral issues and speech and language delays in their child and worried about the long-term effects of the "illness." however, while they detailed signs of developmental delay in their child, they did not fully believe there was something wrong with the child until later in development when changes were noticeable. raising a child of color with developmental disability for some latino families, parents begin with very little knowledge about developmental disabilities. however, they would learn about developmental disability over time and become more knowledgeable about their child's disability. zuckerman et al. (2014) found that latino parents had low knowledge about autism, and it was even lower in parents who only spoke spanish. many parents did not know what the word "autism" even meant. at the start of their discovery of their child's disability, parents felt ashamed of their child's symptoms or felt strain, anger, and frustration towards their child. a study showed that mexican parents who watched vignettes of children with autism felt embarrassed of their autism symptoms (zuckerman et al., 2014). these parents felt that asd was shameful, worried about facing rejection from society for having a child with asd, and believed the child would place an unpleasant burden on family members. finally, kim et al. (2020) showed that for parents of african american children with autism, the higher the family resilience, which is strength against adversity, the lower the parenting stress. this means that african american parents of children with asd who had lower resilience experienced more stress and strain due to their child's symptoms. some parents immediately took responsibility for their children's development and even quit their jobs or lived alone to take care of their children. in burkett et al. (2017), african american parents of children with asd showed a core theme of responsibility. these parents believed that respect was an essential learned skill, and they thought it was their responsibility to teach respect to their children. they believed this would cause their children to develop manners and not engage in their symptoms. the single mothers in the study lived alone with their children due to their personal experience of having single mothers. the responsibility of parenting their children with autism increased their sense of isolation. they believed this was the best way to raise their children and take responsibility. these mothers watched over their children and monitored their children's progress to prepare them to grow into independent adults. meanwhile, two-parent african american families expressed that they shared the responsibility for their children's care. they depended on each other to help the children and felt sincere appreciation for the other parent. thus, parents put the responsibility of raising their child of color with a developmental disability on themselves, which led to the belief that it was their role to treat their child rather than seek help. some parents of children of color with developmental disabilities learn to be optimistic about their child's disability by using spirituality, faith, and religion. in habib et al. (2017), some pakistani mothers with a child with asd reported that they were satisfied with their situation and had a positive experience raising their child in ireland. also, the mothers' religious beliefs were an essential protective factor for them, as they could use religion as a coping mechanism. a protective factor is defined as a trait or circumstance that allows parents to cope with their mental health and their child's condition. they also viewed their child's disability as god's will. lastly, for african american parents of children with asd, a significant theme in their experience was their faith in god. they expressed they were blessed to care for their child with asd, with many saying it led to personal and spiritual growth. although these parents did not regularly attend church, they believed they were connected spiritually to god. this connection was essential for their personal development, coping with stress, and maintaining hopefulness (burkett et al., 2017). as a result, religion helped african american families handle the diagnosis better. research shows that african american mothers cope better than white mothers with their child's diagnosis of asd; they have higher well-being, fewer burdens, and graduate student journal of psychology graduate student journal of psychology modirrousta & harris lower negative impact (bishop et al., 2007). while negative impact increased as their child grew into adolescence, the negative impact was significantly lower for african american mothers than white mothers. this was partly due to the african american culture of kinship and spirituality (carr & lord, 2013). stigma and social reaction stigma and social reaction are also influential. the response of society to a child with a developmental disability constitutes stigma when it is negative. when children with developmental disabilities are stigmatized, this can harm their development, decrease social support, and cast guilt and shame on parents (werner & shulman, 2013). as an illustration, african american parents of children with asd faced stigma with regards to their child's diagnosis. they described how they were often judged in public and blamed for their child's behavior. some mothers were told they lacked "knowing how to discipline their child" (burkett et al., 2017, p. x). asian american parents also feared being stigmatized for their child's symptoms by their community. due to fear of being shunned or judged by their community, asian american parents isolated themselves and kept their child's diagnosis a secret (he, 2017). this isolation and discrimination led to fewer social supports for their child and worsened psychological disorders for the parents. due to the parents' mental health problems, they were less likely to seek help for their child (jegatheesan, 2009). shame and stigma can also lead to parents underreporting their child's diagnosis and delayed intervention (leong et al., 2013). filipino american parents of children with asd negatively perceived their child's disability due to societal discrimination, which kept them from seeking help for their child (anzaldo, 2021). in some cultures, societal stigma can result in high-stress levels for parents of children with developmental disabilities. in arab culture, having a family member with a developmental disability could decrease social status and hinder chances of marriage (dababnah & parish, 2013). as a result, arab parents of children with asd felt shame and guilt at their child's symptoms. due to this shame, these parents only sought treatment as a last resort (dardas & simmons, 2015). these children may also receive adverse reactions from family members. for african american parents, their family members or friends believed that their child's behavior was their fault. single african american mothers would heavily rely on their mothers and other family members to care for the child. when they received unhelpful feedback, the mothers experienced guilt and shame, which kept them from giving their child the best care (burkett et al., 2017). in pakistani families, some mothers of a child with asd explained that due to increased awareness of asd in pakistan, they could speak with their family about this issue. it helped with their interactions with their family members. however, some mothers said their family members lacked knowledge about asd and that an increase in knowledge could help meet their child's needs with asd (habib et al., 2017). lack of access to education and resources can heighten this stigma, which we will address in the next segment. lack of resources and assistance from providers many children of color in the united states experience higher poverty rates than their white counterparts. according to costello et al. (2001), in north carolina, 52% of african american families lived below federal poverty, compared to 18.2% of white families. african american families' mean income was 62% that of white families. also, african american and hispanic children are overrepresented in low-income families (cooper et al., 2010). the 2007-2011 american community survey (macartney et al., raising a child of color with developmental disability 2013) found that 25.8% of african americans and 23.2% of latinos lived in poverty compared to 11.6% of whites. poverty also affects ethnic minorities in other countries; one-third of palestinian minorities in israel live in poverty (hilal, 2012). this discrepancy in wealth results in fewer resources available to the parents. a lack of resources also reduces the urgency of a diagnosis. african american children were 30.0% less likely to be diagnosed than white children (baio, 2014). latinos were half as likely to get diagnosed as non-latinos and more likely to have severe symptoms. this is because african american, latino, and low-income children had decreased access to services that would allow them to get a diagnosis. they lacked proper insurance, money, and access to a provider nearby, which made treatment more difficult (liptak et al., 2008). african american children received their diagnosis 1.6 years after white children and took more time in care before getting diagnosed; latino children received their diagnosis 2.5 years later than white children (mandell et al., 2002). overall, african american, hispanic, or other minority race children were less likely than white children to be documented with asd. however, despite the lower rate of diagnosis, minority and low-income children were more likely to exhibit symptoms of a developmental disorder than high-income and white children (mandell et al., 2009). palestinian parents living in israel also had a hard time getting treatment for their child with id due to low socioeconomic status (ses) and social status in israel (nasser et al., 2017). low socioeconomic status, defined as living in poverty, is associated with early life stress and delays in development and lead to the inability to afford services and treatment (farah et al., 2006). also, there were few culturally competent services within their community, and there were few resources for their children. children with id of palestinian parents in israel especially struggled with high disability rates, extreme inequality, and high personal and family stress (nasser et al., 2017). another issue that parents faced was that their children received less help from providers than white children. zuckerman et al. (2014) found that latino parents with a child with asd felt uncomfortable interacting with doctors because they thought the doctors made them feel unsafe. therefore, they would not be forthcoming with their concerns or would deny issues. guerrero et al. (2011) also found that parents of minority children were less likely to be helped by a healthcare provider. specifically, african american and latino parents were significantly less likely to have their concerns validated by a healthcare provider than white parents. low-income parents also experienced this phenomenon, which brings up the intersection between race and ses. also, son et al. (2020) found that latino children with developmental disabilities such as asd whose parents received passive or reassuring responses from their providers, such as dismissing any doubts or not providing information about a diagnosis or referrals, were less likely to receive specialty services than white children. in this instance, specialty services are defined as specialty treatments geared towards developmental disabilities to help people with these conditions. this meant that when parents were passively rather than actively treated by providers, their children did not receive the proper service. latino parents reported fewer specialty services for their child than white parents due to access, communication, or cultural barriers to asd care for latino children. parents of these children receive few resources or access to medical care due to low ses and their language background. for example, latino parents of children with asd struggled to obtain resources to help with their child's disability. this happened because of the lack of adequate spanish resources or difficulty understanding english resources due to poor interpreters (zuckerman et al., 2014). parents felt that the information graduate student journal of psychology graduate student journal of psychology modirrousta & harris available to them about asd was low quality because there were no spanish materials available. the english material was written in jargon, and the available material was written in incorrect spanish. interpreters were unavailable or poorly trained and were therefore of little help to the parents. due to low levels of information and the high stigma of autism (as mentioned in the first two sections), parents normalized their child's behavior. they denied any problems, which led to hesitation to get treatment for their child. due to poverty, low english proficiency, and lack of empowerment to get services, these parents had poor care access. providers would dismiss concerns, and the diagnostic process was uncomfortable for the child (zuckerman et al., 2014). many children of color with developmental disabilities struggle with receiving care services of high quality and access to specialty services. magaña et al. (2016) found that latino children were less likely to receive specialty services than white children for their developmental disabilities. the types of specialty services include behavioral intervention, occupational therapy, social skills training, and sensory integration therapy. the national survey of children with special health care needs (liptak et al., 2008) showed that latino parents had a bad relationship with providers compared to white parents, such as feeling unwelcome, not spending much time with their child, and low cultural sensitivity. an example of feeling unwelcome includes not feeling like a partner to the provider and feeling like the provider did not listen to parental concerns. this led to fewer services for their child with asd (parish et al., 2012). providers struggled with recognizing asd symptoms in latino children, viewed latino parents as less knowledgeable about asd, and did not refer children to specialists (zuckerman et al., 2013). latino parents struggled with dealing with the diagnosis, stigma, and using services (blanche et al., 2015). when providers offered a passive or reassuring response, latino parents used fewer services for their children with a developmental disability (gannotti et al., 2004). asian american parents of children with developmental disabilities also struggled with communicating with providers. this is due to the use of complex language, stereotypes about asian culture, providers' negative views of alternative medicine, focusing on the child's weaknesses rather than strengths, and providers' bluntness contrasting with parents' hesitancy (jegatheesan, 2009). meanwhile, african american parents of children with asd felt that providers were rude and acted "like they knew everything," which soured their relationship. they also felt that providers did not listen and disregarded parents' concerns (burkett et al., 2015). lastly, these parents struggled to receive assistance from their child's school. habib et al.'s (2017) study showed that some pakistani mothers complained about the lack of resources at schools, the lack of measures including children with asd in classrooms, the lack of asd-specific training for teachers, and the poor communication between education and health services. however, other mothers in the study had positive experiences of schools, communicated effectively with schools and healthcare providers, and believed in the positive impact of parenting a child with asd. conclusion and suggestions for future directions in summary, we identified three major themes in this review paper regarding parents' experiences raising children of color with developmental disabilities. first, parents appraise and react to their child's disability differently. second, parents face stigma from society and family members due to their child's developmental disability. third, parents struggle with finding proper resources and assistance from providers and schools. these three themes merge to form an image of those parents and their children's experiences. raising a child of color with developmental disability negative parental appraisal of their child's disability can lead to parents not getting help for their child, worsening providers' lack of willingness to treat the child. also, stigma can impact parents' views of their child's disability and make them feel ashamed of their child's condition, preventing parents from getting help for their child due to fear of judgment. figure 2 demonstrates the core themes of this review. figure 2 according to figure 2, for parental appraisal, parents have different expectations of their child's development and take responsibility for their child's disability. for social stigma, society judges parents and their families, which results in stress for the parents. for lack of help and resources, children of color with developmental disabilities are diagnosed at less frequency and they receive less care from providers. parents have trouble communicating with providers due to language barriers. this paper includes a few limitations. first, due to the scarce literature on the subject, we could only have a limited number of studies, which hindered generalizability. a future article would delve deeper into the topic and do a systematic review. second, we could only include a few developmental disabilities (such as asd and id) but did not include other conditions. as a result, this paper is mostly skewed toward autism research. third, this paper did not examine all ethnic minorities; future authors should analyze a broader range of cultures. from our perspective, it is vital to take an ecological/systems approach to address these issues, examining how the individuals in families react to the systems in society by which they are affected. as explained in bronfenbrenner (2015), this approach involves finding correlations between the microsystem of families, the exosystem of the healthcare system and schools, and the macrosystem of societal expectations. the goal is to design culturally relevant and culturally anchored interventions for parents. mendelsohn et al. (2005) tested an intervention program called the video interaction project (vip) on latino mothers of children with risk of developmental delay. the parent-child interactions in the intervention resulted in improved development of highrisk young children. other solutions must address faulty appraisals parents have regarding the disability of their child of color. this may involve teaching parents about developmental disabilities and educating them on the causes of these disabilities. such an approach could counter certain false beliefs parents may hold, such as believing their child will grow out of symptoms, and their negative feelings, such as strain, anger, and frustration. as for the stigma, increasing general awareness and knowledge about graduate student journal of psychology core themes parental appraisal different expectations parents take responsibility social stigma judged in public results in stress lack of help and resources fewer diagnoses poor communication graduate student journal of psychology modirrousta & harris developmental disability in communities of color is a start. in doing so, the blame and guilt that parents experience might decrease. finally, to resolve the lack of resources or help, we must inform providers, educators, and practitioners of the differences in the child's symptomatology and the parents' reactions based on ethnicity. this will improve their communication, diagnosis, and treatment plans for children of color with developmental disabilities. also, practitioners must provide better resources to these parents, whether it be resources in their native language or providers fluent in their native language. in addition, the knowledge gained from this review paper could serve to encourage rigorous research examining the topic further. acknowledgments the author declares no conflict of interest. the author received no financial support for the research, authorship, and/or publication of this article. correspondence to this article should be addressed to annahita modirrousta, miami university department of psychology, 90 north patterson avenue oxford, oh, 45056, usa. email: modirra@miamioh.edu references ahmedani, b. k. 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(2014). latino parents' perspectives on barriers to autism diagnosis. academic pediatrics, 14(3), 301-308. https://doi.org/10.1016/j.acap.2013.12.004 94 pretty privilege vs. ingroup bias in decision making vicky zhu & daniel white university of technology sydney, psychology, faculty of health, sydney, nsw graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university throughout our lives, we face situations that require us to make appropriate and sound decisions. often, people make decisions under the misconception that their choices are purely the result of objective and conscious processing. nonetheless, research indicates that we are susceptible to external influences, including attractiveness and in-group bias (mackie & ahn, 1998; voit et al., 2021). attractiveness and in-group bias may lead individuals to form inaccurate beliefs, which in turn influence decision-making. attractiveness bias refers to the tendency for individuals to positively view attractive people, solely on the basis of their physical appearance (shahani et al., 1993). meanwhile, in-group bias refers to individuals' tendency to view members of their own group positively, which is driven by perceived group membership (knoblock-westerwick et al., 2020). studies examining attractiveness bias and its influence in a group setting have shown that attractive individuals are stereotyped as being more trustworthy, leading to favoritism within groups (cellerino, 2013). although research has considered the impact of attractiveness within in-groups, little research has evaluated their simultaneous impact. when individuals face a conflict between appealing to attraction and in-group bias, it is unknown which factor has a greater influence on the decision-making process. the current study aims to explore the outcome of these conflicting influences on individuals’ decisions. in-group bias in-group bias describes the tendency of an individual to favor members of their own group (scheepers et al., 2006). for early humans, the development of collaborative social systems (i.e., division of labor and trade) ensured survival (baumeister et al., 2015). although salient, group membership results in outgroup members being less persuasive as compared to in-group members (mcgarty et al., 1994). when examining the influence of national in-group identity on persuasiveness, adam-troian et al. (2020) found that when national group identities were made salient, negative attitudes towards ethnic minorities (out-group) were more prevalent. furthermore, it has been established that humans are innately drawn to their own group and display out-group xenophobia (tidwell et al., 2017). these traits have historically led to greater survival rates. in-group bias has been prevalent since ancestors formed closely connected groups that competed with others for survival (hare, 2017). presently, group adhesion is central across various fields, including education and conventional workplaces (rathbone et al., 2023). when examining how individuals behave in the presence of other in-group members, castelli et al. (2008) found that individuals exhibited more egalitarian responses when their behaviors aligned with the group’s social norms. additionally, while egalitarian group members were not subject to active discrimination, in-group members who exhibited behaviors aligned with the group’s collective interest received more favorable evaluations (castelli et al., 2008). if an individual expressed negative attitudes toward egalitarian members, it could diminish the group’s overall cohesion and potential contributions. consequently, individuals are less inclined to engage in prejudiced behavior and are more likely to make decisions they perceive as beneficial to the group’s welfare (terry et al., 2000). this is supported by terry et al. (2000), which looked at attitudes and behaviors in terms of in-group bias and decision-making. participants took part in a mock-jury paradigm in which they were presented with a hypothetical case and asked to render a verdict based on the evidence provided. participants were in-group and attractiveness bias are well-established concepts in social psychology. this study examines the concurrent influence of these concepts on the decision-making process using the minimal group paradigm. confederates, individuals who appear to be participants, were used to simulate out-group members. participants (n = 119, aged 20–30 years) answered a series of mathematics questions, followed by a response, agreeing or disagreeing with the participant’s answer, from a confederate. participants were then asked to rate the attractiveness of the confederates. results indicated that in-group bias significantly outweighed attractiveness bias. participants changed answers more frequently when their group disagreed, regardless of the confederate's attractiveness. results highlighted the robust effects of group membership on decision-making. additional research is required to explore confounds within decision-making, such as individual differences and familiarity bias. keywords: in-group bias, attractiveness bias, decision-making, minimal group paradigm, group dynamics 95 zhu & white more likely to make decisions consistent with their attitudes when they aligned with the in-group’s attitude (terry et al., 2000). many organisations thrive on teamwork, as performance is largely dependent on group members’ ability to work together towards a common goal (espín et al., 2019). consequently, groups may be hindered or facilitated by in-group bias, underscoring the importance of identifying when it is present. chai et al. (2022) showed that in-group bias was present between the ages of 5 and 6. when given a fictional story about an in-group/out-group member’s sharing behavior, researchers predicted that in-group members would share more than their out-group peers. as such, it is worth noting that these biases became stronger in different contexts, and achieving intergroup collaboration can depend on how well in-group biases are managed (li et al., 2021). when li et al. (2021) investigated fate control — the belief that the future is largely predetermined but can be influenced by individuals’ actions — on in-group bias during the covid-19 pandemic, it was found that higher fate control was associated with higher risk perception, and this led to stronger in-group bias in donating to help with covid-19. however, such behaviors change when resources are scarce. cui et al. (2023) looked at how participants allocated resources to themselves and an in-group/out-group. the in-group bias was more prevalent in the scarcity condition, where participants were observed to allocate more resources to in-group members. these studies highlight situations when ingroup bias increases, allowing either to reduce its harm or use it for positive outcomes. in-group bias can manifest in the tendency to agree with the group’s opinions (scheepers et al., 2006). this can be seen through members favoring members of their own group, with individuals being more likely to select attractive people as being supporters of their own party (nicholson et al., 2016). in addition, knippenberg and wilke (1992) investigated the effects of framing arguments on persuasiveness. participants were presented with arguments that either aligned or contradicted their group’s attitudes and arguments. results show that individuals were most likely to agree with the argument that best aligned with their group’s views. another expression of in-group bias is evident in the tendency to agree with group decisions depending on the salience of group identity. skinner and stephenson (1981) explored how highlighting group identity and contrasting in-group views with out-group views influences individuals’ expression of their opinions. it was found that emphasising group affiliation led to participants intensely expressing their opinions, agreeing with group views. these findings highlight how in-group bias shapes individual decision-making. formation of a “group” it is widely known that individuals are more likely to cooperate with others with whom they share a group identity (calanchini et al., 2022). however, recent evidence suggests that prior interaction may not be necessary to identify them as an in-group member (kurzban et al., 2001). instead, humans use symbolic cues and other ways to elicit favoritism towards ingroup members. hence, to create a group in laboratory settings, it is necessary to understand the minimal group paradigm, which consists of three main components (otten, 2016). firstly, categorization must be novel and arbitrary, meaning there must be no history of experiences with any in-group or out-group. second, categorization is anonymous; participants are to have no face-to-face interaction with group members. lastly, there are no direct relationships between allocations and self-interest. a minimal group designed correctly should evoke behaviors where individuals favor their own group members. the minimal group paradigm montalan et al. (2012) examined empathy towards in-group/out-group members using the minimal group paradigm. participants were split into two groups using a dot-estimation task: the underestimators (who allegedly underestimated the number of dots shown) and the overestimators (who allegedly overestimated the number of dots shown). due to the fictive nature of the groups, participants would have had no previous experiences with the in-group or out-group. after participants were split into groups, participants did a pain stimulator task individually, having no face-to-face interactions with other members. results showed evidence of in-group bias: participants made decisions to show more empathy for those in their own group in comparison to those in the out-group. in another study, reynolds et al. (2007) looked at predisposing factors that could lead to discrimination. participants were assigned to minimal groups. participants in the random condition were told that group 96 attractiveness vs. in-group bias allocations were done on a completely random basis. on the other hand, participants in the voluntary condition were asked to circle the group they wanted to be in. after the group assignment, participants completed various personality measures. results showed behaviors expected of an in-group member, with ingroup identification alone being the strongest predictor of participants’ tendency to discriminate. attractiveness attractiveness plays an undeniable role in evolutionary success, with attractive traits being associated with potentially fitter offspring (gangestad & scheyd, 2005). although it is difficult to standardize an attractive face, certain features are preferred. attractive women often had fuller lips, high-arched eyebrows, smaller and more tapered noses, and less angular jaws (pflüger et al., 2012). these feminine features were associated with disease resistance, high estrogen levels, and fertility (muñoz-reyes et al., 2014). in men, those with large eyes, prominent cheekbones, large chins, big smiles, and high-status clothing were considered attractive (cunningham et al., 1990). attractiveness bias attractiveness plays a role in social encounters, as many first impressions are based on visual features (nordholm, 1980). attractive people are often associated with positive personality traits, such as being sociable and intelligent (tsukiura & cabeza, 2010). whereas non-attractive individuals are characterised by negative personality traits, such as being less altruistic and less intelligent. in their study of attractiveness and selective bias in attributing moral character, tsukiura and cabeza (2010) found that attractiveness biases hinder perceptions of others. participants were more likely to attribute moral states to attractive rather than less attractive individuals. in addition, attractive individuals are more highly rated in perceived warmth in comparison to non-attractive individuals (klebl et al., 2021). this is due to the beauty-is-good (big) stereotype. the big stereotype can be explained using the halo effect: the positive evaluation of one trait influences the evaluation of other unrelated characteristics (klebl et al., 2021). individuals perceive attractive people as more correct, and this can lead to the desire to conform to their decisions. batres and shiramizu (2022) looked at attractiveness having a “halo effect,” where people associated social desirability with attractive individuals and provided evidence of the halo effect cross-culturally. hence, simply being attractive produces a “halo” effect that increases the chances of other people assigning positive traits to them, impacting the decision-making process. being perceived as attractive offers advantages in various aspects of life. in relationships, many attractive people report being more satisfied with their dating life (berscheid et al., 1971). in a job setting, it was found that non-attractive job candidates need to submit 33% more applications in comparison to their attractive counterparts (maurer-fazio & lei, 2014). additionally, unattractive individuals were found to earn 7–10% less than average-looking individuals (hamermesh & biddle, 1993). as well as this, attractive people were found to pay lower bail and fine amounts for misdemeanor charges (downs & lyons, 1991). in griffin and langlois’ (2006) study, the advantages of attractiveness and the disadvantages of unattractiveness were examined. the results suggested that being unattractive has disadvantages, with adults and children both giving low scores of positive attributes (sociability, altruism, and intelligence) to unattractive individuals. another study also found that more physically attractive individuals were viewed in both a positive light and more accurately in first impressions (lorenzo et al., 2010). individuals forming quick impressions often lead to inaccurate judgments, and these biases influence the decision-making process in many different social situations (zuckerman et al., 1995). people often make inferences about individuals’ character by judging their facial appearance (øvervoll et al., 2020; willis & todorov, 2006). as exposure to individuals with attractive faces increases due to media portrayal, it is important to know how often this occurs. in herbozo et al.'s (2004) study, where three raters coded messages present in children’s videos, it was found that 72% of the analyzed videos emphasized physical attractiveness. additionally, 84% of the videos associated female attractiveness with sociability and kindness. the results from this study indicate the prevalence of attractiveness stereotypes, hence the need to understand how this can affect decision-making. willis and todorov (2006) investigated the conditions in which participants are likely to make inferences based on facial appearance. it was found that merely exposing participants to images for 100 milliseconds was enough for judgments of attractiveness to be made. 97 zhu & white additionally, longer exposure time was found not to affect participants’ judgement of characteristics. such results show that exposing participants to just the face region is sufficient in generating attraction judgements. the chicago face database (cfd) was created using face morphing software and provides sets of faces and norming data (ma et al., 2015). the benefits of using the cfd include access to a large variety of faces (ma et al., 2020). the availability of large databases of faces offers the potential for valuable contributions to the field of psychology. the cfd has previously been used in various research done on appearances (freud et al., 2020; landy et al., 2020; marini et al., 2021). impact of attractiveness on in-group bias despite the concrete evidence on in-group bias, recent research suggests that group membership biases are malleable (rudman et al., 2001). rudman et al.’s (2001) study demonstrated that affective and cognitive processing play a role in reducing prejudice. furthermore, individuals’ prejudices are dependent on their biases as well as the situation. despite compelling evidence of the impact of in-group bias, the influence is not absolute. dang et al.’s (2019) study was conducted to look at the impact of criticism on in-group favoritism. when participants were criticized by an authoritative outside figure, it was found that in-group favoritism decreased. it was proposed that these results were due to the authoritative figures being viewed with admiration and possessing qualities that are considered attractive. however, the study did not investigate its impact on the subsequent decision-making of the group members. additionally, those who were experiencing a threat to their social self-esteem (their in-group) allocated fewer resources to their own group members, showing a decrease in behavior consistent with in-group bias. however, substantial research is still required on the interaction between attractiveness and group membership. in another study, kniffin et al. (2014) explored how perceptions of leader attractiveness are influenced by group membership. the results from this study were that in-group leaders were rated as more attractive than out-group leaders. this finding suggests that, despite similar levels of familiarity with both leaders, the out-group leader’s attractiveness was not stronger than the in-group bias. the impact of attractiveness on groups has been recognized as influencing people’s feelings and behaviors (krendl et al., 2011). a study looked at sorority recruitment and what factors influenced acceptance of potential members into high-status and low-status groups. the results revealed that high-status sororities prioritized the attractiveness of participants during the decision-making process. these results highlight the complexity behind the effect of attractiveness on social groups, and the increased likelihood of accepting a member depending on attractiveness. individuals affiliate with others who are like themselves, and many groups are formed by a shared interest in certain topics (chen & kenrick, 2002). a study was conducted to investigate the effects of group membership on the perception of others. results showed that individuals assumed that other members of the in-group share attitudes similar to their own, and that out-group members tend to have attitudes dissimilar to their own. interestingly, it was found that when a member of the out-group shares similar attitudes, participants become more attracted to them, especially when the out-group has negative stereotypes. these results suggest that although an individual may be part of the out-group, it is possible that there are other external factors that can change how an in-group member perceives them and consequential decision-making. given that most research looks at how in-group bias interacts with attractiveness, there is a need to examine scenarios wherein they contradict each other. while there have been many independent studies on attractive and in-group bias, further research is needed to investigate their conflicting influence. results studying these two factors affect our understanding of decision-making and the need to consider attractiveness while forming decision-making groups (e.g., jury panels, debating teams, and soccer teams). with research suggesting that in-group bias is not as resilient as previously believed, there is a possibility that the attractiveness of an out-group member will affect how strong in-group behaviors are. furthermore, results further support the use of the cfd in future experiments. further research is required to delve into decision-making and how attractiveness can interfere with in-group bias to affect this process. hence, the purpose of the current experiment is to investigate whether attractiveness influences in-group bias. it is hypothesised that the presence of an attractive out-group member will overpower in-group bias and participants will be more likely to change their answer when they deem 98 attractiveness vs. in-group bias the out-group member attractive, regardless of their group’s answer. method participants the convenience sample consisted of 119 university of technology sydney (uts) students aged 20 to 30. recruitment was conducted through online postings on the sona system, and participants were reimbursed with 0.5 credits for their participation. ethical clearance ethical clearance to conduct research with human subjects was obtained through uts psychology low and negligible risk (lnr) ethics panel (g-15-2023; see appendix a). informed consent from participants was obtained through a participation information sheet provided prior to the commencement of the study. participants were informed that they could withdraw consent at any time without penalty. the cfd the study utilized the cfd (ma et al., 2015). for the purposes of the current experiment, only eight faces were chosen as the confederates. using the norming data provided, the chosen faces had to be between the ages of 20 and 30, as this reflected the ages of the participants. this allows for controlling age as a confounding variable for perceived attractiveness, as it has previously been shown that younger people are considered more attractive (zebrowitz & franklin, 2014). for the cfd, attractiveness was measured on a 7-point likert scale (1 = least attractive to 7 = most attractive). the images used (confederates) were chosen from the extreme ends of the given attractiveness ratings. four of the most highly rated faces were chosen as the attractive confederates. this included faces with the ratings of 5.48, 5.31, 5.24, and 5.12. in addition, four of the lowest-rated faces were chosen as the non-attractive confederates. this included faces with the ratings of 1.61, 1.55, 1.54, and 1.52. attractiveness ratings and ages were the only two factors considered when choosing confederates. the minimal group paradigm to stimulate in-group bias in a short period of time, the current study utilized the minimal group paradigm (otten, 2016). creating a new group was necessary as it eliminates the confounding effect of biases on results. this means that any preconceptions and previous experiences would not influence participants’ responses. it has been established that prior interaction may not be necessary for participants to identify themselves as an in-group member (kurzban et al., 2001). additionally, it has been found that merely categorizing individuals into two social groups is enough to elicit behaviors of group members. a novel or arbitrary categorization means participants had no prior experiences with the in-group or out-group. the current experiment addresses this through participants being randomly assigned to groups, as well as them being informed that their groups are based on their study sign-up time. this also ensured that participants had no relationship between their allocated group and their self-interests. anonymous categorization means participants do not have any face-to-face interactions with in-group or outgroup members. the online nature of the experiment addresses this. participants’ identities were kept anonymous, and they did not encounter other participants. a minimal group designed correctly will evoke behaviors of in-group favoritism (hertel & kerr, 2001). this study utilized the minimal group paradigm in an online format. janneck et al. (2013) conducted an experiment to replicate the minimal group paradigm in an online setting. arbitrary groups were created, and varying degrees of information about other group members were made available to participants. in both informal and work settings, participants showed in-group favoritism. additionally, when less information was made available to participants, in-group bias was more prominent. this study exhibits the effectiveness of minimal group paradigms in online settings. online groups the current study was conducted online via qualtrics. this was due to convenience, time constraints, financial constraints, and being a standard practice for research conducted with uts. furthermore, online environments allow for the convenience in creating and conducting experiments involving manipulation online if the task does not require any physical presence (horton et al., 2010). this environment ensured participant anonymity while allowing for controlled deception regarding the existence of other peers. group allocation participants were informed that there were groups as well as independent individuals. however, the participants were unaware that they had been placed in 99 zhu & white group a and completed the study individually at different times. they were informed that their group allocation was dependent on the time frame in which they signed up for the study. as per the minimal group paradigm, categorization was novel, and there was no relationship between allocations and participants’ self-interests. testing phase to ensure that participants answered honestly, they were informed that their responses and choices would be anonymous (schitter et al., 2019). participants were asked to complete eight multiple-choice mathematics questions (see appendix a). they were given 10 seconds to answer each question. none of the questions had correct answers. the intention was to create uncertainty within the participants regarding the correct answer. after the participants answered each question, they were shown a summary of their group’s (group a) response and a response from a confederate (see appendix b). the responses from the group and the confederate were predetermined and not dependent on active participation. the eight possible responses were randomized (see table d1). participants were then given 10 seconds to decide if they wanted to change or retain their answer. this was repeated eight times. rating phase after participants had completed the mathematics questions and made their decision to change or maintain their original question, they were asked to state whether they think the person in the image is attractive in a yes/no questionnaire (see appendix c). although the more “attractive” faces from the cfd have been included, it is important to factor in individual preference. participants were again reminded that their responses were kept anonymous. calculator use and debrief participants with incomplete responses and participants who responded “yes” when asked whether they used a calculator had their responses removed. a total of 32 responses were removed. participants were then informed of the manipulation being used. they were debriefed as per uts requirements. results data management data was collected on qualtrics, and a copy of the data was placed on uts’s onedrive as per uts’s requirements. data was de-identified and password-protected. data was de-individualized and exported onto a personal laptop to conduct analysis, and was deleted promptly after data analysis was complete. statistical test and hypothesis the relationship between in-group bias and attractiveness bias was examined using a chi-squared test of independence. this was done by looking at participants’ likelihood of changing their answer when presented with the group and an attractive/unattractive individual who agreed or disagreed with their answer. chi-square test of independence attractiveness of confederate vs. answer change the results of the chi-squared test of independence revealed no significant difference between answer change and attractiveness, x2(1, n = 696) = 2.12, p = .145. there was some variation between the observed and expected scores (table d2 in appendix d), and participants were more likely to retain their answer when the confederate was unattractive (see figure 1). however, the chi-squared test of independence indicated that these results were non-significant (p > .05). cramér’s v of .06 revealed little, if any, association between the two variables. group response vs. answer change results from the chi-squared test of independence revealed a significant relationship between group response and answer change, x2(1, n = 696) = 20.80, p < .001. there was variation between observed and expected results (table d3 in appendix d). participants were more likely to change their answer when the group disagreed with their answer (see figure 2). cramér’s v value of .17 revealed the strong relationship between the two variables. attractiveness vs. answer change when group agrees and confederate disagrees the chi-squared test of independence was used to examine the relationship between answer change and attractiveness bias when the group agreed, and the confederate disagreed with the participants’ answer. it showed that the relationship between these two variables was non-significant, x2(1, n = 348) = 1.88, p = 1.70. although there was some variation in observed (figure 3) and expected values (table d4 in appendix d), cramér’s v of 0.07 revealed the low association between answer change and attractiveness of the confederate when the group agrees, and the confederate 100 attractiveness vs. in-group bias disagrees with participants’ answers. the relationship between the answer change and attractiveness when the group disagreed and the confederate agreed with the participant's answer showed no significance, x2(1, n = 348) = 0.34, p = .562. there were variations in observed and expected scores (table d5 in appendix d), and the likelihood of retaining an answer was observed (figure 4), but the chi-square test of independence showed that there was no significant difference between conditions. the cramér’s v of .03 revealed little to no significance between answer change and attractiveness in this context. discussion the aim of the study was to examine whether attractiveness influences in-group bias. more specifically, the present study investigated whether the presence of an attractive out-group member would override the effects of in-group bias in decision-making. contrary to the initial prediction that participants would be more likely to change their answer in the presence of an attractive out-group member, the results of the study revealed no significant differences. this suggests that attractiveness does not affect in-group bias. however, group responses had a significant effect on whether participants changed their answers. more specifically, when the group disagreed with the participant’s answer, participants were more likely to change their answer, irrespective of the attractiveness of the out-group member (confederate). this suggests that in-group bias is stronger than the attractiveness bias. such results highlight that the minimal group paradigm is a valid approach to developing a sense of cohesion within individuals. there was a lack of significant findings when looking at: 1. individuals’ ratings of attractiveness versus answer change. 2. individuals’ ratings of attractiveness versus answer change when the group agrees and the confederate disagrees. 3. individuals’ ratings of attractiveness versus answer change when the group disagrees and the confederate agrees. the current study explored the contradicting effects of attractiveness and in-group bias, and the weight individuals give each influence by creating a situation wherein these two influences come into conflict. while both factors are known to have an influence on individuals, the current study reveals their relative weighting. results suggest that in-group bias has a stronger influence than attractiveness on decision-making. a few factors could explain the findings. the context in which participants were required to decide may have led to these results. based on previous research, the nonsignificant results suggest that although attractiveness has been shown to have a “halo effect” on individuals, its influence may not be as strong as in-group bias (batres & shiramizu, 2022). such results highlight the importance of social context over individual traits. another notable limitation is the lack of direct supervision during survey completion. without supervision, there is a possibility of participants colluding with other participants. such interactions could disrupt the minimal group paradigm and affect the findings. while it is clearly identified that in-group bias had a stronger influence than attractiveness bias, there was substantial variation in the responses of individuals. this suggests the possibility of other factors having an influence on the results. while this level of analysis is beyond the scope of the current study, a comprehensive analysis on some confounding variables is worthwhile for future research. individual differences individual differences could have also played a role in the insignificant results. these differences affect how individuals interact with the world and could affect how participants perceive group dynamics and attractiveness (newheiser et al., 2012). although the relationship between attractiveness and answer change was insignificant, participants were most likely to retain their answers when they found the confederate unattractive. this suggests the possibility that the influence of attractiveness and in-group bias has differing levels of influence on different individuals. this is not the first study identifying the impact of individual differences in terms of decision-making. a study looking at a dual-strategy model of reasoning suggests that people have two reasoning strategies which affect the way social cues affect them (gagnonst-pierre et al., 2021). this includes a statistical strategy which involves estimating a likely conclusion of a social interaction or the counterexample strategies which involve generating counterexamples of a con101 zhu & white clusion. results from this study suggest that these processing distinctions underlie individual differences in responding to attractiveness and in-group bias. cultural differences the current study did not identify culture as a confounding variable, and this could prove to be a rich area of research for the future. the sample was a convenience sampling, meaning participants were selected due to availability. all participants were also enrolled in an australian university. while their cultural identification was not collected, it can be assumed that students have had interactions with australian culture, which is a highly individualistic culture (emiko & hidehumi, 2019). cultural differences are known to affect how individuals perceive others who are part of their group (sam & berry et al., 2010). hence, it is possible for individuals to have varying levels of loyalty to their group. cox et al. (1991) examined the role of cultural backgrounds on teamwork. it was found that people from collectivist cultures displayed more cooperative behaviors compared to those from individualistic cultures. in other words, people from collectivist cultures place more emphasis on group success compared to individual success. in another study, fischer and derham (2016) examined cultural influences on in-group bias across 18 societies. the results showed that in-group bias was present but varied across the societies. the variation of in-group bias was dependent on the following cultural influences: individualistic versus collectivist cultures, uncertainty avoidance, and power distance. similarly, it was found that collectivist cultures tend to exhibit stronger in-group biases. in cultures wherein hierarchical structures are more acceptable, more in-group behaviors were displayed. cultures with high uncertainty avoidance, the extent to which individuals are affected by unfamiliar/unknown situations, displayed high levels of in-group bias. these cultural differences can affect how substantial the influence of attractiveness is in a group setting. personality traits and familiarity bias personality traits have also been shown to influence responses to social cues. traits such as agreeableness, extraversion, openness, and conscientiousness have been linked to group cohesion (larsen et al., 2020; saapna & suman, 2012). this may shape how individuals engage with attractive others, affecting decision-making. additionally, familiarity bias –where repeated exposure increases preference – was not accounted for in the current study (monin, 2003). prior research shows that even brief exposure to faces can enhance attractiveness ratings (rhodes et al., 2001) and increased interaction fosters interpersonal attraction (rei et al., 2001). both these factors may have influenced responses and, therefore, should be considered as potential variables in future research examining the interplay between in-group bias and attractiveness. implications the results from the current study suggest that facial attractiveness—a measure of overall attraction— is dependent on the context, and in situations where there are other social cues—such as in-group bias—it may not be as influential. this demonstrates the benefits of considering social context when looking at how attractiveness influences behaviors. rather than solely addressing and mitigating the attractiveness bias in a group setting, it may be more advantageous to promote inclusive behaviors and encourage the acceptance of out-group individuals. results from previous experiments show that a properly designed minimal group paradigm promotes in-group behaviors. this study’s results support the fact that arbitrarily created groups can lead individuals to display in-group behaviors, as indicated by individuals choosing to change their answers when the group disagreed with them. these findings enhance the understanding of the underlying themes of group creation and allow for the promotion or mitigation of group biases. future directions future research should consider replication of the current experiment in broader contexts with application of potential factors as described above and beyond,such as considering subjectivity due to race and/ or ethnicity. exploring dimensions such as personality traits and familiarity bias not only mitigates some individual differences but also offers a better understanding of different ways other dimensions interact with attractiveness and whether this could override other biases, such as in-group bias. while the current study did not offer evidence for the effect of attractiveness on answer changes in group settings, it further supports evidence of in-group bias in decision-making. it enhances the understanding of social influences and encourages further research on how individual characteristics interact in group settings. 102 attractiveness vs. in-group bias references adam-troian, j., bonetto, e., & de oliveira, p. 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(1995). effects of attractiveness and maturity of face and voice on interpersonal impressions. journal of research in personality, 29(2), 253–272. https://doi. org/10.1006/jrpe.1995.1015 106 attractiveness vs. in-group bias table d1 response possibilities note. this table displays all the possible responses from group a and group b. 107 zhu & white figure 1 answer change vs attractiveness of confederate 108 attractiveness vs. in-group bias figure 2 group response vs. answer change 109 figure 3 attractiveness vs answer change when group agrees but confederate disagrees zhu & white 110 figure 4 answer change vs. attractiveness when group disagrees and confederate agrees attractiveness vs. in-group bias 111 zhu & white appendix a quiz this appendix consists of the mathematical questions and summaries of group and confederate answers. 1. √8.237 = ? a) 2.56 b) 2.67 c) 2.78 d) 2.97 1a. members of group a agree with your answer. this member of group b disagrees with your answer. are you going to change your answer? a) yes b) no 2. √7.338 = ? a) 2.134 b) 2.456 c) 2.356 d) 2.982 2a. members of group a disagree with your answer. this member of group b agrees with your answer. are you going to change your answer? a) yes b) no 3. √10.234 = ? a) 3.356 b) 3.423 c) 2.951 d) 2.999 3a. members of group a agree with your answer. this member of group b disagrees with your answer. are you going to change your answer? a) yes b) no 4. √4.222 = ? a) 1.572 b) 2.132 c) 1.794 d) 1.994 112 attractiveness vs. in-group bias 4a. members of group a disagree with your answer. this member of group b agrees with your answer. are you going to change your answer? a) yes b) no 5. √12.343 = ? a) 2.988 b) 3.261 c) 3.942 d) 3.619 5a. members of group a agree with your answer. this member of group b disagrees with your answer. are you going to change your answer? a) yes b) no 6. √85.263 = ? a) 9.163 b) 8.859 c) 7.295 d) 9.255 6a. members of group a disagree with your answer. this member of group b agrees with your answer. are you going to change your answer? a) yes b) no 7. √124.33 = ? a) 12.483 b) 12.131 c) 11.173 d) 11.298 7a. members of group a agree with your answer. this member of group b disagrees with your answer. are you going to change your answer? a) yes b) no 8. √78.452 = ? a) 7.762 b) 8.583 c) 7.589 d) 8.969 113 zhu & white 8a. members of group a disagree with your answer. this member of group b agrees with your answer. are you going to change your answer? a) yes b) no 114 attractiveness vs. in-group bias appendix b attractiveness questionnaire this appendix consists of the questions regarding whether participants find the confederates depicted attractive. 1. is this person attractive? a. yes b. no 2. is this person attractive? a. yes b. no 3. is this person attractive? a. yes b. no 4. is this person attractive? a. yes b. no 5. is this person attractive? a. yes b. no 6. is this person attractive? a. yes b. no 7. is this person attractive? a. yes b. no 8. is this person attractive? a. yes b. no 115 zhu & white appendix c contingency tables table d2 contingency table for the attractiveness of confederate and answer change note. n = 696 table d3 contingency table for group response vs answer change note. n = 696 116 attractiveness vs. in-group bias appendix c (cont.) table d4 attractiveness and answer change when the group agrees and confederate disagrees note. n = 348 table d5 attractiveness and answer change when the group agrees and confederate disagrees note. n = 348 35 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university effect of brain injury on post-deployment relationship satisfaction in veteran couples savannah grier1,2 and deborah a. perlick, ph.d.2 1department of counseling & clinical psychology, teachers college, columbia university, new york, ny 2jj peters department of veterans affairs medical center and visn 3 mental illness, research, education and clinical center, bronx, ny and department of psychiatry, icahn school of medicine at mount sinai, new york, ny reintegration of veterans from the operation enduring freedom-operation iraqi freedom (oef/oif) era presents numerous challenges for both the veteran and their partner, particularly when the veteran returns with physical and psychological injuries. the proposed study aims to explore the factors that affect relationship satisfaction, including depression, emotion dysregulation, and communication patterns in oef/oif veterans with a history of mild traumatic brain injury (mtbi) and their partners. cross-sectional analyses were conducted to compare measures of these factors between 35 veterans and 35 partners from greater new york and baltimore, md. initial analyses of variance indicated that veterans were more likely to be more depressed and emotionally dysregulated, and less likely to engage in positive communication compared to partners. hierarchical regression suggested that veterans were less likely to report relationship satisfaction when accounting for depression, emotion dysregulation, and positive interaction patterns. partners were less likely to report relationship satisfaction only when accounting for depression. these cross-sectional analyses identify key areas that present challenges to oef/oif veterans reentering civilian life with their significant other, which could inform mental health services targeting military couples. limitations and future directions are discussed. reintegration of veterans from the operation enduring freedom-operation iraqi freedom (oef/ oif) era following multiple deployments and extended absence presents numerous challenges for both the veteran and their spouse or partner (bowling & sherman, 2008; cohen et al., 2009). traumatic brain injury (tbi) has been termed the ‘signature injury’ of returning oef/oif service members, affecting up to 44% of soldiers wounded in combat with 80–90% classified as mild (mtbi) (hoge et al., 2008). this injury is defined by the va/dod clinical practice guideline for management of concussion/mild traumatic brain injury (concussion/mtbi guideline working group, 2009) as an injury or concussion associated with at least one of the following: brief (< 30 minutes) loss of consciousness, altered state of consciousness or post-traumatic amnesia for < 24 hours following the injury. moreover, veterans come home with a number of emotional wounds of war that can disrupt the harmony of the relationship such as posttraumatic stress disorder (ptsd) and depression (bowling & sherman, 2008), which often occurs in tandem with mtbi (perlick et al., 2014). research suggests that veterans with a history of tbi are 1.5 times more likely to die by suicide than veterans without a history of tbi (brenner et al., 2011). in addition, veteran depression has been linked to role uncertainty, poor marital adjustment and disturbed family functioning (dekel & monson, 2010). veterans with a history of mtbi can also contend with impulsivity and emotion dysregulation, which can lead to serious ramifications within the couple. studies of combat veterans have found high rates of marital distress and intimate partner violence reported by 54% override (hidden running head text): grier, perlick effect of brain injury keywords: veterans, military couples, intimacy, ptsd, tbi acknowledgements: this study is supported by va merit award 1i01rx001106 from the va office of research & development and the visn 3 mirecc. please address correspondence regarding this article to: savannah.grier@gmail.com 36 grier, perlick of oef/oif couples (dekel, & monson, 2010). as a result of the veteran’s impaired interpersonal skills, both those with tbi and their family members experience a “shrinking of support networks” (lobello et al., 2003), reducing the couple’s ability for enjoyment and companionship which might provide a buffer against the challenges of reintegration. low spousal relationship satisfaction has been associated with poor socio-emotional skills, particularly empathic ability, which is a common sequela of tbi (burridge et al., 2007). furthermore, military couples often must re-establish relationship routines, reallocate household responsibilities, renegotiate parental roles in caregiving and discipline, while addressing financial strain and reconnecting emotionally (gerwitz et al., 2010). as such, studies have found that tbi has a more negative impact on spouses than on other caregivers, supported by high rates of marital distress and intimate partner violence, reported by 54% of oef/oif couples (dekel, & monson, 2010). while there is a growing body of research establishing the validity and efficacy of family and couples interventions tailored specifically to the oef/oif cohort, targeting ptsd, depression, and relationship functioning post-deployment (monson et al., 2008; sautter et al., 2011; schumm et al., 2013; sherman et al., 2009; 2012), there has yet to be an evidencebased intervention developed to specifically meet the needs of veterans with a history of mtbi and their partners. rodgers et al. (2007) adapted the multifamily group (mfg) model (macfarlane, 2002) for civilian tbi and family members, which was then recently adapted by perlick et al. (2014) in a pilot study for veterans with a history of mtbi and their partners. perlick et al. (2014) found overall increases in caregivers’ feelings of empowerment, greater occupational activity and interpersonal relationships on the part of the veteran, and decreases in veteran anger and depressive symptoms. furthermore, participants noted that the group helped to reduce feelings of isolation by providing a space to discuss common struggles and aided in restoring relationships through communication and understanding (straits-tröster et al., 2014). these promising results prompted the researchers to develop and test a multifamily group treatment for mtbi in military couples in a randomized controlled trial. the intervention would address problem-solving challenges due to compromised executive functioning, emotion dysregulation, and challenges related to couples communication. although the study’s test groups are still underway, there has already been meaningful data collected from the enrolled participants that could provide some insight to the challenges military couples from the oef/oif era are facing post-deployment. the current study aims to explore the relationship among depression, emotion regulation, communication patterns, and relationship satisfaction in oef/ oif veterans with a history of mtbi and their partners. cross-sectional data collected will be analyzed to compare these constructs between veterans and partners and to define the variables that predict relationship satisfaction. we hypothesize that veterans will score higher on measures of depression, emotion regulation, and conflict communication patterns compared to partners. moreover, we hypothesize that depression, emotion regulation, and communication patterns will significantly predict relationship satisfaction when controlling for each variable. in examining these factors, we hope to illuminate the constellation of constructs that better predict relationship satisfaction in oef/oif veterans with mtbi. method participants and procedure a sample was drawn from an ongoing larger randomized controlled trial, which aims to expand upon perlick et al.’s (2014) mfg adaptation for veterans with mtbi and their partners. these participants, 35 veterans and 35 partners, were recruited via clinician or program director referrals from the tbi/polytrauma clinics, oef/oif centers, and caregiver support groups from the james j. peters va medical center, va new york harbor healthcare system, and va maryland healthcare system. because mtbi often overlaps with other conditions, the inclusion criteria were selected to ensure veterans met diagnostic criteria for mtbi that could only be explained by combat exposure in iraq or afghanistan. thus, veterans who had other neurological conditions that either exacerbated the mtbi (i.e., borderline moderate) or better explained the mtbi were screened out. the previous mfg adaptation for this population found a significant cognitive gap between veterans with mtbi versus those with a moderate tbi, 37 effect of brain injury which would have disrupted treatment (perlick et al., 2014). for this reason, veterans were only included if they received a diagnosis for mild tbi. a detailed list of inclusion and exclusion criteria can be found in table 1. couples read and signed separate informed consent forms prior to completing the screening and baseline assessment. veterans and partners were assessed separately in private offices. couples were compensated $90 for completion of the assessment battery. materials depression. the center for epidemiologic studies depression scale (ces-d; radloff, 1977) is a 20-item selfreport measure of depressive symptoms. participants indicated the extent to which items applied to themselves within the past weeks on a scale of 0 (rarely or none of the time) to 3 (most or all of the time). sample items include “i had crying spells,” “i felt sad,” and “i felt hopeful about the future.” radloff (1977) found high internal consistency (cronbach’s α = .90). table 1 inclusion criteria for veterans • deployment-related mtbi, confirmed by the va tbi identification clinical interview (vanderploeg et al., 2012) and in accordance with the va/dod clinical practice guideline for management of concussion/mild traumatic brain injury: injury or concussion associated with at least one of the following: brief (< 30 minutes) loss of consciousness or altered state of consciousness or post-traumatic amnesia for < 24 hours following the injury • oef/oif era • no pre-existing neurologic condition(s) (head trauma unrelated to deployment, seizures, strokes, neurosurgery, other neurologic impairments based on medical record or self-report) • no severe cognitive deficits, as defined by a montreal cognitive assessment (moca; nasreddine, 2005) score ≥ 19. the 30-item moca screens for impairment in specific areas of cognitive functioning deemed necessary for participation in a 90-minute, structured group including attention and concentration, executive functions, language and conceptual thinking. we have specified a moca cut-off at the lower end of the range for mild cognitive dysfunction (≥ 19), in order to exclude veterans with severe memory and/or other cognitive deficits, while admitting those with more mild deficits, as these represent our target population, i.e., veterans with a history of mtbi inclusion criteria for veterans and partners • currently married or cohabitating with a partner for 6+ months • 18 years old or older • no current alcohol or drug abuse or dependence defined by a short michigan alcoholism screening test (smast; selzer, 1975) ≥ 3, based on the recommended cut-off for tbi survivors (gentilello et al., 1995) or a drug abuse screening test-10 (dast-10; skinner, 1982) ≥ 3l • no life diagnosis of a psychotic disorder or active psychosis (schizophrenia, schizoaffective or bipolar disorder) or active psychosis based on the structured clinical interview for dsm-iv-tr (scid-l; first et al., 2007) • absence of “severe” inter-partner violence as defined by the revised 20-item conflict tactics scale short form (cts2s) (straus & douglas, 2004) • no suicide attempt (actual, aborted, or interrupted) within the past six months indicated on the columbia suicide severity rating scale (c-ssrs) • absence of medical condition or life event (e.g., ongoing or pending legal action in another state) that would compromise participation • no participation in another psychosocial intervention trial or couples’ treatment six months prior to or during study or follow-up. 38 grier, perlick emotion dysregulation. the difficulties in emotional regulation (ders; gratz & roemer, 2004) is a 41-item self-report measure that assesses emotion dysregulation across the following dimensions of emotion regulation: (a) awareness and understanding of emotions; (b) acceptance of emotions; (c) the ability to engage in goal-directed behavior and refrain from impulsive behavior, when experiencing negative emotions; and (d) access to emotion regulation strategies perceived as effective. participants were asked to rate the extent of which items apply to themselves, with responses ranging from 1 (almost never) to 5 (almost always). cronbach’s alpha was .93 (gratz & roemer, 2004). communication. the communication patterns questionnaire (cpq; christensen & sullaway, 1984), is a 35-item self-report measure of conflict communication that addresses partners’ behavior during three stages of an argument: (a) when some problem in the relationship arises; (b) during a discussion of a relationship problem; and (c) after a discussion of a relationship problem. the participants’ scores are factored into three subscales: demand/withdraw, high conflict, and positive interaction. christensen (1988) found a relatively high agreement between partners’ independent reports for these three subscales (r’s above .70). in addition, he found that positive interaction and demand/withdraw communication subscales were significantly related to marital adjustment in the expected direction. relationship satisfaction. the dyadic adjustment scale (das; spanier, 1976) is a 32-item measure of relationship quality in married or unmarried cohabiting couples. participants are asked to rate 30 questions relating to various aspects of intimacy and relationship satisfaction on a likert scale and 2 questions with “yes/ no” responses (e.g., “has either of the following been problems in the relationship in the past month?”). the entire scale’s cronbach’s α was .96 (spanier, 1976). data analysis to test the first hypothesis, one-way analyses of variance (anova) were conducted to compare scores on ces-d, ders, cpq, and das between veterans and partners to examine differences in depression, emotion dysregulation, communication patterns, and relationship satisfaction, respectively. hierarchical regression models were run to determine statistical predictive significance of the above measures in the veteran sample and partner sample to test whether depression, emotion regulation, and communication patterns predicted relationship satisfaction. predictors that were statistically significant at an alpha level of .05 were retained for further analysis. three multivariate linear regression models were used to analyze the predictive power of these variables separately and together, when controlling for each other. as a result, the models could delineate whether all predictors better explained variance in relationship satisfaction, as hypothesized, or if there were any significant predictors independent of the others. results table 2 presents demographic characteristics of the veteran and partner sample. data from 70 participants (i.e., 35 couples) were used in the current investigation. findings suggest that veterans scored significantly higher on measures of depression (f(1, 63) = 18.86, p < .01) and emotion dysregulation (f(1, 63) = 25.85, p < .01) and lower on positive interaction patterns (f(1, 63) = 7.44, p < .05) compared to partners. these results partially support the first hypothesis, which states that veterans would score higher on measures of depression and emotion dysregulation. while veterans scored significantly higher on each subscale of emotion dysregulation (see table 3), no significant findings emerged from the high conflict cpq subscale. furthermore, no significant differences were found in veterans’ and partners’ scores of relationship satisfaction. medium to large effect sizes were observed. overall, these initial results suggest that there are significant differences in depression, emotional regulation, and positive communication patterns when comparing veterans to their partners. to test our second hypothesis, an incremental test was run to determine the potential predictive power of each measure and the subscales within the ders and cpq, specifically. results suggested that the following measures reached statistical significance: the ders nonacceptance of emotional responses (nonaccept) subscale, the cpq positive interaction subscale, the ces-d, and the das. as such, only these variables were used in subsequent multivariate regression analyses. the findings of these final regression runs partially supported our second hypothesis in that all three constructs were significant predictors of relationship satisfaction in veterans but not partners. table 4 39 effect of brain injury summarizes the findings of three regression models run to test whether accounting for the above covariates predicts relationship satisfaction. for veterans, all three regression equations reached statistical significance suggesting that variance in relationship satisfaction is better explained when accounting for greater depression (β = -.65, t(24) = -4.80, p < .01), greater emotional non-acceptance (β = .45, t(24) = 3.47, p < .01), and fewer positive interaction patterns (β = .57, t(24) = 5.15, p < .01). however, the depression-only regression equation was the only model to reach significance for partners (β = -.55, t(23) = -3.14, p < .01), suggesting that depression predicts relationship satisfaction while non-acceptance of emotional responses and positive interaction patterns do not play a considerable role. discussion the current study assessed common factors affecting veterans with a history of mtbi and their partners, table 2 participant demographics veterans (n = 35) n (%) partners (n = 35) n (%) age (x̅ ± s.d.) 35.60 (8.545) age (x̅ ± s.d.) 34.41 (9.74) gender male 33 (94) gender female 32 (91) race black white multiracial native american 16 (46) 17 (48) 1 (3) 1 (3) race black white asian multiracial east indian unknown 13 (37) 17 (49) 1 (3) 2 (6) 1 (3) 1 (3) ethnicity hispanic non-hispanic missing 12 (35) 22 (63) 1 (3) ethnicity hispanic non-hispanic 8 (24) 26 (76) education completed college and/or beyond completed 12th grade or ged missing 6 (17) 26 (74) 3 (9) education completed college and/or beyond completed 12th grade or ged completed 8th grade 17 (49) 17 (48) 1 (3) employment status full time unemployed retired student missing 12 (34) 11 (31) 3 (9) 7 (20) 2 (6) employment status full time part time unemployed retired student 12 (34) 5 (14) 11 (31) 1 (3) 6 (17) couples (n = 35) marital status married cohabiting engaged 22 (62) 11 (31) 2 (7) 40 grier, perlick hypothesizing that depression, emotion dysregulation, and communication patterns were key predictors of relationship satisfaction. initial analyses suggested veterans were significantly more depressed, more emotionally dysregulated, and less likely to engage in positive interaction patterns compared to partners. hierarchical regression models then determined the specific constructs that significantly predicted relationship satisfaction. finally, multivariate linear regression modeling showed that veterans who were more depressed, less likely to accept their emotional responses, and less likely to engage in positive interaction patterns reported less relationship satisfaction. for partners, depression was the only factor that significantly predicted relationship satisfaction, with greater depression leading to lower relationship satisfaction. these results potentially inform future studies examining relationship difficulties post-deployment. among spouses, research has shown that caregiver burden generally increases over time after tbi and is sustained 7 years post-injury (blais & boisvert, 2005). in line with the results, relationship satisfaction and positive communication patterns could be important factors leading to decreases in caregiver burden, which are changes targeted in future analysis upon completion of the current study. interviews with partners of veterans with mtbi have also demonstrated the therapeutic qualities of better communication and understanding within the relationship, particularly when emotions run high (straits-tröster et al., 2014). this study demonstrated that veterans who have sustained a mtbi struggle with emotion regulation difficulties post-injury table 3 characteristics of veterans on emotion regulation, depression, and communication vs. partners veteran (n = 35) partner (n = 35) measure m(sd) m(sd) cohen’s d r depressiona 23.65 (14.12)** 11.06 (8.1) 1.09 .48** emotion dysregulationb non-acceptance 15.65 (7.29)** 11.24 (5.06) .70 .33** goal-directed behavior 17.9 (5.53)** 10.64 (4.62) 1.42 .58** impulse 15.12 (6.96)** 9.45 (3.64) 1.02 .45** awareness 17.35 (5.18)* 14.34 (6.24) .52 .25* strategies 20.56 (8.06)** 12.94 (4.56) 1.16 .5** clarity 12.56 (4.94)** 8.64 (2.70) .98 .44** total 99.15 (28.66)** 67.09 (20.41) 1.29 .54** communication patternsc high conflict 14.88 (5.60) 12.87 (6.93) .32 .16 demand/withdraw 18.81 (5.63) 17.10 (6.58) .28 .14 positive interaction 17.97 (5.40)* 21.30 (4.69) -.66 -.31* relationship satisfactiond 103.20 (20.86) 110.90 (17.22) -.40 -0.20 a measured by center for epidemiological studies depression scale; higher scores indicate higher levels of self-reported depressive symptoms. b measured by difficulties in emotion regulation scale; higher scores indicate greater self-reported emotion dysregulation. c measured by the communication patterns questionnaire; higher scores indicate greater self-reported use of pattern. d measured by the dyadic adjustment scale; higher scores indicate greater self-reported relationship satisfaction. *p ≤ .05. **p ≤ .01. 41 effect of brain injury compared to their romantic partners, which could help explain caregiver burden in terms of how partners must navigate explosive tempers, emotional numbing, and isolation. in sum, this study provides preliminary data on the predictive value of specific factors related to problem areas for military couples, which can then lead to more causal explorations of the types of treatment that effectively target and treat these post-deployment challenges related to reintegration and reestablishing intimate relationships. limitations the following study has several limitations that affect the generalizability of the results. a major limitation arises from the homogeneity of gender in the veteran sample and the partner sample, which are nearly exclusively male and female, respectively. studies suggest that women are almost twice as likely to suffer from depression compared to men of the same age (pratt & brody, 2008). as such, it remains unclear whether the results relating to depression in partners is a function of their relationship to the veteran or to the majority of partners identifying as women. in the larger social context, men are also often expected to limit their range of emotions, while women are expected to be highly emotional and communicative of their feelings (plant et al., 2000). thus, the near-exclusive male status of the veteran cohort cannot be ruled out as a possible explanation for the differences in emotional acceptance and positive interaction patterns compared to partners. as the larger study continues and sample size increases, efforts to disperse gender differences among the veteran and partner samples will hopefully dilute any biases that are likely to confound the results related to depression, emotional acceptance, and communication patterns. in addition, the study did not account for the possible confound of comorbidity. specifically, veterans who have sustained a mtbi not only tend to suffer from depression and/or ptsd, but also from cognitive and neurologic challenges. the neuropsychiatric sequelae table 4 summary of hierarchical regression analysis for variables predicting relationship satisfaction veteran (n = 35) model 1 model 2 model 3 variable b se b β b se b β b se b β depression -.92 .23 -.61 -1.3 .27 -.86** -.98 .20 -.64** non-acceptance of emotions 1.19 .51 .42* 1.24 .36 .44* positive interactions 2.21 .43 .57** r2 .369 .479 .748 f for change in r2 15.81** 5.49* 26.68** partners (n = 35) model 1 model 2 model 3 variable b se b β b se b β b se b β depression -1.2 .40 -.55** -1.33 .44 -.59** -1.20 .55 -.53 non-acceptance of emotions .40 .76 .10 .45 .79 .12 positive interactions .37 .88 .10 r2 .30 .309 .315 f for change in r2 9.88** .27 .17 *p < .05. **p < .01. 42 grier, perlick of mtbi may include cognitive dysfunctions (problems in memory, attention, executive functions, affect recognition, empathy, self-awareness) as well as comorbid mood, posttraumatic stress and other neurobehavioral disorders (halbauer et al., 2009; cicerone et al., 2006; wehman et al., 2009; huckans et al., 2010). as such, the interaction between the neuropsychiatric sequelae and mood or anxiety disorders could be the defining characteristic that leads to greater emotion dysregulation, which then leads to lower relationship satisfaction. the present study does not allow for us to discount the possibility that mtbi is exclusively responsible for the factors explored in the current study. while exclusion criteria filtered those veterans with more severe cognitive impairments, the study did not completely rule out the possible effects of the aforementioned comorbidities in the relationship among emotional and interpersonal factors that predict relationship satisfaction. finally, the study only compares veterans post-injury with their civilian partners, which does not account for the veterans’ overall character and disposition before the injury occurred. in addition, many of the partners did not know the veteran pre-injury and thus could not provide reliable data as to the nature of the relationship before the veteran sustained the mtbi. the current study’s findings would have been strengthened with an additional cohort of veterans without mtbi and their partners to control for related factors that may better explain the variance in relational difficulties, such as preexisting mood disorders or turbulent personal history. thus, this study cannot rule out the possible influence of extraneous variables based on the findings of the current sample. conclusion this preliminary study of the factors that contribute to relationship satisfaction 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culture at a faster rate and to a greathu� h[whqw� wkdq� dgxow� lppljudqwv�� vwxglhv� ri � àuvw� jhqhudwlrq� lppljudqwv� kdyh� ryhuorrnhg� wkh� h[shulhqfhv� ri � the “1.5-generation,” those who immigrate before or during their teen years. the purpose of this study was to examine the relationship between generation level and acculturation among chinese immigrants. the sample consisted of 112 chinese american adults who were recruited from the local chinese community in los angeles county. participants completed a demographic questionnaire and the asian american multidimensional acculturation scale. the result from a one-way analysis of variance indicated that 1.5-generation chiqhvh� $phulfdqv� uhsruwhg� d� vljqlàfdqwo\� kljkhu� ohyho� ri � dffxowxudwlrq� wrzdugv� wkh� (xurshdq�$phulfdq� fxowxuh� wkdq�àuvw�jhqhudwlrq�&klqhvh�$phulfdqv��7kh� olqhdu�pxowlsoh� uhjuhvvlrq� uhvxowv� lqglfdwhg� wkdw� wkh� wzr� lqghshqghqw�yduldeohv³djh�ri � wkh� lppljudqwv�dqg� wkhlu�dffxowxudwlrq� wrzdugv�(xurshdq�$phulfdq�fxowxuh³froohfwlyho\� dqg� vljqlàfdqwo\� h[sodlqhg�pruh� wkdq� ���� ri � wkh� yduldqfh� ri � dffxowxudwlrq� wrzdugv� wkh� (xurshdq�$phulcan culture. this study demonstrated that 1.5-generation chinese immigrants reported critical differences in wkhlu� dffxowxudwlyh� h[shulhqfhv� frpsduhg� zlwk� àuvw�jhqhudwlrq� &klqhvh� lppljudqwv�� 7dnhq� wrjhwkhu�� wkhvh� uhsults highlight the importance of considering 1.5-generation chinese immigrants or their age at their time of immigration in the measures of acculturation in future studies. limitations of this research are also discussed. an increasing number of studies in the past decade kdyh� vkrzq� wkdw� ´àuvw�jhqhudwlrq� $phulfdqµ� lv� dq� ryhuvlpsolàhg� fdwhjru\� iru� fdswxulqj� wkh� dffxowxuative experiences of all immigrants (gonzales & chavez, 2012; hao & woo, 2012; kim & sakamoto, 2010). young immigrants often acculturate to the mainstream culture at a faster rate and a higher level of immersion than adult immigrants because of their exposure to school settings and the media in american society (wu & chao, 2005). however, many studies have overlooked the experiences of the 1.5-generation (huer, saenz, & doan, 2001; hurh, 1990; kim, brenner, liang, & asay, 2003; zhou & bankston, ������e\�jurxslqj�wkh�����jhqhudwlrq�zlwk�àuvw�jhqeration immigrants (chan, hamamura, & janschewitz, 2013; kennedy, parhar, samra, & gorzalka, 2005). this overgeneralization of generational status can potentially minimize or distort the experiences of the 1.5-generation group, and hence disaggregated gdwd�e\�vshflàf�jhqhudwlrq�jurxsv�duh�fulwlfdo�wr�vkhg� light on their unique experiences of acculturation. acculturation acculturation� lv�frpprqo\�ghàqhg�dv� wkh�surfhvv�e\� which new immigrants attain the cultural characteristics of the dominant cultural group (hwang & wood, 2008). acculturation was initially assumed to be a straight-line and linear process whereby individuals surrendered their cultures of origin as they acculturated to new cultures (gordon, 1964). this assumption is referred to as a unidimensional model in which higher acculturation represents an increased adherence and adjustment to the mainstream culture while endorsement of native culture is either a rejection or less acceptance of the new culture (shen, & takeuchi, 2001). later researchers found this assumption of linearity problematic and suggested that acculturation models should allow for the existence of individuals who are immersed in their culture of origin as well as in mainstream culture. discussing asian american populations in particular, for example, berry (1980) conceptualized acculturation in four forms: (a) assimilation, which involves abandoning one’s culture of origin in order to adhere to the majority culture; (b) integration, which involves a bicultural process of maintaining one’s native culture and adapting to the mainstream culture; (c) rejection, which may result from segregation and which involves isolation from the mainstream culture; and (d) deculturation, which involves a loss of identity ties to either cultural group. this bidimensional model hypothesizes an independent relationship between acculturation and enculturation. indeed, recent studies have consistently suggested that acculturation is not a linear process and that there are multidimensional components to the acculturation process (wang & mallinckrodt, 2006). multidimensional models reveal the process of ac-keywords: 1.5-generation, acculturation, age of immigration, asian american, chinese american 119 culturation as a complex practice in which cultural identities can coexist with the mainstream culture. immigrants, unavoidably exposed to two or more cultures, must adapt to cultural differences in terms of language, traditions, values, and other culturally related domains (berry, 1997), and asian immigrants may enculturate to their culture of origin, to mainstream u.s. culture, and to asian american culture simultaneously (chung, kim, & abreu, 2004). given the diversity of behavioral and attitudinal directions between different cultures regarding the process of acculturation, proponents of multidimensional models argue that acculturation should be viewed as a multifaceted and dynamic process that cannot be captured linearly. in a literature review of quantitative empirical research on acculturation and enculturation published over the past 22 years, yoon, langrehr, and ong (2011) found that the unidimensional conceptualization has been the most commonly used model for understanding acculturation, regardless of its limitations, but that an increasing number of researchers have used dimensional or multidimensional models since 2005, suggesting that the trend is shifting away from unidimensional models. the 1.5-generation asian americans the term 1.5-generation refers to individuals who immigrated to the destination country before adrohvfhqfh��7klv�whup�kdv�ehhq�xvhg�wr�vshflàfdoo\�ghscribe asian americans who immigrated to the united states before age 13 (kim et al., 2003; lee, 2001; 6klq� �$oed���������&rpsduhg�wr�wkh�àuvw�jhqhudwlrq� who immigrated as adults and second-generation who were born in the united states, 1.5-generation asian americans were born outside of the united states but lppljudwh�ehiruh����\hduv�ri �djh�dqg�vshqg�d�vljqlàcant period of developmental years in the host society. because of their exposure to u.s. culture at an earlier age compared to adult immigrants, 1.5-generation individuals potentially encounter distinct adjustment and acculturative experiences in comparison to other generations (hurh, 1990). in particular, 1.5-generation individuals may have a higher level of immersion wr�wkh�pdlqvwuhdp�fxowxuh�frpsduhg�wr�wkh�àuvw�jhqeration and/or higher immersion to their cultures of origin compared to the second-generation. for example, huer, saenz, and doan (2001) studied a group of vietnamese american immigrants and found that ����jhqhudwlrq� sduwlflsdqwv� kdg� vljqlàfdqwo\� kljkhu� ohyho�ri �dffxowxudwlrq�wkdq�wkh�àuvw�jhqhudwlrqv��.lp�� brenner, liang, and asay (2003) conducted a focus group with 10 1.5-generation asian american participants and found that the participants reported feeling lghqwlàhg�zlwk�erwk�wkh�8�6��dqg�$vldq�fxowxuhv��wkdw� some participants reported experiences of racism, dqg�wkdw�wkh�(qjolvk�odqjxdjh�eduulhu�zdv�d�vljqlàfdqw� fkdoohqjh�iru�wkhp�zkhq�wkh\�àuvw�lppljudwhg��3dun� (1999), for example, in his qualitative interview study of 1.5-generation korean americans, found that the study’s participants from this generation experienced frustration and anger owing to feeling rejected by their family members and discriminated against by mainstream society. simultaneously, the same participants reported that, since they are familiar with both korean and mainstream cultures, they can connect with people from either culture. in comparison to 1.5 jhqhudwlrq� .ruhdq� $phulfdqv�� àuvw�jhqhudwlrq� .ruhdq�$phulfdqv�rshudwh�pruh�suràflhqwo\�lq�.ruhdq� culture, and second-generation korean americans function better in u.s. culture. consistent with these àqglqjv��+xuk��������irxqg�wkdw�����jhqhudwlrq�lqglviduals possess a high level of socialization both to mainstream u.s. culture and their culture of origin. while some 1.5-generation chinese americans are able to adjust to the mainstream society and maintain connection with their home culture, others may experience different emotional disturbances from the friction between the two cultures and historical traumas. lee (2001) conducted a qualitative study comparing 1.5-generation and second-generdwlrq�ri �+prqj�$phulfdqv��7kh�àqglqjv� lqglfdwhg� that 1.5-generation hmong americans experience more feelings of isolation and discrimination, language barriers, acculturative stress from the new mainstream culture, and the stress from their parents’ efforts to restrain them from being “american.” furthermore, 1.5-generation hmong americans may suffer from intergenerational traumas from the laotian civil war (secret war in laos), which result in secondary traumatic stress disorder symptoms and exclusion from the mainstream society (lee & clarke, 2013). 1.5-generation asian americans can also expelee 120 reconsideration of acculturative experiences rience a sense of a loss of their families and friends, dqg�wkh\�àqg�wkhpvhoyhv�fdxjkw�lq�d�whqvlrq�ehwzhhq� preserving their bond to their country of origin and maneuvering under the pressure to adjust to the new country. moreover, 1.5-generation asian americans whqg� wr� vxiihu� iurp� vwuhvv�uhodwhg� gliàfxowlhv�� wurxble communicating with their parents, and the added social pressure of managing racial discrimination �6xqplq� hw� do��� ������� 7khlu� vshflàf� dffxowxudwlyh� stressors can result in depressive symptoms, poor mental health, and substance use (mossakowski, 2003). despite the numerous studies that have examined the 1.5-generation in various asian subgroups, there is virtually no literature investigating the unique experiences of 1.5-generation chinese americans. chinese culture and the mainstream american culture possess notable cultural differences (fang & wark, 1998). within traditional chinese culture, people ascribe high value to collective identity, family obligation, harmony, and group interdependence (fang & wark, 1998). these values stand in contrast to western individualistic cultural values of autonomy, competition, primacy of personal goals over group goals, and emotional independence (fang & wark, 1998; 7uldqglv���������)dplo\�frqálfw�riwhq�dulvhv�ehfdxvh� members of different generations expect conformity to their norms despite discrepancies in the cultural values among generations (wu & chao, 2005). due to these differences, acculturation theorists propose that chinese immigrants tend to experience acculturative stress and identity struggles because of these clashing cultural values (juang & cookston, 2009). for adult immigrants to the u.s., there is the option to stay in local chinese communities and retain their connections with their culture of origin. suarez-orozco and qin (2006) point out that many chinese immigrant parents are often more removed from american culture than their children, particularly if they work in chinese cultural settings. further, adult immigrants have more resources to travel to their country of origin, maintain connections with family and friends abroad, and immerse themselves in wkh�fxowxuh�ri �wkhlu�àuvw�frxqwu\�wkurxjk�pdvv�phgld�� in contrast, it is inevitable for adolescent immigrants to have regular contact with teachers and peers at school and to become immersed in the mainstream culture in terms of language, food, values, and other domains, while mass media and friends further prompt them to adapt to a new social environment by adopting the values of the mainstream culture (lim, yeh, liang, lau, & mccabe, 2009). in this way, adolescent immigrants tend to assimilate or acculturate in a more rapid and consistent manner and adhere to the values of the new culture more closely than adult immigrants, who have more opportunities to retain their traditional cultural values and practices (uba, 1994), especially when they live in areas populated with chinese residents, such as los angeles and new york. although young chinese immigrants are more likely to adopt norms of mainstream american culture than those of their culture of origin, they are simultaneously and continually exposed to and learn chinese cultural values through interactions with their family members (wu & chao, 2005). these adolescent immigrants are likely to understand and appreciate both mainstream and chinese cultural norms and continuously immerse themselves in both cultures. although discrepancies of experiences between generations indicate the possibility of intergroup yduldelolw\�ri �dffxowxudwlrq�zlwklq� wklv�´àuvw�jhqhudtion” group, no study to date has focused on chinese americans using a community sample. due to this very reason, the main objective of our study is wr� dqvzhu� d� uhvhdufk� txhvwlrq�� duh� wkhuh� vljqlàfdqw� differences in the level of acculturation between ����jhqhudwlrq�dqg�àuvw�jhqhudwlrq�lppljudqwv��6shflàfdoo\��rxu�vwxg\�irfxvhv�rq�dffxowxudwlrq�wrzdugv� the mainstream european american culture and enfxowxudwlrq��zklfk� lv�ghàqhg�dv� wkh� ohyho�ri � lpphusion to the chinese culture of origin. moreover, most studies of acculturation among chinese americans have relied on online surveys. therefore, this project involves the collection of data from a community sample in order to gather information from chinese americans who use the internet infrequently or do not have internet access. our general hypothesis zdv� wkdw� àuvw�jhqhudwlrq� lppljudqwv� zrxog� uhsruw� a higher level of enculturation towards the chinese culture of their origin and 1.5-generation immigrants would report a higher level of acculturation towards the mainstream european american culture. method 121 method participants the participants were 112 chinese american immigrants (m age = 37.9, age range: 18–66; 42.9% males and 57.1% females) who agreed to take part in the study. participants immigrated after 13 years of djh�zhuh�fodvvlàhg�dv�àuvw�jhqhudwlrq�dqg�sduwlflsdqwv� who immigrated before 13 years of age were clasvlàhg� dv� ����jhqhudwlrq��2i � wkh�sduwlflsdqwv�� ������ zhuh�àuvw�jhqhudwlrq�lppljudqwv�zlwk�dq�dyhudjh�djh� of 25.82 years (sd = 10.09, range: 13–40) and 39.3% were 1.5-generation immigrants with an average age of 9.02 years (sd = 3.34, range: 1–12). all particisdqwv�vhoi�lghqwlàhg�dv�&klqhvh�$phulfdqv�zkr�zhuh� born outside of the united states. approximately 61.6% of participants were born in the people’s republic of china, 24.1% were from hong kong, and 14.3% were from taiwan. all measurements zhuh�wudqvodwhg�lq�wudglwlrqdo�&klqhvh�dqg�vlpsolàhg� chinese using back translation. for living situations prior to immigration, there were 22 participants who reportedly resided in a country other than their country of origin before immigrating to the united states. a bivariate correlation was run between their years of residing in that country and each of the aamas vfruhv��dqg�qrqh�ri �wkh�fruuhodwlrqv�zhuh�vljqlàfdqw� measurement acculturation: in this study, i measured acculturation using the asian american multidimensional acculturation scale (aamas). chung, kim, and abreu (2004) have conducted exploratory and conàupdwru\�idfwru�dqdo\vhv�wr�ydolgdwh�wkh�$$0$6�dqg� found that acculturation can be measured in the domains of cultural identity (i.e., values and attitudes), language (e.g., preference for a particular language), cultural knowledge (i.e., knowledge of history and customs), and food preference (i.e., preference for food). in addition to taking into consideration these four domains, the aamas has three unique characteristics. first, it measures the orthogonality of fxowxudo�glphqvlrqv��zklfk�lv�ghàqhg�dv�wkh�lqglylgual’s independent immersion in different cultures and which indicates the level of cultural adherence to both the culture of origin and the mainstream culture. second, the aamas includes a pan-ethnic dimension to measure cultural adherence to asian ethnic groups other than the group of origin. third, it is applicable across multiple ethnicities because it uses the phrase “culture of origin” instead of listing particular countries or using a generic term, which makes it appropriate for many asian ethnic groups. the aamas scale consists of 15 items, one of which is worded in a reverse direction, that measure irxu� grpdlqv� ri � dffxowxudwlrq³fxowxudo� lghqwlw\�� odqjxdjh��fxowxudo�nqrzohgjh��dqg�irrg�suhihuhqfh³ using a six-point likert-type scale, ranging from not very much to very much (chung et al., 2004). in terms of the construct domains of acculturation measured by the 15 items, 10 items measure cultural behavior, three items measure cultural identity, and two items measure cultural knowledge. the aamas consists of three scales: (a) aamas culture of origin (aamasco), (b) aamas asian american (aamas-aa), and (c) aamas european american (aamas-ea). the current chinese version of this instrument has a cronbach’s alpha of 0.90, indicating that it is reliable. the aamas consists of three scales: (a) aamas culture of origin (aamas-co), (b) aamas asian american (aamas-aa), and (c) aamas european $phulfdq� �$$0$6�($��� &urqedfk·v� doskd� frhiàcients, or the reliability of each subscale are found to be 0.90 for the aamas-co scale, 0.90 for the aamas-aa scale, and 0.92 for the aamas-ea scale. procedure the author recruited participants in person in community settings including local restaurants and community centers in the cities of alhambra and san gabriel in los angeles county. these cities were chosen because they contained large populawlrqv�ri �àuvw�jhqhudwlrq�&klqhvh�$phulfdq�uhvlghqwv�� which helped to maximize sample size. after the author introduced the study, participants received a printout of the survey and a pen upon agreement to participate. the completed surveys were put in an envelope that was then sealed. participants were given a chance to draw a lottery for a $100 target gift card as an incentive at the end of the study. lee 122 results � 7kh� jhqhudo� k\srwkhvlv� zdv� wkdw� àuvw�jhqhudtion immigrants would report a higher level of enculturation towards chinese culture of their origin compared with 1.5 generation immigrants and that 1.5-generation immigrants would report a higher level of acculturation towards the mainstream europedq�$phulfdq�fxowxuh�frpsduhg�zlwk�àuvw�jhqhudwlrq� immigrants (see table 1). results showed that there zhuh�vwdwlvwlfdoo\�vljqlàfdqw�gliihuhqfhv�ehwzhhq�jhqeration levels and level of acculturation as measured by the mean of the aamas-ea as determined by one-way analysis of variance, f(1, 17.17) = 18.22, p < .001. in particular, 1.5-generation chinese americans (m = 4.33, sd� �������uhsruwhg�d�vljqlàfdqwo\�kljkhu� level of acculturation towards the european amerifdq�fxowxuh�wkdq�àuvw�jhqhudwlrq�&klqhvh�$phulfdqv� (m = 3.53, sd = 1.05). with a one-way anova to examine the differences in enculturation towards the chinese culture of origin among generation levels as measured by the mean of the aamas-co, there was dovr�d�vwdwlvwlfdoo\�vljqlàfdqw�gliihuhqfh��7kh�àuvw�jhqeration chinese americans (m = 5.02, sd = .75) resruwhg� d� vljqlàfdqwo\� kljkhu� ohyho� ri � hqfxowxudwlrq� towards their chinese culture of origin than 1.5-generation chinese americans (m = 4.43, sd = .89) at p < 0.01. therefore, the main hypothesis was supported. several post hoc analyses also revealed significant results. pearson correlations of the measured variables were obtained, and the results showed negative correlation between the age of immigration and level of acculturation as measured by the average composite score on the aamas (r = -.459, p < .01). moreover, the age of immigration negatively correlated with the subscale of acculturation toward asian americans (r = -.369, p < .01) and the subscale of acculturation toward european americans (r = -.542, p ��������,q�dgglwlrq�wr�wkh�àqglqjv�iru�wkh� subscales, the level of enculturation toward chinese cultures was found to be positively correlated with acculturation toward the generic asian american culture (r = .381, p < .01). additionally, level of acculturation toward the generic asian american culture was found to be positively correlated with acculturation toward european american culture (r = .527, p < .01). to further understand the relationships between the subscales and age of immigration, a multiple regression analysis was carried out to predict the values of acculturation towards european american culture by different independent variables. aamasea scores were regressed on acculturation scores towards asian american culture and age of immigration. these two predictors accounted for more than 40% of the variance in test scores, r2 = .41, which zdv�vljqlàfdqw��)���������� ��������s�������3duwlfxoduly, acculturation towards asian american culture (ơ = .34, p<.001) and age of immigration (ơ=-.49, p<.001) ghprqvwudwhg� vljqlàfdqw� hiihfwv� rq� dffxowxudwlrq� towards european american culture, respectively. discussion this study demonstrated that 1.5-generation chinese immigrants reported critical differences in their acculturative experiences compared to àuvw�jhqhudwlrq� &klqhvh� lppljudqwv�� ,q� frqwudvw� wr� wkh� àuvw�jhqhudwlrq� zkr� lppljudwhg� dv� dgxowv�� wkh� 1.5-generation immigrated at a young age, which the old word file: ����������������� ����� ������������������������ � � ��������� ������� � � � � � � � � � � � � � � � � table 1�. �analysis of covariance by generat�ion on aamas �c�omposite �s�cores (n = 112) � � � � � � � � generation� � mean� � sd� � n� � f� � p� �value� � � � � � � � 1�.0� � 3.53� � 1.05� � 68� � 17.7� � <.001� � 1.5� � 4.33� � 0.82� � 44� � � � � � � � � � �� reconsideration of acculturative experiences 123 gave them greater exposure to american culture by attending school in the united states, interacting with peers from different cultural groups, and speaking english as a their primary language in daily life. therefore, after spending their pre-teen years in chinese countries and then immigrating to the united states as adolescents, the 1.5-generation chinese immigrants may share characteristics with both immigrants and the second-generation (oh & min, 2011). ����������������� ����� ������������� � � � � table 2�.� �summary of intercorrelations for �a�ge of �i�mmigration�:� �m�ain �s�core and �s�cores on the � s�ubscales of aamas� � variables� � 1� � 2� � 3� � 4� � 5� � 1.� �aamas� � —� � � � � � 2. aamas�-�co� � .50�*� � —� � � � � 3. aamas�-�ea� � .62�*� � -�.20� � —� � � � 4. aama�s�-�aa� � .82�**� � .38�**� � -�.527�**� � —� � � 5. age of � immigration� � -�.46�**� � .28� � -�.542�**� � -�.37�**� � —� � note. �—� �= not applicable; aamas = asian american multidimensional acculturation scale; � aamas�-�co = asian american multidimensional acculturation scale, culture of origin � subscal�e; aamas�-�ea = asian american multidimensional acculturation scale, european � american subscale; aamas�-�aa = asian american multidimensional acculturation scale, � asian american subscale�.� � * �p �< .05. ** �p �< .01.� � �� leelee 124 erik erikson’s stages of psychosocial development may shed some light on explaining why the 1.5 generation is more similar to the second-generation wkdq�àuvw�jhqhudwlrq�&klqhvh�$phulfdqv��$v�rqh�ri � the most widely used approaches to explain identity development, erik erikson’s model views develrsphqw� dv� d� olihorqj�surfhvv� dqg�ghvfulehv� vshflàf� experiences in each developmental stage. although the original model was criticized for using mostly caucasian males in the theory deduction (josselson, 1989), a number of contemporary researchers and practitioners found that erikson’s model could be applied with diverse populations (e.g. kropf & greene, 2009; yoon, 2011). according to erikson’s (1966) enculturation model, adolescents undergo enculturation e\�àuvw� hqwhulqj� wkh� identity versus role confusion stage, in which they explore, experiment with, and develop their new values and identity through their relationships with peers and role models (erikson, 1966). for minority adolescents, ethnic identity includes this subjective, choice-driven sense of belonging to a group or culture (phinney, 1990). particularly for 1.5-generation asian americans, the developmental task of acculturation may encompass a struggle between maintaining one’s loyalty to the culture of ruljlq� dqg� àqglqj� d� vhqvh� ri � ehorqjlqj�zlwklq� wkh� host culture (le & stockdale, 2008). in other words, the adolescent period is a particularly crucial time for developing one’s cultural identity by experimenting with and choosing from available cultural values. after growing up in their native countries, the 1.5 generation starts their identity vs. role confusion stage in america. american culture provides them with a multifaceted level of experiences in which they may experiment with different identities, such as those of chinese americans, asian americans, and/or european americans. the 1.5-generation may (a) have to adopt american values and beliefs, learn to speak english, and become accustomed to the american life style in order to manage school and interpersonal relationships; (b) maintain ties with their culture of origin through the local chinese subculture (e.g., chiqdwrzq�� &klqhvh� uhvwdxudqwv��� wkhlu� àuvw�jhqhudwlrq� parents, and their family and friends in homeland; (c) be exposed to a new and unique asian american identity, which encompasses a generic identity of various asian american subgroups. as a result, 1.5-generation individuals may enculturate and/ or acculturate to any one of these identities simultaneously. our project only illustrated that the 1.5 generation is more similar to the second generation wkdq� wkh� àuvw� jhqhudwlrq� lq� whupv� ri � dffxowxudwlrq�� but future research can examine the unique identity development of 1.5-generation chinese americans. � $�txhvwlrq�wklv�vwxg\�udlvhg�lv�zkhwkhu�wkh�ghàqlwlrq�ri �àuvw�jhqhudwlrq�&klqhvh�$phulfdq�lv�dq�ryhugeneralized category that may overlook the distinct acculturative experiences within this subgroup. some uhvhdufkhuv�pd\�djjuhjdwh�wkh�����dqg�wkh�àuvw�jhqhuations together for methodological convenience (e.g., increasing their sample size in the analysis). however, this method does not warrant any theoretical or empirical reason (oh & min, 2011). this overgeneralization can minimize the differences on the degree of linguistic attainment, cultural adaptation, and rwkhu�fkdudfwhulvwlfv�ehwzhhq�wkh�àuvw�jhqhudwlrq�dqg� the 1.5-generation. furthermore, categorizing the 1.5-generation as a distinct analytic category may also test the hypotheses from the assimilation theory (rumbaut & portes, 2001). for example, several multicultural studies on adolescent immigrants have suggested that students who have a high level of acculturation tend to have higher levels of academic motivation and schooling compared to their counterparts (as cited in oh & min, 2011). as the 1.5 generation is likely to have bilingual and bicultural advantaghv�frpsduhg�wr�wkh�àuvw�dqg�vhfrqg�jhqhudwlrqv��wkhvh� advantages may facilitate their academic achievements and even career development (oh & min, 2011). at the same time, other studies have suggested that the 1.5-generation experiences more acculturative stress wkdq� wkh� àuvw� dqg� vhfrqg� jhqhudwlrqv� ehfdxvh� wkh\� duh� lq� wkh�plggoh�ri � wkh�frqálfwlqj�ydoxhv�ehwzhhq� two cultures and may feel rejected by both sides (sunmin et al., 2009). therefore, further studies should consider identifying the 1.5 generation as a distinct group in order to provide disaggregated data in order to demystify experiences of this particular subgroup. � 2xu� àqglqjv� dovr� vxssruw� wkh� lqwhjudwlyh� lghd� that acculturation to the mainstream society is mutually exclusive to the endorsement of the native culture �:dqj� �0doolqfnurgw�� ������� 7kh� àqglqjv� ri � wklv� reconsideration of acculturative experiencesreconsideration of acculturative experiences 125 vwxg\�frqàuphg�wkh�pxowlglphqvlrqdo�qdwxuh�ri �dfculturation in chinese americans that 1.5-generation chinese americans can simultaneously acculturate to mainstream u.s. culture and enculturate to their chinese culture of origin. however, this study has several limitations. with regard to its external validity, a community sample recruited from several community settings may not be representative of all chinese american adults of different ages, educational backgrounds, or geographic regions. there was also a sampling bias in that data was collected in los angeles, california, which is highly populated with chinese americans. chinese americans living in cities with different ethnic makeup may have a very different acculturative experience. for these reasons, applications ri �wkh�àqglqjv�wr�rwkhu�&klqhvh�$phulfdq�lqglylgxals warrant great caution. the small sample size (n = �����ixuwkhu�olplwv�wkh�jhqhudol]delolw\�ri �wkh�àqglqjv� clinical implications $v�wkh�pdlq�àqglqj�ri �wklv�vwxg\�lqglfdwhv�wkdw������ dqg�àuvw�jhqhudwlrq�&klqhvh�$phulfdqv�kdyh�gliihuent acculturative experiences, clinicians should not overgeneralize the identities and characteristics of each generation. level of acculturation is an important factor in therapy because it can impact clients’ values, beliefs, protective factors, family relationships, and many other important aspects in life. when working with chinese immigrants, therapists can assess and raise their awareness of level of acculturation using the domains in aamas (cultural identity, language, cultural knowledge, and food preference). for example, some processing questions could be: how much do you identify with &klqhvh�$phulfdqv"�+rz�surxg�gr� \rx� ihho� derxw� ehlqj� &klqhvh� $phulfdq"�+rz� riwhq� gr� \rx� kdqj� rxw�zlwk�iulhqgv�zkr�duh�&klqhvh�$phulfdqv"�0ruhover, this study also suggests that age of immigration may be an estimation for level of acculturation. from their experiences growing up in the united states, 1.5-generation chinese americans are exposed to many different cultures such as u.s. mainstream culture, chinese american culture, asian american cultures, and other subcultures. this immersion to multiple cultures during a developmenwdo� shulrg� pd\� uhvxow� lq� uroh� frqixvlrq�� lghqwlàfdtion of one primary identity, or development of a multicultural identity. for example, a 1.5-generation chinese american client may identify himself as “asian american” instead of “chinese” or “chinese american.” therapists need to empathize with clients’ possible identity struggles and the related role responsibilities in chinese culture such as the 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(1998). growing up american: how vietnamese children adapt to life in the united states. new york, ny: russell sage foundation. lee microsoft word manuscript 1_cl.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 perceptions of lockdown measures in response to covid-19 among uk university students: a qualitative analysis rocio celeste mejia avila department of psychology, university of westminster alison fixsen department of psychology, university of westminster tom nadarzynkski department of psychology, university of westminster young individuals between 20 and 40 years of age have been reported to drive the spread of covid-19. university students are likely part of this group. perceptions, in comparison to personality traits, account for more variance in compliance to measures during the pandemic. different personal and relational factors influence how individuals evaluate information and may shape how they perceive their surroundings. using thematic analysis and saliency analysis, this study aims to understand how students perceive and experience lockdown, the management of the pandemic, and the implications of lockdown. as a result, data will allow for better comprehension of how these perceptions may translate to a health context and personal behaviors. data drawn from semistructured interviews with 17 university students based in london revealed a strong disagreement with the government’s actions, questioning of lockdown measures, and participants’ reflective processes throughout lockdown. important implications concerning the well-being of the public and policymakers’ efforts to manage the pandemic are discussed. keywords: coronavirus, covid-19, perception, preventive measures, students covid-19 is a disease resulting from a zoonotic coronavirus that was first recognized in individuals in wuhan, china after being exposed to a wet market (perlman, 2020). cases were first reported in late 2019 (li et al., 2020). by march 2020, the outbreak was declared a pandemic by the world health organization (who) after its quick progression (lui et al., 2020). on august 18, the who announced that young people between 20 and 40 years old were driving the spread of the virus, as they may not realize they are infected due to experiencing mild or no symptoms (who, 2020). as of october 27, the united kingdom (uk) was one of the most impacted regions in europe, where 894,690 confirmed cases and 44,998 deaths were attributed to covid-19 within the uk (european centre for disease prevention and control, 2020). covid-19 overwhelmed the entire world and urged the institution of social distancing measures (galea et al., 2020). the spread of covid-19 was reported to be significantly lowered by lockdown (atalan, 2020), but many factors appear to influence adherence to quarantine, such as people’s knowledge about measures and the outbreak, social norms, feasibility of quarantine, and perceived advantages and perils of quarantine (webster et al., 2020). it has been suggested that the ideal approach towards specifying lockdown © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. avila, fixsen & nadarzynski graduate student journal of psychology restrictions is to consider the needs of the community which should fit a particular context and location (nazareth et al., 2020). lockdown measures in the uk, this study’s setting, were not announced until march 23, even though 335 lives had already been lost to covid-19 (iacobucci, 2020). these restrictions mandated that people stay at home unless they required medical care, needed to exercise, or were engaging in essential travel and shopping (davies et al., in press). throughout lockdown, the public was advised to wash their hands frequently, wear a face covering when outside, and practice social distancing (public health england, 2020). on june 1, the public was authorized to meet up outdoors with six other individuals (prime minister’s office, 2020). however, covid-19 cases started soaring late in the summer after restrictions were relaxed (davies et al., in press). although initially the four governments in the uk worked together in their response to the pandemic, each country’s government planned a different response to the lifting of lockdown (institute for government, 2020). the imposition of lockdowns has impacted university students around the world and may have presented them with novel challenges. rather than focusing on the development of skills with a long-term impact, such as effective coping strategies, university students have paid more attention to short-term responses that provide instant relief to the issues presented by the pandemic (charissi et al., 2020). students who revealed a surge in gaming behavior were likely to consider gaming a stress-reliever and a coping strategy which may prove maladaptive (singh balhara et al., 2020). female students were reported to have increased their snacking frequency and caloric intake, while the rates of physical activity decreased in both genders (gallo et al., 2020). in comparison to measures taken prior to the pandemic, mental health trajectories worsened, which was related to unfulfilled social and emotional needs as well as worries associated with the virus (elmer et al., 2020). lockdown measures appear to have tradeoffs, but their adoption is essential. nevertheless, adapting to this novel situation may prove to be overwhelming and confusing. influential factors on covid-19-related perceptions health literacy refers to an individual’s capacity to obtain, comprehend and employ health-related information (batterham et al., 2016), as well as the ability to apply analytical and decision-making skills in health contexts (zhang et al., 2014). the global population has experienced firsthand a continuous flow of complicated and conflicting information regarding covid-19 when it comes to detecting, preventing, and treating the virus (abdel-latif, 2020). given the significant uncertainty surrounding the body of knowledge concerning the virus, it proves troublesome to make an adequate interpretation of covid-19 news and official recommendations (abel & mcqueen, 2020). health literacy is also important as it predicts whether individuals will engage in preventive behaviors in the covid-19 pandemic (gautam et al., 2020). however, health literacy is influenced by personal and relational factors (batterham et al., 2016). to ensure effective health literacy, a better understanding of the factors that might be contributing to people’s assessment of the management of the pandemic, lockdown measures themselves, and individual responses to the experience of the covid-19 pandemic is required. trust concerns the willingness to allow others to represent oneself because one believes they will make sound decisions while considering one’s best interests (beshi & kaur, 2019). the adoption of preventive behaviors in the uk during the previous h1n1 influenza pandemic was found to be influenced by trust in government officials (quinn et al., 2013), and not much is currently known about university students’ general perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology perceptions of trust. unfortunately, the uncertainty surrounding the covid-19 pandemic poses a challenge when trying to build public trust, which in turn affects the perceived severity of the virus and how it is transmitted, willingness to seek information, and the likelihood of adopting social distancing (balog-way & mccomas, 2020). as decisionmaking shifts among authorities managing the pandemic crisis, the potential to affect public trust increases because the public perceives health and the economy as contradictory (bekker et al., 2020). additionally, the backtracking and withdrawal of scientific findings have the potential to impact science-based policies and can result in the politicization of these policies as well (kreps & kriner, 2020). although essential to manage the pandemic, building trust in the government might prove to be an arduous task for these reasons. health beliefs play an important role when fighting the pandemic as well. the british and american public hold major misconceptions about covid-19 (geldsetzer, 2020). misinformation about covid-19’s transmission and exposure can be found online, which increases confusion, virus transmission, and progression of the virus (mian & khan, 2020). conspiracy theories are rampant, and those who support them have been suggested to be more likely to disregard the cautionary advice of public health experts concerning the gravity of the pandemic (miller, 2020). university students have been reported to have increased rates of beliefs in conspiracy theories (patsali et al., 2020). a considerable endorsement of covid-19 conspiracy thinking was identified in england, and such thinking is linked to reduced compliance to government guidelines and reluctance to get tested or vaccinated (freeman et al., 2020). current health beliefs may shape how students perceive lockdown measures. the experiences of university students during lockdown might shape their views on the implications of the pandemic and lockdown. this experience may prove to be an opportunity to foster altruism, especially towards the more disadvantaged. altruistic behaviors in university students have been previously linked with social adaptation and happiness (feng et al., 2020). unfortunately, the covid-19 pandemic has been suggested to worsen health inequalities, and disruption to emergency care services will prove detrimental to marginalized groups (coronini-cronberg et al., 2020). mutual aid groups have become more prevalent as a result of the pandemic (van bavel et al., 2020). however, higher education appears to be a barrier to the teaching of health inequalities (muntaner, 1999), and individuals with better socioeconomic status in england and scotland were found to be less aware of health inequalities and their repercussions (davidson et al., 2006). similarly, mental health awareness must be assessed, as lockdown may be isolating. covid-19 psychological morbidity has been linked to university students and those under 50 years of age, whereas compliance to measures is more likely in individuals over 30 and participants scoring low in depression (solomou & constantinidou, 2020). mental health awareness in british students has previously been reported to be poor, reflecting low levels of mental health literacy (pinfold et al., 2005). nevertheless, positive effects arising from hardship are possible, which is why fostering resilience may help buffer the pandemic’s repercussions (kalaitzaki et al., 2020). in situations where behaviors are prompted by fixed guidelines, such as the covid-19 pandemic, perceptions account for more variance in compliance than do personality traits (zajenkowski et al., 2020). given their novelty and intensity, the covid-19 pandemic, lockdown, and quarantine were perceived as disorienting by greek university students (charissi et al., 2020). risk perceptions appear to be influenced by multiple factors, avila, fixsen & nadarzynski graduate student journal of psychology including the trust individuals have in science and government officials, degree of knowledge about governmental strategy, coming across virus-related information from relatives and friends, and firsthand experience with the virus (dryhurst et al., 2020). in certain circumstances, the public’s opinions concerning social distancing as well as social isolation prove to be contradictory, as these measures are tied to unfavorable economic and social consequences and stigma (williams et al., 2020). increased public collaboration with restrictions may result from studying how individuals perceive governmental responses to covid-19 (lazarus et al., 2020)—in this case, lockdown restrictions. at the time of this study, research exploring the unique perceptions of university students towards lockdown measures, particularly in the uk, is meager. thus, this study aims to explore the perceptions of lockdown measures in university students in england by answering three research questions: 1. what do university students think about lockdown measures being put in place in england as a response to the pandemic? 2. what is students’ appraisal of lockdown measures? 3. what has been the experience of students throughout lockdown after witnessing the consequences of the pandemic? as a result, this study offers insight about the factors influencing university students’ perceptions and how these perceptions might translate to a health-related context and their behaviors. to the best of our knowledge, this is the first study in england exploring perceptions of lockdown measures among university students. methods design a qualitative analysis was chosen, as qualitative research is appropriate for the development of strategies to deliver health messages to specific cohorts as well as to address the reasoning or motive behind a matter (coyne et al., 1993). ethical approval was granted for this study by the university of westminster. participants and recruitment participants were selected according to specified inclusion criteria: english-speaking male and female university students over 18 years of age based in england. recruitment was achieved via purposive and snowball sampling. initially, recruitment proved difficult despite social media usage as is expected in a pandemic. this may have resulted from a lack of incentive or reciprocity. although several students expressed their interest in participating in this study, many were working on their dissertations or studying for exams when the study was conducted. students expressed that completing an interview would possibly disrupt their schedules. students also refused to participate due to the sensitive nature of the topic, as the virus has had numerous biopsychosocial repercussions. snowballing proved to be a suitable sampling approach, as it made recruitment attainable and cost-effective. recruitment stopped after new participants failed to come forward. potential participants were approached in student accommodation facilities in london, which house students from different universities, and provided with an overview of the study. london was chosen as a recruitment location due to its high rates of covid-19 infection and easy access to the diverse student population. students who showed interest were asked to provide their email addresses. after participants participated in semi structured interviews, they were asked to share details of the study with their friends, perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology along with contact information. recruitment and data collection took place between may 31 and june 11, 2020. students residing in student halls were recruited by snowball sampling. these were not friends of the researcher. this recruitment method was the most appropriate when researching lockdown measures and observing social distancing. it is also not the aim of qualitative research methods to provide generalizable sampling, but rather to generate novel ideas and knowledge that could be translated into a quantitative study. we believe that our analysis offers important new findings in the context of the covid-19 pandemic measures and their impact on health and well-being in the student population. data collection a participant information sheet and a consent form were sent and returned via email. a debrief form with contact information of mental health charities was provided after interviews had finished. consent forms were stored separately from interview transcripts. semi-structured interviews were conducted in this qualitative study. the interview schedule was developed after reviewing the literature for factors that appeared to play a role in the management and impact of previous outbreaks, epidemics, and pandemics. questions were kept broad for future contrast and comparison with different cohorts while maintaining the lens of this study’s sample. interviews were conducted via a password-protected phone. consent and interviews were audio-recorded with a password-protected recorder. technical difficulties were often experienced due to network congestion as a result of social distancing. interviews lasted an average of 30 minutes. the complete interview schedule was covered with each participant. interviews were transcribed verbatim in a password-protected computer making use of express scribe (version 10.08) transcription software’s variable speed playback feature. completed transcripts were reviewed with the corresponding audio files to ensure accuracy. potentially identifiable information in transcripts was anonymized, and participants were given pseudonyms. a separate record was kept noting observations of the data throughout the transcription process. this ensured familiarization with the data prior to data analysis. data analysis thematic analysis within an experiential framework was utilized to explore participants’ viewpoints in relation to their assessment and experience of their surroundings (clarke & braun, 2013)—in this case, lockdown measures. thematic analysis was chosen due to its ability to explore differing views, produce unforeseen realizations, and emphasize likeness and contrasts (nowell et al., 2017) as well as provide a thorough and nuanced report (vaismoradi et al., 2013). saliency analysis was employed to examine codes that are relevant but not necessarily recurrent in the data to enhance thematic analysis; this proves useful when findings are novel, improve comprehension of a topic, and have a real-world application (buetow, 2010). the aforementioned allowed the identification and exploration of patterns in students’ perceptions that arose from their experiences of the pandemic. as described by maguire and delahunt (2017), a high standard thematic analysis allows the identification of themes beyond summarizing the data only. this study looked at the latent level of themes by exploring the beliefs and ideas that were considered to shape the surface meanings of the data collected. the focal point of the analysis lay in an in-depth interpretation of the data (maguire & delahunt, 2017). coding and analysis consisted of avila, fixsen & nadarzynski graduate student journal of psychology seven stages: transcription, familiarization with the data, complete coding, generating themes, reviewing themes, establishing and naming themes, and completing the analysis and the write-up (clarke & braun, 2013). codes and themes were revisited to ensure they reflected the content in the data. buetow’s (2010) saliency analysis enabled the evaluation of both the recurrence and the relevance of coded excerpts. the coded excerpts were examined in consideration of these two attributes to decide whether codes should be merged and incorporated into existing themes. consequently, the interrelationships of codes were disclosed, codes were not lost, and themes were not overstretched (buetow, 2010). see table 1 for themes and codes used in data analysis. google docs was used to analyze and organize the data. data extracts were modified to improve readability, but the content remained the same. the analysis of data was discussed between co-authors to ensure reliability. the generated themes and subthemes were validated through discussion until agreement was reached, reflecting the transparency of the analytical method and clarity of the findings. all authors were involved in the data analysis stage. the first author coded the transcripts independently to generate ideas. these were then discussed with the co-authors to reach agreement on the final set of themes. saturation, which specifies that data collection is no longer necessary based on current data collection (saunders et al., 2018), was not reached. as per nelson (2017), the concept of saturation can be problematic in many qualitative studies as there is no consensus about its meaning or application. we tested the process of our concept formation in order to reach agreement on whether the inductive process of thematic analysis was capable of producing novel concepts informing themes and subthemes. in many published research studies, 17 participants is justified as an optimal sample size when the depth and range of ideas have been sufficiently explored. using the criteria set out by guest et al. (2020), we believe we reached a new information threshold that allowed us to formulate the findings we presented. positionality statement from the first author the interview process proved somewhat challenging, as sometimes it proved difficult to hear that some participants were not complying with lockdown measures or obtaining reliable information about the virus. as a health psychology researcher who strictly follows social distancing measures due to her belief in their effectiveness, i found some participants’ perceptions and beliefs shocking. nevertheless, participants were always encouraged to share their honest opinions. listening to completely different opinions than mine proved to be a learning experience, as i separated my feelings from my research. also, as an introspective individual, it sprung to my attention that despite their struggles, participants made sense of their experiences and acknowledged how they had changed after experiencing lockdown. although i had originally thought that all participants would share similar views, as they were all in higher education, conducting research on this topic helped me understand the complexity of individual perceptions. it was fascinating to learn about participants’ perceptions that had not occurred to me before. results a total of 17 interviews were analyzed to understand students’ perceptions of lockdown measures (see table 2 for demographic information). all participants were based in london. ages ranged between 18 and 42. seven participants identified as female and ten as male. participants had different ethnic backgrounds: asian, black, latino, white, and arab. students were studying at both the undergraduate and postgraduate (master’s and perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology ph.d.) levels and belonged to different schools: social sciences, life sciences, business and management, arts, humanities, computer science and engineering, and health sciences. thematic analysis generated three themes: (a) dissatisfaction with the government, (b) views on the effectiveness of lockdown measures, and (c) lockdown-encouraged reflection. dissatisfaction with the government dissatisfaction with the government captures the implicit disagreement with the government’s efforts to contain the virus, its actions throughout lockdown, and the influence of politics over health matters. first, many participants criticized the late response to enact lockdown and how lockdown appeared to be relaxed and lenient in comparison to other countries, which might have resulted in a high number of deaths. maddie further explained that “things should not be taken lightly. . . . they didn’t quite understand the extent of how hard this could go and even though they were advised by people in the who, i think they took their advice casually.” maddie appeared frustrated with what seems like an unresponsive decision by the government. measures in england had been advised rather than enforced. participants noted that guidelines in england are more indulgent than those in other countries, which might play a role in the virus’s impact in england. as alexander commented: for example, france and spain or other countries, you have to have a written permit, like you have to have a certificate that explains why you’re going outside, it’s like there are police, like, everywhere so you kinda get stopped, like you’re gonna be questioned of why you’re outside, and does that happen here? no. although timothy commented that fines were not initially enforced “because [the government] has the trust with the public,” jennifer expressed uneasiness about trusting others to “only meet six people at a time or two, three people at a time outside their household and not meet, you know, their extended families that they haven’t seen for months.” feelings of ambivalence resulted from the public not being monitored after lockdown was relaxed, given that the public’s social needs had been disrupted, which may instill the desire to break social distancing. personal behaviors and perceptions also appeared to be influenced by what was identified as faults within governmental leadership. the motive behind the support to the nhs was questioned as “maybe it was only publicity,” as there seemed to be a lack of evidence to demonstrate the tangible support given to them. further, arthur remarked, “this whole dominic cummings thing. . . didn’t help at all. people were saying if he’s not going to be punished then what’s the point of us doing this, it’s not one rule for one and one rule for another.” in this case, dominic cummings, senior aide to the british prime minister, broke lockdown rules to visit family when his wife had covid-19 symptoms and lockdown measures were strict. growing frustration was identified given that relevant governmental figures were not adhering to the guidelines they provided or being punished for their behaviors, which comes across as a double standard. when assessing the lifting of lockdown, although several participants agreed that it will prevent the downward spiral of the economy, others questioned what this might mean for the public’s health. victoria expressed that “it has stopped being about covid-19, but rather its impact…now everybody is pushed or asked to probably go out there again to live their lives, but we still haven’t dealt with covid-19…the uncertainties have not been answered.” this comment reflects the belief that health is perceived by the government as a secondary problem rather than a priority. participants considered that the virus had been politicized, as governmental influences had permeated vital information related to covid-19. as mason explained, “it seems to be so political and point-scoring… there doesn’t seem to be that much evidence, like, avila, fixsen & nadarzynski graduate student journal of psychology based on anything… it seems to be also a political sort of blame in the natural stuff.” participants observed that rather than making sound leadership decisions and addressing the virus containment, governmental figures seem to focus on blaming others. this constant “blame” in the political realm over the origin of the virus has encouraged the spreading of conspiracy theories. for example, noah, like sarah, believed that the virus “had to be man-made…somebody did something in china, a certain lab or something…either the chinese or the u.s.a., somebody has to answer for it… it’s not just a natural phenomenon.” given the extent of the virus’s impact, individuals believe that it originated as a bioweapon by a powerful nation. politicization of the virus was also identified by several participants in what they perceived as biased news coverage. arthur commented, “there’s gonna be some influence on what they can and can’t report, especially in regards to this conservative government. i don’t think it’s quite overtly, i think it’s quite subtle.” participants stated that the government appears to be pushing political agendas by manipulating what is reported to the public. in return, news sources are lacking neutrality. views on the effectiveness of lockdown measures this theme captures how, even when participants were aware of what self-isolation and social distancing measures involved, the measures’ clarity, feasibility, and efficacy were often put into question. participants’ health beliefs also appeared to be influential when weighing whether the measures were worth adhering to. participants frequently described self-isolation as a state of confinement and the limiting of social contact with people outside their place of residence. nevertheless, only a few participants mentioned that self-isolation must be practiced when individuals believe they have been exposed to covid-19 or might have the virus themselves, suggesting a lack of clarity to the term. for example, harry stated that “self-isolation is when you voluntarily go and cut every physical connection, you know, because of what was happening, with the outside world.” the word “voluntarily” might prove problematic, as self-isolation is no longer about containing the spread of the virus. rather than being the corresponding course of action for this given scenario, self-isolation is perceived as a choice. interestingly, self-isolation also appears to have an emotional facet that disrupts humans as social beings and might even affect mental health after not being able to engage in face-to-face social interaction. sarah commented: i think that self-isolation is a good way to prevent the spread of the virus but it hugely affects mental health because, in this situation, patients are in need of support, talking to people, even if they can talk over the phone, but support is personally more effective. it means nightmare to me because i can’t imagine myself self-isolated. tradeoffs were identified wherein one must choose between preserving physical and mental health. well-being appears to be compromised in both scenarios, which might make a person feel that no course of action is beneficial. self-isolation also seems to induce dread. concerning its feasibility, sophie wondered “if it’s realistic to be practiced by everybody…it’s almost impossible to have no contact at all with anybody, just considering what you need to do to, like, serve yourself and care for yourself.” the feasibility and convenience of self-isolation are questioned, as it would prove disruptive to be completely isolated when one does not have anybody providing for their needs. when it came to social distancing, most participants agreed that, unlike self-isolation, it allows you to interact with others face-to-face as long as you maintain a distance from others. however, a few participants attributed a degree of vagueness to the term. gerald stated, “let’s say if you’re in a bus, there’s no way you can maintain two meters of perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology distance, it’s not possible so, in such situations, i think the definition has to change.” social distancing can only be practiced “wherever possible,” regardless of participants’ desire to follow the measures, because the term is not fitting to every situation. thus, this ambiguity must be addressed. while other participants described social distancing as strictly physical, some perceived it as disruptive in personal aspects. rather than a preventive measure, it appeared to be seen as a political statement by a few participants. sarah explained that “social distancing means that my freedom is restricted because i think it’s my right to be close to any person and i have the right to decide if i want to be close to any people or not.” the belief that the government or others are trying to “oppress” them appears to overpower the need to protect oneself and others from the virus. these participants would prefer to decide for themselves whether they want to engage in social distancing rather than it being an official guideline. as he considered safety, arthur encouraged socially distant interactions. he commented: i mean, visiting is fine. . . as long as, you know, you do the whole standard standtwo-meters-away-from-their-house-and-chat-through-the-window or something like that… what’s the point of having this social distancing…to a point it’s going to ruin your life if you feel lonely. rather than avoiding social interaction altogether, the ideal social distancing approach includes following preventive measures and addressing humans’ social nature. to fulfill their social needs, some participants mentioned technology usage. josh said that the virus “doesn’t transfer through phone calls or zoom calls so that’s why we can resort to those kinda technological channels, otherwise it’s sad but you have to distance yourself.” this signals an active approach to lockdown measures as individuals adapt to the new difficulties posed by the pandemic while remaining safe and attributing the lockdown measures with their corresponding importance. lockdown measures mentioned by participants, who agreed on their validity, included handwashing, sanitizing, wearing masks, social distancing, outdoor exercise once a day, and avoidance of gatherings. nonetheless, participants mentioned reasons why they might struggle to adhere to them. as alexander commented, “in the city, you’re gonna feel claustrophobic in quarantine even if you’re just, like, out on the street because things are so close together so you kinda have this desire to just go out into open spaces and live.” the lack of immediate, available space proves to be overwhelming and anxietyinducing, especially when having to remain inside for a long period. when residing in student accommodation with others who participants were not necessarily roommates with, struggles with social distancing were present. gerald stated, “i make it a point to follow whenever i can… i consider these people to be my family…if one of us catches the virus it’s gonna spread to all of us because we share communal facilities.” two aspects are highlighted in this comment. social distancing has an emotional component, wherein participants might overrule its necessity as it might come off as callous. second, a sense of helplessness is implicitly expressed. similarly, victoria indicated that “with time. . . i knew exactly that social distancing would not help me anyway…that didn’t really mean that i will not get the virus, because standing two meters away from someone doesn’t make you safe.” social distancing cannot guarantee full protection from the virus, which makes one question its purpose. the virus’s potential impact was not always fully acknowledged. in practice, the measures were not perceived by participants as useful or convenient. for instance, ava stated: i haven’t seen evidence that being super aseptic, like, you know, um, religiously sanitizing my hands every two minutes works. that doesn’t work. it reduces your avila, fixsen & nadarzynski graduate student journal of psychology immunity, makes you more susceptible ’cause there is such a thing as being too clean. health beliefs are used to question and disagree with the soundness of measures, despite those measures being issued by an official authority. additionally, ed found masks troublesome, commenting, “wearing a mask all the time causes practical difficulties for me… my breath just gets onto my glasses and… fogs it… i don’t prefer wearing a mask.” the inconvenience of wearing a mask is emphasized and renders the mask an inefficient measure. lockdown-encouraged reflection lockdown encouraged reflection indicates that although the pandemic has had serious repercussions that will possibly remain and prevent a complete return to pre-pandemic conditions, participants came to favorable realizations after witnessing the aftermath of lockdown, which raised awareness to relevant issues concerning individuals and society. the prominence of inequalities in society was identified. those without financial security were frequently cited to be one of the most affected groups, which appeared to shock many, including christina: i don’t have to worry about being able to afford basic things like food and water and things like that, but it’s come to my attention that some people, when out of a job, have to worry about that, like to a great extent and that can be very scary. the pandemic allowed participants to break the distance with this persisting issue as the existence of poverty and its accompanying struggles were revealed and acknowledged by participants. luke emphasized that poverty prevents access to a covid-19 vaccine and health care, which must be made “accessible to everyone… you can’t solve problems like that, much less a global problem like that… basic needs should be accessible to everyone.” this comment explains the complexity of fighting any global crisis, where the less privileged are often forgotten or overlooked, which could potentially perpetuate the crisis, especially if a vaccine is not made available to everyone. gerald commented that “lockdowns have their dignity until and only if people follow it… they’re fed up, people are like, ‘if we’re gonna die, we’re gonna die anyway, we don’t wanna die of hunger.’” participants observed that some individuals found themselves in the difficult position of choosing whether they want to remain healthy or starve to death due to how impractical remaining at home is for some. in turn, people might not follow the measures due to these reasons. noah highlighted the intricacy of lockdown by saying that “those who would depend on, like, hand-to-mouth. . . cannot get any sustenance checks ’cause they’re not on any jobs that qualify for that, but. . . they still need to be in lockdown and just survive until the end of all this.” adhering to lockdown measures may add tremendous pressure for some individuals, as lockdown measures prevent them from fulfilling their most basic needs. the importance of mental health, another valuable need, and the desire to treasure it was often mentioned by participants and reflected upon in these difficult times. as a result of his struggles throughout lockdown, ed now believes in mental health: i always thought of mental health as something that, for example, when people used to complain of panic attacks at night, i used to think they are just being overdramatic. . . until i went through that. i realized how important mental health is… i think that has been one thing that i will definitely take for a lifetime. after experiencing psychological difficulties as a result of lockdown measures, views shifted as the importance of mental health was acknowledged. these experiences appear to have fostered empathy towards those struggling with mental health and taught a valuable lesson to preserve mental well-being even after lockdown. sarah stated that perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology mental health issues “had started before the lockdown, not because of the lockdown, so we have to take care of our mental health and normalize it in lockdown.” this comment highlights how preexisting mental health problems were exacerbated by lockdown and should be considered a relevant problem to target during lockdown. detrimental effects on mental well-being caused by an overload of information were also mentioned by some participants. noah commented, “in recent times, i haven’t been too in-depth because i’m trying to maintain my peace and too much news at a time just brings anxiety.” the constant flow of news reporting the repercussions from the pandemic negatively impacts the well-being of participants, which prevents them from accessing news channels altogether. likewise, victoria stated, “it’s more of what information do i need to have in my mind or store in my mind.” although staying informed is beneficial, well-being was prioritized, and its importance acknowledged. besides valuing mental health, participants discussed a newfound appreciation of life and demonstrated personal growth. lockdown provided more leisure and encouraged them to reflect on their lives. harry commented, “many things are not necessary at all and actually your life can be even better because you can focus on other stuff that are actually important, like personal ruin, like building relationships… ” being materialistic is deemed worthless, whereas building emotional connection and personal growth are priceless and more fulfilling at a spiritual level. gerald stated, “my parents have some sort of underlying health conditions… this lockdown has made me realize their importance in my life even more so now i value the time we spend together.” given the health risk that the virus poses for some families, some realized that their time together is finite, and this made them more mindful about cherishing each other’s company. perceptions appear to have evolved after lockdown. discussion participants expressed a sense of discontent with how the government has managed the pandemic, questioned the effectiveness of the lockdown measures, and voiced the realizations they attained as a product of their lockdown experience. a strong disagreement towards governmental decisions, lockdown measures, and political figures was expressed, resulting in feelings of distrust, uncertainty, and frustration as well as painting a picture of an unresponsive government. when lockdown was first announced, confidence in the government rose, but after the government announced on may 10 that the country would reopen again, confidence levels have remained low (fancourt et al., 2020). after dominic cummings, senior aide to the prime minster, broke lockdown rules, experts stated that the uk mismanagement of this event damaged public health messaging, efforts to build trust with the public, and the public’s adherence to measures (mahase, 2020). this might suggest that participants may feel conflicted on whether the government has their best interests in mind, as they disagree with the management of the pandemic. it may prove useful to improve confidence among the public to focus on what really is important during the pandemic, alleviating its consequences and following advised guidelines. in former pandemics, trust in the government has been linked to adherence to advised health measures (sibley et al., 2020). interestingly, in contrast to prior research, uk individuals with low trust in the government and who considered themselves low risk followed the advised covid-19 measures to a great extent (williams et al., 2020). given that the covid-19 pandemic proves to be a situation unlike others, more research is needed in this area. although they held the government accountable for the repercussions of the pandemic, participants were aware of the purpose of the advised measures but still questioned their avila, fixsen & nadarzynski graduate student journal of psychology effectiveness, feasibility, and clarity, which might have an impact on participants’ engagement in appropriate health behaviors. although it is possible that they held these beliefs due to misinformation, perceiving covid-19 measures as effective did not influence compliance in the uk; however, evidence from hong kong has demonstrated that perceived effectiveness relates to the adoption of measures (atchison et al., 2021). this may be explained by attitudes towards morality and justice. the advocacy for social distancing measures demonstrated by some individuals may showcase their willingness to self-sacrifice for the collective good, including the protection of healthcare services (gollwitzer et al., 2020). it is possible that cultural background may play a role in these perceptions. additionally, perceived barriers decrease adherence rates to preventive measures (shahnazi et al., 2020). previously, participants had reported that social distancing information in the uk was ambiguous (williams et al., 2020), which was also expressed in the current study. perceived barriers can also concern inconvenience and emotional upset (jose et al., 2020), as described in this study. kim and kim (2020) found that the commonalities surrounding varied responses to measures included that measures were not official recommendations, were hard to engage in, and were demanding. therefore, they suggest that behavioral habits and efforts to adopt preventive measures must be considered when promoting strategies to the public. after participants witnessed the consequences of the pandemic and lockdown, they shared the impact these experiences have had on them. participants acknowledged inequalities as a result of the economic impact of lockdown. this has significant implications, as the awareness and positions of the general public contribute to and influence political will (shankardass et al., 2012), which may lead to a development in the health equity agenda, and in turn, reaffirm the public’s perception of the government’s responsiveness and trust. participants also reported a newfound appreciation for mental health and deep introspection about their relationships and materialism. the mental health of uk university students has been reported to be impaired throughout lockdown (savage et al., 2020). however, a positive impression on mental health under similar circumstances has previously been reported after the sars epidemic and was suggested to act as a “cushion” against its repercussions (lau et al., 200). this suggests protective effects to individuals’ well-being during and after the covid-19 pandemic. nevertheless, the lasting impact of the pandemic on students’ well-being remains unknown and requires more research. altogether, in support of batterham and colleagues (2016), participants’ ability to use and apply health-related information appeared to be strongly influenced by personal beliefs, emotions, and experiences that shaped how they perceived lockdown. strengths and weaknesses overall, the findings from this study prove useful to educationists in understanding the impact of the pandemic in university students and what a return to academic facilities might involve regarding their health behaviors and beliefs. findings are also helpful for policymakers, as insight is provided about the factors that must be considered to improve efforts to manage the covid-19 pandemic and future outbreaks as well as to cater to the public’s needs. this is the first study to date that explores the perceptions of lockdown measures in england from the perspective of university students. the study shares a detailed and real-time account of the perceptions of students when they were experiencing lockdown, rather than after the pandemic had ended, which would potentially have influenced the memory of their experiences. given that information on covid-19 is constantly changing, the views and perceptions of individuals might change accordingly, so the context of the study is essential when interpreting the findings. perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology additionally, the sample included international students, meaning that participants have different cultural backgrounds, which may influence their perceptions. previous research has demonstrated that the relationship between negative affect and health varies among cultures (curhan et al., 2014). similarly, individualistic and collectivistic logic influence individual behavior and decision-making (airhihenbuwa et al., 2020), and these factors were not considered in the study. nevertheless, the inclusion of international students was deemed suitable, as this study focused on conducting an in-depth exploration of participants’ perceptions of a shared, distinct phenomenon at a time where all participants were students and resident in london. testing whether cultural factors may influence pandemic-related perceptions is out of the scope of the current study, and a quantitative study may be more fitting to isolate these variables and ensure the representativeness of findings. london is also a relatively liberal area where residents might feel more inclined to question the government’s actions, in comparison to more conservative regions in england prone to agree with the government’s decisions. lastly, the length of interviews varied, as some students were busy with their schoolwork. saturation was not reached. this may be attributed to different reasons. a few participants were unforthcoming, which may have been a result of the sensitive nature of the topic. therefore, participants may have held back their opinions. the small sample size may explain the inability to reach saturation, and more participants were most likely needed. difficulties were also experienced in recruitment efforts (as described in methods). this study’s sampling method (snowball sampling) enabled the recruitment of participants in a timely manner. building rapport with participants was easy, as they had a desire to share their experiences. however, the disadvantages of snowball sampling must be discussed. snowball sampling employs a nonrandom participant selection that is based on the subjective assessments of other participants, whose reasons for referring others may not be readily available to the researcher (johnson, 2005). there may be a potential sampling bias that could influence the results. individuals who did not volunteer to participate may have held different perceptions than those reported. these limitations must be considered when interpreting this study’s conclusions. future research future research should explore the perceptions and experiences of cohorts that were immediately affected by the virus, such as those who experienced financial struggles or were above 65 years of age, as their perceptions might differ. a few students mentioned their struggle to adapt to an online educational environment. it might be worth exploring the impact of the pandemic on educational endeavors. also, the experience of lockdown was speculated to be different in the city than in the countryside by a participant. a future study might explore the relationship between well-being and the availability of immediate space when having to remain at home for long periods as a result of a health crisis. conclusion altogether, participants’ perceptions of the lockdown measures were found to be influenced by their personal beliefs, experiences, and emotions resulting from the lockdown. it appears that participants were not satisfied with government efforts to manage the pandemic, which may have diminished their confidence in the government as an institution. more research in this area is required, as the literature is divided on the effects of low trust in the government on compliance (sibley et al., 2020; williams et al., 2020). the feasibility, effectiveness, and clarity of lockdown measures were questioned, which may be attributed to attitudes towards justice and morality, as well as participants’ perceived barriers. these factors may impact adherence to measures. a heightened graduate student journal of psychology avila, fixsen & nadarzynski awareness of relevant matters was also displayed by participants, which has the potential to foster well-being and change in themselves and the community. finally, this study provided insight into university students’ perceptions, which educationists and policymakers might find useful to improve efforts to manage the current pandemic and its repercussions. acknowledgements the authors declare no conflict of interest associated with the publication, and no significant financial support for this work that could have influenced its outcome. correspondence to this 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(2014). impact of health literacy on medication adherence: a systematic review and meta-analysis. annals of pharmacotherapy, 48 (6), 741-751. https://doi.org/10.1177/1060028014526562 appendix table 1 themes and codes used in data analysis theme: dissatisfaction with the government describes participants’ lack of approval for the government’s decision in the pandemic and lockdown & their influence over health-related matters codes description of content example disagreement with government’s actions reference to the implicit disagreement expressed with the government’s efforts and actions in the pandemic “they could've been a bit serious about this and they could've applied these lockdown measures maybe two or three weeks earlier than they did”[c1] late response from the government reference to how late the government was to put lockdown measures into place in comparison to other countries “uk was so late in applying or enforcing the lockdown and now, they are late as well in easing down the lockdown, erh, because erh europe countries have started to already open shops” relaxed lockdown measures reference to how permissive lockdown measures are in england and the negative impact it has led to “it could've been more restricted, like more strict, um, earlier on because it's been a bit lax, like more lax than other countries so obviously there have been more deaths” government’s enforcement of measures reference to how lenient the government appears “especially compared to my home country, it's a lot more relaxed so i don't know if it was necessarily perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology with the enforcement of measures, or lack thereof responding to the scale of the pandemic” importance of effective governmental leadership reference to governmental figures not acting accordingly to the best interest of the public “had it not been the prime minister himself eventually got affected by the virus, certain things might have never been put in place” misinformed decisions from the government reference to how the government did not give the pandemic enough importance as they should have done “it was their inefficiency, they could've done so many things beforehand but didn't do it” politicization of the virus reference to the virus being used to push a certain political agenda “a lot of the political leaders sort of mainly between america and china trying to blame, particularly america trying to blame china for the virus and also sort of criticizing the world health organization” acknowledgment of bias in news reference to participant’s awareness of the lack of neutrality in the news which is influenced by politics “it's quite difficult but um you wanna try and get the most neutral so that you can transform your own ideas in something that's not sort of clouded by such nationalistic sentiment or so much propaganda” theme: views on the effectiveness of lockdown measures describes participant’s criticisms towards the efficacy and practicality of preventive measures as well as the measures’ lack of clarity codes description of content example facets of selfisolation reference to participant’s interpretations of selfisolation which included perceptions outside of the standard definition “it means you are isolating yourself from other people but emotionally, nobody wants to do that, that's against our human nature.we as humans were made to be in community” facets of social distancing reference to participants’ interpretations of social distancing which included “that goes broader than just being physically separated, in my case it's more like, also, emotionally separated” avila, fixsen & nadarzynski graduate student journal of psychology perceptions outside of the standard definition humans as social beings reference to the disruption that lockdown measures have imposed in people’s social lives “you have to be so mindful, if you are going to social distance. in a way, it's such, again, an unnatural thing, like who talks to someone two meters away?” compliance to an extent reference to participant’s admissions that they would not always follow lockdown measures and their justifications for doing so due to different factors “i felt like if i needed to wear [a face mask] around them that i was going to be wearing it anywhere except for inside my room but i just felt like it was more because it was a burden” ‘guideline’ provides choice reference to participants’ statements where they only followed the measures in certain scenarios after making their personal assessments “i haven't seen evidence that supports myself as an asymptomatic and an infected person using a mask so i haven't used a face mask” misunderstanding of the virus reference to the lack of awareness of the extent of impact of the virus “ah social distancing, i think if we wear a face mask, it doesn't matter if we are in social distance or not” theme: lockdown encouraged reflection describes how participants experienced advantageous realizations that may potentially benefit them and society as a whole codes description of content example awareness of inequality reference to how apparent inequalities have become as a product of lockdown “the people that are most affected are gonna be those who are most marginalized, the lowest income, people from groups who already have the most limited access to healthcare” impact dependent on unemployment and finances reference to how the impact of the virus does not only concern health but also finances “getting people back to work i think was quite good because a lot of people also lost their jobs” no financial support for the poverty stricken reference to the lack of support to those who are disadvantaged in our society “because of lack of shelter and because it makes [those who are homeless] more prone to acquiring the virus so being out in the open just makes them more perceptions of lockdown measures in response to covid-19 among uk university students graduate student journal of psychology vulnerable to catching the disease” awareness of mental health importance reference to participants’ beneficial discussion of mental health and its significance “like i said, trying to use technology as much as possible to make sure that i am still in contact with other people which is very important for my mental health” lockdown encouraged introspection reference to how participants reflected upon their lives and values throughout lockdown “for me in a personal level, i've had a lot of time to spend on myself which i never used to do earlier and i've had lot of time to introspect my own life, introspect what i'm doing” newfound appreciation of connection reference to the realization of how meaningful and important relationships are “i think people are gonna be more considerate of each other. i think people are gonna enjoy hugs more often, people are going to really value each other and not take for granted physical touch” newfound appreciation of life reference to participants’ acknowledgment of having prioritized unimportant, materialistic things “they might find that there's generally more to life than full shelves of clothing” avila, fixsen & nadarzynski graduate student journal of psychology table 2 demographic information of university students participating in the study name age gender ethnicity course type school of alexander 18-26 male white postgraduate arts arthur 27-35 male white postgraduate social sciences ava 36-42 female black postgraduate health sciences christina 18-26 female asian undergraduate social sciences ed 27-35 male asian postgraduate health sciences gerald 27-35 male asian postgraduate computer science & engineering harry 18-26 male latino undergraduate arts jennifer 27-35 female black postgraduate social sciences josh 18-26 male asian postgraduate business & management luke 18-26 male asian undergraduate computer science & engineering maddie 18-26 female asian undergraduate social sciences mason 18-26 male white postgraduate social sciences noah 18-26 male black postgraduate computer science & engineering sarah 27-35 female arab postgraduate life sciences sophie 18-26 female arab postgraduate humanities timothy 27-35 male arab postgraduate computer science & engineering victoria 27-35 female black postgraduate life sciences 25 the mental health of indonesian male breadwinners: family harmony as a moderator between perceived stress and psychological well-being in recent generations, the topic of mental health is more prevalent than ever before. there is a rise in mental health acknowledgment as an integral part of overall health (mance, 2022). be that as it may, there is surprisingly very little research done on the mental health of men. this may be caused by societal views of men that expect them to adhere to harmful outdated gender roles prohibiting them from showing any kind of “weakness” to be strong breadwinners (dyer, 2021). in the book “troubled men”, discussing the psychology, emotional conflicts, and therapy of men (fine, 1988), men are noted to be infamously reluctant to openly express their feelings, especially if they are characteristically tender feelings. men do not easily communicate with others because they are often regarded as the “strong and silent type.” this is most likely due to the mainstream ideology of masculinity (brannon, 1976), which dictates that men must avoid anything that seems remotely feminine; men must seek out respect, especially as breadwinners; men are expected to always remain calm by being the “strong and silent type” (as aforementioned); and men must have the virtue of risk-taking and adventure, even to the point of violence when need be. taken from a book on male psychology (levant & wong, 2017), these ideologies are products of sociocultural beliefs about what it means to be a man, which are then appraised within the community. although these pillars of masculinity could certainly lead to harming others and oneself, men may still adhere to such unhealthy gender roles to avoid social punishment and gain social rewards for being masculine (p. 140). the same set of norms that push for self-reliance and emotional control make it challenging for men to seek help or even acknowledge their struggles. according to erikson’s theory of psychosocial development, the age of 30 to the late 40s would be the phase of generativity vs. stagnation, which is considered to occur during middle adulthood (malone et al., 2016). this stage starts when the individual has established their own family and career. these individuals strive to do well in both work and family settings to ensure their future success. this period is described as a time when an individual is satisfied with family life and occupation amongst other life milestones, but because of this, they also face the burden of financial obligation when they have yet to secure a high income while facing crucial family-related choices. a review of the assumptions surrounding men’s mental health (smith et al., 2016) explains how there is an issue of men being less open to talking about psychological problems due to negative societal stereotypes. therefore, they might downplay their struggles and escape through addiction or unsafe practices, causing practitioners to erroneously recognize symptoms for a different mental evaluation. a more recent study (shepherd et al., 2023), adding to smith et al.'s (2016) theories, posits that masculine socialization these days, despite the increasing attention directed to mental health, men are typically placed on the back burner of these discussions due to the social stigma that men are supposed to be strong breadwinners. multiple studies have found a negative association between perceived stress and psychological well-being, ergo, it is important to expand these studies to include the well-being of male breadwinners. other literature has also suggested that the presence of a harmonious family might help buffer the effects of stress on well-being. therefore, this study consisting of 304 participants aimed to understand the relationship between perceived stress and psychological well-being, and whether family harmony can moderate this relationship in male breadwinners. results from linear regression models found that perceived stress predicted psychological well-being in male breadwinners (r2 = .30, p < .01), and the moderated regression models also showed family harmony to be a significant moderator between perceived stress and psychological well-being in male breadwinners (r² = .40, β = -.04, p < .001, 95% ci [-.06, -.02]). aside from adding to the body of research on stress and family psychology, the practical implications of this study highlight the need for family-centered therapy and workplace policies that support the well-being of male breadwinners. keywords: male breadwinner, perceived stress, psychological well-being, family harmony agathea maybelle budyantara1 & naomi soetikno2 ¹master's degree psychology (science) study program, tarumanagara university, jakarta ²master's degree psychology (profession) study program, tarumanagara university, jakarta graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 26 the mental health of indonesian male breadwinners and masculine hegemony are partly responsible for the men’s reluctance to reveal their mental distress. they described masculine socialization as the learned values and behaviors from other men, which typically favor “aggression, stoicism, individuality, and self-sufficiency” (p. 1). meanwhile, masculine hegemony was identified as the cultural expectation for men to be immune to emotions and vulnerability. this mental health crisis for men should warrant a state of alarm because deteriorating mental health can lead to the development of mental disorders, which then increases the risk of suicidality (yeh et al., 2019). hence, if that is the picture of poor mental health, then the perspective of good mental health would not only be the absence of mental illnesses but also a state of psychological well-being. in itself, psychological well-being is conceptually defined as the state of an individual thriving in every aspect of human life despite challenges (keyes et al., 2002; ryff, 1995). in this generation where the fight for equality is higher than ever before, men who are stereotypically called to be breadwinners are facing a dilemma. they would like to do things that are more meaningful to them, but they simultaneously wish to provide for their family financially (stone, 2022). despite the increasing number of women joining the workforce, and even replacing their husbands as the family breadwinner, there are still some families who uphold the male-breadwinning model. the combined feeling of inadequacy faced by male breadwinners with the burden of societal gender roles creates the expectation that they should be all-capable breadwinners, leading to feelings of stress. every individual has different thresholds for stress; what may be considered a normal occurrence for one may be a source of distress for another (selye, 1978), which is why stress is subjective to the perceiver. perceived stress is conceptually defined as the subjective responses of individuals when faced with stressful occurrences (cohen et al., 1983). according to a study by casipong et al. (2022), breadwinners were found to be sensitive to social support, especially from their family members. although they are undoubtedly motivated by their love for their family to work hard, they are still susceptible to work-related stressors and challenges. their stress could also be exacerbated by their sense of responsibility to provide for their family. however, having their family as the closest connection to receiving support can enhance their subjective well-being despite facing stress. even in the face of pandemic stress, engaging with family members managed to buffer the effects of stress (bates et al., 2021). generally, relationships hold the most pivotal role in shaping well-being in multiple cultures (delle fave et al., 2016, as cited in demirci, 2021; wissing et al., 2019). another definition of psychological well-being is to flourish (diener et al., 2010, as cited in demirci, 2021), and harmonious family relationships have frequently been found to facilitate that (bethell et al., 2019; kaya & önder, 2023; wang et al., 2019). the concept of family harmony itself could be defined as a family relationship with its own identity built on communication and tolerance to resolve conflict, while also enjoying quality time spent with each other (kavikondala et al., 2016). interdependence and this interpersonal harmony are essential for people’s well-being in eastern societies (demirci, 2021), and it has been recorded decades ago (kwan et al., 1997). although indonesia is located in southeast asia, its culture of valuing interpersonal relations is still aligned with most eastern countries. while studies on stress and family relations are scarce, findings by kavikondala et al. (2016) suggest that family harmony has a buffering effect against stress, which could preserve the individual’s well-being. hence, it has become the main focus of this research. current study this study observed the breadwinner male population. as the topic previously touched upon, male breadwinners face their own unique set of problems (crowley, 1998), but this issue is rarely discussed due to misconceptions surrounding men’s mental health (smith et al., 2016). selye (1978) wrote that stress is an inseparable part of life; any emotion and activity could be a source of stress. however, it is how an individual adapts to stress that impacts their overall well-being. on that account, there was a more prominent gap on whether family harmony can buffer the effects of perceived stress to keep it from affecting an individual’s overall well-being, leading to several research questions for this study: 1) could the perceived stress of the male breadwinner predict their psychological well-being? 2) could family harmony moderate the relationship between perceived stress and psychological well-being in male breadwinners? 27 budyantara & soetikno relationships. one interesting finding from a study on dual-earner families (schwartzberg & dytell, 1996) pointed out the significance of family matters in predicting fathers’ psychological well-being. although both work and family stressors could predict fathers’ depressive symptoms, the study highlights how one significant predictor was a “lack of spousal support” (p. 216). they also discovered an unexpected negative relationship between the support from their child and the fathers’ depression, wherein “the greater the reported lack of support from children, the lower the level of reported depression.” (p. 216). family psychology is grounded in the theory that families are structured by relational systems that interact with their environment, such as demographic cultures (thoburn & sexton, 2015). within asian contexts, family harmony could be tied to the relational models theory and confucian ethics (chuang, 2005). it was also concluded that the communal sharing model is fundamental for family relationship quality. in chinese families, the facets of family harmony partially draw from the family strengths model while adding traits of forbearance and family identity (kavikondala et al., 2016). according to an indonesian perspective, family harmony is marked by a general sense of happiness and overall satisfaction when there is a lack of tension and disappointment (gunarsa, 2002). alternatively, another indonesian perspective believes that family harmony is achieved through the synthesis of both husband and wife as a married couple, basing their relationship on sincerity and shared values even in the face of differences (walgito, 1991). a study by demirci (2021) conducted a correlational analysis of the relationships between “family harmony, interdependent happiness, harmony in life, and flourishing.” their results indicated a positive relationship between all the variables, consistent with past findings. in a study exploring the facets of well-being in china (wang et al., 2019), family harmony was strongly associated with the happiness, meaning, purpose, and social dimensions of well-being. the participants reported that family harmony made them feel satisfied and valuable; it also increased their worldview optimism. a qualitative study analyzing the factors determining people’s well-being also included family harmony for the participants (xu & liu, 2023). meanwhile, ruptured family relationships were correlated with decreased life satisfaction and heightened depresresearch question 1: could the perceived stress of the male breadwinner predict their psychological well-being? although there have been numerous definitions of stress, cohen et al. (1997) have consolidated the various perspectives on stress to define it as a process when demands of stressors exceed an individual’s capabilities, resulting in adverse physical and mental health risks for an individual. prior to this definition, cohen et al. (1983) developed a global measure of perceived stress based on the subjective responses of individuals towards specific stressful occurrences. in the transactional model of stress and coping, lazarus and folkman (1984) discovered that a person’s interpretation or reaction towards the stressor has the most significant impact on their stress levels compared to the stressful situation itself. the broad understanding of stress is a person’s state when an event exceeds their adaptive resources to cope (monat & lazarus, 1991). therefore, the primary appraisal of the model is to assess how the event will affect a person’s psychological well-being. psychological well-being is a broad construct encompassing all quality-of-life dimensions (eiroa-orosa, 2020). ryff (1995), the developer of the six-factor psychological well-being model, described psychological well-being as “a breadth of wellness that includes … self-acceptance, positive relationships with other people, autonomy, environmental mastery, purpose in life, and personal growth” (p. 99). many studies have found that perceived stress could have damaging effects on psychological well-being (see ceri & cicek, 2021; chen et al., 2022; nazir et al., 2020). even though it has been proven that stress is inversely related to psychological well-being, prior studies typically center specific professions. therefore, this study would like to add a new perspective in which the focus would be the general perceived stress of male breadwinners and its relation to their psychological well-being. h1: perceived stress predicts the psychological well-being of male breadwinners. research question 2: could family harmony moderate the relationship between perceived stress and psychological well-being in male breadwinners? while stress initially seems to be closely related to psychological well-being, many studies have found that there is more than meets the eye in their 28 the mental health of indonesian male breadwinners ing, and family harmony. data collection was conducted in the jakarta metropolitan area of indonesia through an online survey. since this study was conducted online, there were no tools needed aside from a working device to fill in the questionnaire for the participants to utilize at their disposal. participants participants were mainly recruited through social media platforms and word-of-mouth; this included messaging app broadcasts, social media posts, and referrals. there were 304 participants in total. criteria for participants included: adult males between the age of 30-40 years old, married with children between the age of 3-12 years old, act as the breadwinner of the family, live within the jakarta metropolitan area, and live with their nuclear family (no extended family members in the household). the age restriction (30–40 years old) was chosen because this period aligns with key developmental stages in adulthood, where men typically face peak career demands and family responsibilities. additionally, focusing on the jakarta metropolitan area hopes to limit extraneous variables from living conditions, family and work cultures, and commuting times. this restriction on the children’s age of the participants is due to the consideration that parents have usually adapted better to new parenthood after their child reaches the age of three. furthermore, the indonesian education system typically spans from 3 to 12 years old, equating to a child’s school age. beyond 12 years old, children typically begin adolescence, and this age group has different sets of problems for the parents to handle. the geographical limitation was decided with the consideration that the jakarta metropolitan area is the center of business trade in indonesia, with the largest working population in the country. these specific criteria aimed to minimize confounding variables possibly affecting the study. measurements demographic questionnaire the demographic questionnaire included questions to assess their age, city address, commuting time from their workplace to their home, marital status, occupational status, income range, spending range, wife's occupational status, percentage of wife’s earnings to total household income, number of children, the age of the youngest and oldest child (if they only had one child, they could state the same age as their youngest). sion in older chinese parents (chen & zhou, 2021). however, it is important to note that although prior studies have focused on family harmony as an antecedent to well-being, some have found poor well-being preceding family harmony (ni et al., 2019). in this case, it is not a matter of causality but merely a trend in research of one being put first over the other. keeping in mind that family harmony is especially related to psychological well-being in asian contexts (see chen & zhou, 2021; demirci, 2021; kaya & önder, 2023), the combination of these concepts creates a reason to believe family harmony could play a role in the relationship between perceived stress and psychological well-being. this assumption is backed by the stress-buffering hypothesis (cohen & wills, 1985), which states that social support could act as a stress buffer because it filters a person’s reaction to stress. such support may lessen the harmful impacts of stress by providing resources to deal with the problem or by putting it into the perspective of a bigger picture. in terms of emotional support, it could counterbalance the threats of stress against self-esteem by serving as a reminder to the person of their worth. however, instead of focusing on social support, this study will highlight the social environment instead, namely the family. within family-oriented cultures, individuals rely on their families as their central source of emotional support when they face work-related stress (fiorilli et al., 2019). the strongest reference point for this study would be the conclusion drawn from kavikondala et al. (2016), where a strong negative correlation between family harmony and depressive symptoms, yet a weak correlation with stressful events was found. this implies family bonds could serve as a safety net against stressors because the bonds are independent of the stressors. additionally, the interaction between family harmony and stress was the link to explain depressive symptoms. therefore, the researchers proposed family harmony might act as a buffer to keep the individual from developing depressive symptoms in the face of stress. h2: family harmony moderates the relationship between perceived stress and psychological well-being in male breadwinners. method a non-experimental quantitative moderation analysis was used for this study, assessing three variables: perceived stress, psychological well-be29 budyantara & soetikno their consent by ticking the box at the very end of the page. afterward, they were given a demographic questionnaire to assess their eligibility for participation. if participants fulfilled all the criteria for this study, they were directed to the next page containing the first set of questionnaires. if they failed to meet even one of the criteria, they were automatically directed to the end of the form with the description that they did not fulfill the criteria for this study. participants who were directed to the next page of the study were presented with the pss first, followed by the pwbs second, and then the fhq last. after participants had finished answering all the questions on the final page, they were thanked for their participation, and a link was included for them to share with other people. the entire sequence was expected to be completed within 20 minutes or less. results this study aimed to study the relationship between perceived stress and psychological well-being, and whether family harmony moderates this relationship in male breadwinners. the measurements used in this study were tested for reliability and were found to be reliable in all dimensions. the perceived stress scale (pss; cohen et al., 1983) has a cronbach’s α of .83, the psychological well-being scale (pwbs; ryff, 1989) has a cronbach’s α of .82, and the family harmony scale (fhs-24; kavikondala et al., 2016) has a cronbach’s α of .83. a total of 304 participants were included in the data analysis. based on their demographics, most of the participants were between the ages of 33 and 35 years old (43.8%), lived in jakarta (57.2%), spent 30 – 60 minutes for work commute (76.3%), were high-school graduates (59.9%), with bachelor’s graduates numbering at (35.2%), worked as private sector employees (87.5%), earned rp 5.000.000 – rp 10.000.000 a month (69.7%) and spent as much as that amount (60.5%), and had housewives (56.9%, instead of working wives) as well as two children (54.6%). this study hypothesized that perceived stress predicts the psychological well-being of male breadwinners; and that family harmony moderates the relationship between perceived stress and psychological well-being in male breadwinners. the data analyzing procedure was done through process by hayes using the moderated regression analysis (model 1). perceived stress (dependent variable) perceived stress was measured by the perceived stress scale (pss; cohen et al., 1983), which had been translated into indonesian (nadyastuti et al., 2021). there are a total of 10 items in the scale, and none of the items are reverse-scored. participants indicated their answers using the 5-point likert scale with 1 being "never" and 5 being "very often." perceived stress is operationally defined as the total score on the pss, wherein higher scores indicate greater perceived stress. the translated version of the pss had high reliability with the value of cronbach’s α scoring at .91. psychological well-being (independent variable) psychological well-being was measured by the psychological well-being scale (pwbs; ryff, 1989), which had been translated into indonesian (salamah et al., 2023). there are 42 items across six dimensions (autonomy, environmental mastery, personal growth, positive relations, purpose in life, and self-acceptance) in the scale, with 20 items reversed-scored. participants indicated their answers according to the 7-point scale with the lowest being "strongly disagree" and the highest being "strongly agree." psychological well-being is operationally defined as the total score on the pwbs, wherein higher scores indicate greater psychological well-being. the translated version of the pwbs had high reliability with the value of cronbach’s α scoring at .91. family harmony (moderating variable) family harmony was measured by the family harmony scale (fhs-24; kavikondala et al., 2016), which had been translated into indonesian (fauziah et al., 2021). there are 24 items across five dimensions (communication, conflict resolution, forbearance, family identity, and quality time) in the scale, with none of the items reverse-scored. participants could indicate their answer according to the 5-point scale with 1 being "strongly disagree" and 5 being "strongly agree.” family harmony is operationally defined as the total score on the fhs-24, wherein higher scores indicate greater family harmony. the fhs-24 had high reliability with the value of cronbach’s α scoring at .91. procedure this study used google forms as a platform to gather responses from the participants through questionnaires. upon clicking the link provided in the study announcement, participants were given an informed consent form where they could indicate 30 the mental health of indonesian male breadwinners ny (fh = 103.30), yet psychological well-being levels were consistently higher in the former compared to the latter. the same goes for the group reporting moderate family harmony (fh = 111.41), which has the slope placed between the high and low groups. this trend was observed to be the same across all the dimensions of psychological well-being and family harmony. this suggests that when family harmony is lower, the impact of perceived stress on psychological well-being is stronger. as family harmony increases, this effect weakens. therefore, it can be concluded that family harmony significantly moderates the relationship between perceived stress and psychological well-being. however, the interaction pattern stays the same, the only difference being the intensity of the relationship. discussion the findings of this study showed that perceived stress predicts psychological well-being, and family harmony significantly moderates the relationship between perceived stress and psychological well-being. this supported both hypotheses, wherein perceived stress predicts the psychological well-being of male breadwinners (h1), and family harmony moderates the relationship between perceived stress and psychological well-being in male breadwinners (h2). therefore, the results are consistent with past literature that found perceived stress could affect psychological well-being (see ceri & cicek, 2021; chen et al., 2022; nazir et al., 2020). furthermore, the findings from this study supported kavikondala et al.’s (2016) implication that family harmony has a buffering effect against stress, protecting an individual’s psychological well-being. however, their implication was drawn based on stressful events being weakly correlated with family harmony. in contrast, this study found family harmony to be significantly correlated with perceived stress. that being said, it is still in line with another study that found family support to be a protective factor that moderates the negative effects of stress, while also being significantly negatively correlated with it (tselebis et al., 2020). the transactional model of stress and coping (lazarus & folkman, 1984), one of the theoretical bases of this study, explains how stress affects well-being since it depends on the cognitive appraisal and coping resources in response to stress. it explains why the results of this study align with past literature despite being assessed on an unexplored demographic based on the categorization of the participants in table 1 (see appendix a), it was found that most of the participants in this study reported low perceived stress (98.0%), high psychological well-being (88.8%), and high family harmony (98.7%). classical assumption tests were conducted for normality, linearity, heteroscedasticity, and multicollinearity to determine the relationship between variables. normality tests showed that the residual data (kolmogorov-smirnov = 1.29, p = .101) were normally distributed. linearity tests showed that the relationship between perceived stress (p < .01) and family harmony (p < .01) with psychological well-being was linear. there were also no signs of heteroscedasticity based on the tests on perceived stress (p = .832) and family harmony (p = .090), neither were there signs of multicollinearity for both perceived stress and family harmony with psychological well-being as the dependent variable (tolerance = .710, vif = 1.408). based on the correlations in table 2 (see appendix b), psychological well-being has a statistically significant negative correlation with perceived stress (r = -.545, p < .01) and a statistically significant positive correlation with family harmony (r = .504, p < .01). however, perceived stress was also found to be significantly negatively correlated with family harmony (r = -.538, p < .01). additionally, linear regression models for perceived stress and psychological well-being also showed a significant linear correlation (r2 = .30, p < .01), which indicates that perceived stress predicts psychological well-being with a 30% rate. table 3 (see appendix c) shows the analysis results through a moderated regression model with process© (hayes, 2013). the model included perceived stress and family harmony as predictors of psychological well-being. the moderated regression model was found to be significant with r²= .40 (p < .001). the effect of family harmony interacting with perceived stress on psychological well-being is shown to be significant (β = -.04, p < .001, 95% ci [-.06, -.02]). figure 1 illustrates how all three levels of family harmony (low, moderate, high) show a downward trend, indicating a negative relationship between perceived stress and psychological well-being at all levels of family relationships. the relationship between perceived stress and psychological well-being in the group reporting high family harmony (fh = 119.52) has the same model as the group reporting low family harmo31 budyantara & soetikno the answers due to self-report bias was possible since this study utilized self-report questionnaires. coupled with the tendency for indonesians to highly value family relations (serrato & melnick, 1995), samples might have wished to rate their family in a positive light, leading to answers based on social desirability. limitations in this study include the exclusivity of male breadwinners who are at the age of peak productivity. therefore, generalizability needs to be taken with caution. husbands in general, especially those who are non-breadwinners, may result in different steepness in the graph between perceived stress, psychological well-being, and family harmony. the location of this study also focuses on the jakarta metropolitan area, which is undoubtedly an urban area. populations in rural areas might also yield different results considering the dissimilarity in culture, occupations, and limitations to structural and digital developments. in addition, one of the criteria for participation was that men had to live with their nuclear family without any extended family members in the household. therefore, the results do not reflect individuals who are considered the sandwich generation. this refers to “a generation of people who are caring for their aging parents while supporting their children” (merriam-webster, n.d.), a trend that is on the rise in indonesia (natalia, 2024). similarly, the age restriction for children only accounts for individuals with preschool to schoolage children, a developmental period that contrasts with newborns and adolescents. further limitations of the study’s design include the aforementioned potential for self-report bias. therefore, future research could consider exploring mixed-method approaches to provide a more comprehensive understanding of male breadwinners' experiences. future studies on this topic could enhance the generalizability of these findings by expanding the population to include breadwinning men of all ages, rather than limiting to a decade age span. it would be interesting to note how perception of family importance relates to their well-being depending on how far along they are in their career path. addressing the geographical limitation, especially focusing on the difference in cultures, rural occupations (e.g. fieldwork, handicrafts, etc.), and the current state of developments, would surely enrich the perspective on this subject. moreover, their involvement with their chil(i.e. male breadwinners). the role of family harmony as a moderator is grounded in the social buffering hypothesis (cohen & wills, 1985), another one of the theoretical bases of this study, which posits that social relationships could mitigate the negative effects of stress. although research focusing on the role of family harmony as a moderator toward stress is nonexistent, there is a high chance that this study could be generalized to other populations. however, variance might occur due to cultural differences between collectivists and individualists (triandis, 1995). while this study highlights family harmony as a key moderator between perceived stress and psychological well-being, an alternative explanation could be the role of economic security in shaping well-being. a stable income may reduce financial stress, provide a sense of achievement, and allow men to support their families, reinforcing their role as successful providers. this aligns with erikson’s psychosocial theory, where middle adulthood is characterized by generativity; in this context, the ability to contribute meaningfully to one’s family. given that the study was conducted in the jakarta metropolitan area, indonesia’s largest economic hub, participants likely have greater economic opportunities compared to those in smaller cities or rural areas. furthermore, urban areas like jakarta offer better infrastructure, healthcare access, and social services, which can improve quality of life and buffer the negative effects of stress. however, while economic security provides a foundational sense of stability, it does not necessarily replace the emotional and relational support provided by strong family bonds. it should be noted that the scores from the participants of this study leaned more toward the positive spectrum. the vast majority of the sample’s perceived stress levels were low to begin with, and their psychological well-being and family harmony were mostly high as well. this phenomenon might be explained by the aforementioned theory from the book “troubled men” (fine, 1988), which mentions how men tend to be in denial of their problems; hence, they may minimize or dismiss their feelings altogether (shepherd et al., 2023). moreover, the burden of feeling responsible for providing and holding the role of head in their family for indonesian men (bps ri, 2023), could have worsened their repression of stress (adamson et al., 2020). the possibility of misreporting their feelings in 32 the mental health of indonesian male breadwinners stress, men who have taken a hit to their well-being and have started to lose meaning in their lives may benefit from turning to the closest interpersonal system with an individual, namely their family. educators can offer psychoeducation to highlight the importance of fostering healthy family dynamics. family psychologists or therapists can focus on strengthening familial bonds as a form of stress reduction. workplaces could also implement employee assistance programs that include family-centered counseling and design family-friendly policies to enhance the well-being of male breadwinners. specifically on workplace mental health policies, employers could consider offering work-from-home options or flexible schedules to allow more family time, issuing paid parental leave for breadwinning fathers, and encouraging employees to invite their families to organizational events or recreational activities. in conclusion, this study emphasizes the need to support the mental health of male breadwinners by strengthening family harmony as a buffer against stress. these findings call for greater collaboration between families, mental health professionals, and workplaces to foster supportive environments. future research should further explore the diverse factors that shape male breadwinners’ well-being across different life stages 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(2020). international prevalence and correlates of psychological stress during the global covid-19 pandemic. international journal of environmental research and public health, 17, 9248. https:// doi.org/10.3390/ijerph17249248 bates, c. r., nicholson, l. m., rea, e. m., hagy, h. a., & bohnert, a. m. (2021). life interrupted: family routines buffer stress during the covid-19 pandemic. journal of child and family studies, 30, 2641–2651. https://doi.org/10.1007/s10826021-02063-6 bethell, c. d., gombojav, n., & whitaker, r. c. (2019). family resilience and connection promote flourishing among us children, even amid adversity. health affairs, 38, 729–737. https://doi. org/10.1377/hlthaff.2018.05425 dren as fathers should also be taken into account. female breadwinners are often associated with dual responsibilities, that of being a breadwinner and a parent (sánchez‐mira, 2021). considering the increasing awareness of the importance of paternal involvement in a child’s life, this aspect of family dynamic should also account for the men’s evaluation of their family harmony and well-being. as previously mentioned in the limitations, qualitative interviews mixed with quantitative findings could provide in-depth insights into participants’ lived experiences. it would be even more ideal if the interviews included the breadwinner’s spouse and children to uncover biases in self-reported data. conducting longitudinal studies on this topic might distinguish correlation from causation in relationships like stress, well-being, and family dynamics. this approach can reveal how family harmony evolves and whether its moderating effect on stress strengthens or weakens over the years. conclusion based on the aforementioned data analysis and discussion, it could be concluded that perceived stress predicts the psychological well-being of male breadwinners, which supports this study’s first hypothesis. furthermore, family harmony moderates the relationship between perceived stress and psychological well-being in male breadwinners, which supports the second hypothesis. although individuals who experience higher perceived stress typically see a reduction in psychological well-being, having higher harmony within their family can mitigate the effects of stress and lessen its impact on their psychological well-being. this study could serve as a brief overview of the male breadwinner population regarding their perceived stress, psychological well-being, and family harmony. it could serve as an illustration on how families as a whole unit could support these men who typically hide their struggles and deal with their mental burden alone. despite stress being an inevitable part of life, it does not have to be detrimental to one’s well-being. moreover, it adds to the body of research on family harmony by creating links towards perceived stress and psychological well-being, specifically for the male breadwinner population. practical implications from this study could be applied to family psychologists and the general public. by shedding light on the buffering effects of family harmony against the deleterious impact of 33 budyantara & soetikno 2909.98.2.310 crowley, m. s. 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(2019). diagnosed mental health conditions and risk of suicide mortality. psychiatric services, 70, 750– 757. https://doi.org/10.1176/appi.ps.201800346 36 the mental health of indonesian male breadwinners figure 1 the moderating effect of family harmony on the interaction between perceived stress and psychological well-being note. pwb = psychological well-being, ps = perceived stress, fh = family harmony 37 budyantara & soetikno table 1 participant categorization note. n = 304 appendix a 38 the mental health of indonesian male breadwinners table 2 correlations note. **correlation is significant at the 0.01 level (2-tailed). *correlation is significant at the 0.05 level (2-tailed). appendix b 39 table 3 moderated regression analysis with process© note. n = 304; dependent variable = psychological well-being; ***p < .001, **p < .01 dan *p < .05; the significance of the estimates is based on a 95% confidence interval; perceived stress → psychological well-being appendix c budyantara & soetikno gsjp volume 16 final 4 t e a c h e r s c o l l e g e c o l u m b i a u n i v e r s i t y � letter from the editors: we are delighted to present volume 16 of the graduate student journal of psychology, continuing our proud tradition as a peer-reviewed journal highlighting the work of doctoral and masters students in psychology from around the world. this year saw an unprecedented number of submissions, among which we have selected and reviewed the nine fascinating articles you’ll find within these pages. this volume features some remarkable work, with four articles addressing the experiences of ethnic or sexual minorities in america, two extensive scholarly reviews on important areas of inquiry (attachment and purpose in life), as well as studies of maternal behavior, trauma symptoms in veterans, and a new model of addictive processes. we have been truly humbled to work with these talented authors, and truly impressed by their ability to weather the sometimes painful experience of writing and re-writing their work in our demanding review process. our mission, as always, is to provide these authors with their first experience of academic publishing. also behind the success of this volume are 18 peer reviewers, doctoral students as well as licensed psychologists, who volunteered their time to read and re-read each piece. it is to this group that we owe our greatest debt. working without pay or recognition, they donate their time to make sure each article is up-to-date with the latest research in its topic area. it is through their hard work that the major educational mission of the journal is accomplished: new authors are trained by these peer reviewers in the hard work of critical thinking and clear writing. we simply cannot thank our reviewers enough. we’d also like to thank our squad of exacting copy editors, as well as our faculty sponsor, dr. barry farber, whose wisdom and good humor has guided this journal since its inception in 1998. and finally, we’d like to welcome you, our readers, to consider submitting your own work at gsjp@tc.columbia.edu. sincerely, matt blanchard marina mazur graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 47 short-term longitudinal peer influence processes associated with binge drinking among first year college students adam bryant miller george mason university mitchell j. prinstein university of north carolina at chapel hill christianne esposito-smythers george mason university this study examined the influence of peer selection and socialization effects on binge drinking (bd) behaviors during the transition to college. participants included 196 first-year college students (72.9% female) from a large southeastern public university who reported bd pre-college (time 1) and three months post-matriculation (time 2). at time 2, participants identified their closest new college friend whose data was linked to the participant. we hypothesized that matriculating college students would select peers with similar pre-college bd and that peers’ pre-college bd would predict post-matriculation bd. results from regression analyses suggested that first-year students chose friends with similar pre-college bd and maintain their bd commensurately with their new best friend’s prior bd. given support for peer influence, implications regarding prevention strategies and future research are discussed. a prospective study of peer influence processes associated with binge drinking among firstyear college students emerging adulthood is a distinct developmental period between adolescence and young adulthood (ages 18-25; arnett, 2000) that has been associated with increases in and maintenance of health risk behaviors (white et al., 2006; white, fleming, kim, catalano, & mcmorris, 2008). binge drinking, defined as consumption of five or more drinks over a short period of time (two hours), has been the focus of much attention in this area. up to 25.5% of high school seniors reported engaging in binge drinking within a 30-day period (eaton et al., 2010). further, approximately two out of five (44.4%) college students can be categorized as binge drinkers (johnston, o’malley, bachman, & schulenberg, 2011). binge drinking during early emerging adulthood is associated with later alcohol dependency and other mental health problems (chassin, pitts, & prost, 2002; viner & taylor, 2007). the purpose of the present study is to examine potential mechanisms through which college students develop relationships with binge drinking peers. many emerging adults transition into college during this developmental period. this transition is associated with increases in binge drinking behaviors as well as the formation of new social networks (schulenberg & maggs, 2002). as such, peer influence is particularly salient when considering the rise in binge drinking rates among first year college students. while research on peer influence and alcohol use behaviors among emerging adults has been growing (pandina, johnson, & white, 2010), research on the effects of the college transition on alcohol-related behaviors has been relatively limited. researchers have investigated peer influence mechanisms from multiple theoretical perspectives to help explain the increase in binge drinking rates during the college transition. two well-studied areas include alcohol expectancies and perceptions of social norms. alcohol expectancies, or the belief that alcohol use will lead to positive or negative outcomes (e.g., increased comfort in social situations) have been shown to predict levels of drinking (chen, grube, & madden, 1994), mediate patterns of drinking (darkes, green this research was supported in part by a grant from the office of undergraduate research, the kimball king undergraduate research award, and a donation from the office of the dean of students, all from the university of north carolina at chapel hill. correspondence concerning this article should be addressed to adam b. miller, department of psychology, ms 3f5, george mason university, fairfax, va 22030. email: amillec@gmu.edu. 48 baum, & goldman, 2004), and alter binge drinking rates (labbe & maisto, 2011). relatedly, neighbors et al. (2007) found that among first-year-undergraduate college students, perceived social norms of alcohol use predicted higher alcohol consumption, even above alcohol expectancies. another study found that perceived social norms also predict severity of drinking behaviors (lewis & neighbors, 2004). as is evident, college students’ perceptions of the social facilitative effects of drinking and general peer use patterns influence drinking behavior. however, the manner in which college students’ perceptions of peer alcohol use and associated behaviors affect the development of binge drinking peer groups has received less attention in the research literature. one potential way to categorize friendship formation is to examine the role of selection and socialization effects. selection effects refer to individuals’ choice of friends whom they perceive to be similar to themselves in attitudes and beliefs (kandel, 1978). socialization effects refer to the processes wherein individuals implicitly and explicitly influence each other to engage in similar behaviors (kandel, 1978; prinstein & dodge, 2008). this influence may serve to increase or maintain a maladaptive behavior, such as binge drinking. these processes, examined together, may help explain how first year college students befriend individuals whom they perceive to have similar binge drinking behaviors, and how these new friendships are associated with the maintenance or increase in each individual’s binge drinking (white et al., 2008). previous studies yield support for peer influence on alcohol use behaviors during the college transition. leibsohn (1994) found that first year students reported befriending college peers with similar drinking habits as themselves. read, wood, and capone (2005) suggested that adolescents’ perceptions of their friends’ drinking behaviors and attitudes were associated with increases in their own drinking during the first year of college. white et al. (2008) found that adolescents who drank heavily in high school were more likely to perceive that their new (post-high school) friends possessed pro-alcohol values which predicted increases in adolescents’ own drinking behavior. thus, some studies have suggested that both selection and socialization effects may be relevant for understanding alcohol use among first year college students. despite significant advances in this area, much of the research on peer socialization and selection effects is hampered by a number of methodological limitations. first, most prior studies examine selection effects by measuring newly formed friendships within a context of familiar peers (i.e., among already-acquainted grademates; white et al., 2008). such examinations of selection effects are confounded by adolescents’ prior knowledge of their peers’ reputations. a more rigorous examination of selection effects involves assessing newly formed dyadic friendships among unfamiliar peers (e.g., during college transition). second, past work has suggested that college students provide poor estimates of their peers’ drinking behavior (borsari & carey, 2006; neighbors et al., 2007; prinstein & wang, 2005), thereby limiting conclusions that can be reached. finally, past studies have often been cross sectional and thus causal inferences cannot be drawn (leibsohn, 1994). to address limitations of prior research, the current study examined peer socialization and selection effects using first-year college students’ peer nominations of new college friends and these friends’ own reported behaviors of prior drinking experiences. thus, actual drinking behaviors, rather than estimations, of each person in a dyadic friendship were compared. this study also employed a prospective design to more accurately characterize friendship formation and binge drinking over a short, ecologically valid time frame. we hypothesized that: 1) matriculating college students would choose friends with similar levels of pre-college binge drinking (selection effects); and 2) students’ binge drinking post-matriculation at time 2 (t2) would be predicted by their new best friends’ time 1 (t1) binge drinking behavior over and above prior binge drinking experiences (socialization effects). finally, given that males have been shown to binge drink more frequently than females (borsari & carey, 2001), we hypothesized that gender would moderate both selection and socialization effects. specifically, males will be more likely than females to choose peers with similar rates of prior binge drinking experience, and males will be more likely than females to be influenced by their new best friends’ binge drinking behaviors post-matriculation. miller, prinstein, esposito-smythers 49 peer influence and college binge drinking method participants participants included 196 first-year students (72.9% female) at a large southeastern university in the united states. the ethnic distribution of this sample was 80.6% white, 6.8% black, 5.2% asian, 4.7% latino/a, and 2.6% other/ mixed race and matched that of the university population. females were overrepresented in this sample compared to the overall gender distribution from the university population (see below). measures binge drinking. questions regarding binge drinking were created for the present study and mirrored well-established alcohol use measures included in the national longitudinal study of adolescent health (add health; harris et al., 2009). at t1 before starting college in the fall, students were asked, “in the last six months, how often did you have five or more alcohol drinks on a single occasion (within a few hours)?” responses were recorded using a likert-type scale (i.e., 1 = 0 times, 2 = 1-2 times, 3 = 3-9 times, 4 = 10-19 times, and 5 = 20 or more times). at t2, participants reported the frequency of their binge drinking in the past three months using the same scale. best friend’s alcohol use. at t2, participants were asked to rank order an unlimited number of friends in college (using first and last names) and indicate whether each listed friend was a “new” friend (also a first-year student) since starting college. the name and data of the new best friend (highest-ranked new friend) who was also a part of this research study was linked to the participant via each person’s university identification number. names of the participants and new best friends were matched (twice for accuracy) using official university records of first year students’ names and identification numbers. friends’ responses to the same t1 question served as an independent report of college friends’ pre-college binge drinking. procedure incoming first-year students were told that they could voluntarily participate in a research study designed to understand the health behaviors of incoming first year students. they were assured that all of their information would be kept strictly confidential. trained research assistants distributed a survey to incoming first-year students during the first day of summer orientation sessions (t1). students provided only their unique university identification number rather than their name, and returned their form in a sealed, confidential folder to facilitate honest responding. the paper and pencil survey took 10-15 minutes to complete, and students were allowed to complete these forms in the privacy of their dorms overnight. additional measures were administered three months after the start of the school year (t2) using a secure online survey. three months was chosen in order to provide adequate time for students to select new peers and establish drinking behaviors. all who completed the t1 assessment were eligible to participate in the t2 measurement. of the 4,000 incoming first year students, 25% (n= 1,000) were under 18 and ineligible to participate in the study. of the remaining 3,000 eligible students, 52% (n = 1,574 [65% female]) returned their t1 surveys. the gender, ethnic distribution, and geographic origin of this t1 sample did not differ significantly from the total population of the full first year class. of all t1 participants, 53.2% (n = 837) completed the t2 survey. students with data at t1 and t2 had to meet two criteria to be included in final analyses. first, only students who selected a new best friend with t1 data (i.e., also a study participant with t1 data) were included to ensure actual reported behavior of the friend. in other words, participants had to be in a newly formed dyad, and both members of this dyad had to have t1 data. second, to eliminate concerns of data duplication and resulting inflated associations, each participant was included as a best friend only once within the data set. in the t2 sample, 9.26% (n = 20) of the participants were doubly nominated as best friends. in such cases, one participant who had nominated the same best friend as another participant was excluded at random from study analyses. in total, 196 participants met all criteria necessary for inclusion. this procedure for examining newly formed friendships (e.g., including unlimited friend nominations, linking dyadic data, and ensuring that participants are only included once in 50 analyses) is consistent with that employed in previous research examining best friend relationships (prinstein & dodge, 2008). affiliated university institutional review board provided approval for this study. data analysis descriptive analyses, including frequencies and bivariate correlations, were conducted first. two separate hierarchical multiple regression analyses were used to examine primary hypotheses. in the first model testing selection effects, college friend’s pre-college (t1) binge drinking was entered as the dependent variable. participants’ pre-college (t1) binge drinking and gender were entered as predictors on the initial step of the regression, with their interaction entered on the second step. to examine socialization effects, participants’ post-matriculation (t2) binge drinking frequency was entered as the dependent variable. in order to show the unique effects of socialization, pre-college (t1) binge drinking was controlled in an initial step. the new friends’ pre-college (t1) binge drinking and gender of the participant were entered in the next step. finally, the interaction between new friends’ pre-college (t1) binge drinking and gender of the participant were entered in the final step. results preliminary results participants with t1 data only (n = 701) reported higher levels of binge drinking than participants who provided data at both t1 and t2 (t (1548) = 2.93, p < .05. more females than males completed the t2 follow-up (x2(1, 1558) = 7.83, p < .05). at the t2 follow-up, students who did not list a best friend at all (n = 109) and students who did not list a best friend that also was in the study (n = 512) were ineligible for final analysis, but did not differ significantly from the overall t2 sample. however, participants who picked a best friend that was also in the original sample at t1 (n = 216) engaged in binge drinking less frequently than those who did not list a best friend in the original sample (t (1,553) = 1.91, p < .05). females (72.9%) were more likely than males to list a best friend who also was in the study (x2(1,789) = 6.32, p< .05) and were overrepresented in the follow-up study. bivariate analyses bivariate correlations and descriptive statistics, including means and standard deviations, of all variables are presented in tables 1 and 2. figure 1 represents the frequency of binge drinking in the prior six months of the final sample. males engaged in binge drinking more frequently than females at both t1 and t2. previous binge drinking (t1) was positively associated with binge drinking behaviors at t2. selection effects results from regression analyses showed a main effect of friends’ binge drinking at t1 on the participants’ pre-college binge drinking (t1). consistent with selection effects, results suggested that higher levels of participants’ pre-college binge drinking was significantly associated with higher levels of pre-college binge drinking (t1) of the participants’ new best friend (see table 3). there was no main effect of gender for participants’ t1 pre-college binge drinking. despite males reporting higher binge drinking rates than females (table 1), gender did not moderate the relationship between participants’ pre-college binge drinking and their new best friends’ pre-college binge drinking. socialization effects results from regression analyses suggested that pre-college binge drinking behaviors explained approximately half of the variance in binge drinking during the fall semester of college (see table 3). consistent with socialization effects, pre-college (t1) binge drinking of participants’ new best friend predicted the participants’ current binge drinking. specifically, higher levels of binge drinking reported by the new best friend at t1 predicted higher levels of binge drinking of the participant at t2 over and above prior binge drinking behaviors of the participant. there was no main effect of gender, and gender did not moderate this association. discussion a primary goal of this study was to examine the influence of peer selection and socialization effects on binge drinking among college students. to address limitations of prior research, this study assessed miller, prinstein, esposito-smythers 51     peer influence and college binge drinking 22 table 1. means and standard deviations for primary variables (n = 196)       males   females   t (df)   time 1         binge drinking   2.22 (1.33)   1.51 (.85)   -4.22** (178)   friend’s binge drinking   1.96 (1.23)   1.61 (.95)   -2.06* (179)   time 2         binge drinking   2.10 (1.20)   1.51 (.87)   -3.69** (186)           note. * p< .05; ** p< .001       peer influence and college binge drinking 23 table 2. bivariate associations among primary variables (n = 196)     t1 binge drinking   t1 friend’s binge drinking   t2 binge drinking   t1 binge drinking   -   .28**   .70**   t1 friend’s binge drinking   .25   -   .34**   t2 binge drinking   .65**   .30*   -           note. correlations below the diagonal represent males, and values above the diagonal represent females. * p< .05; ** p< .001   peer influence and college binge drinking 52     peer influence and college binge drinking 21 figure 1. 61% 19% 11% 7% 2% binge drinking at time 1, n = 196 0 times 1-2 times 3-9 times 10-19 times 20 or more times first year students’ binge drinking 24 table 3. multiple linear regression analysis testing selection effects (1) and socialization effects (2) (n = 196) predictor   b   se b   ß   p   δ r2   1. friend’s time 1 (t1) behavior           step 1 gender   -.16   .18   -.07   .377   .09**   participant binge drinking t1   .27   .07   .27**   .001     step 2 participant binge drinking t1 x gender   .09   .16   .14   .567   .09   2. participant binge drinking at time 2 (t2)           step 1 participant binge drinking t1   .68   .05   .70**   <.000   .50**   step 2 gender   -.10   .13   -.05   .417   .02*   friend’s binge drinking at t1   .15   .05   .15*   .007     step 3 friend’s binge drinking t1 x gender   .04   .11   .07   .735   .00   miller, prinstein, esposito-smythers 53 college students’ binge drinking behaviors preand post-college matriculation and compared it to their new best friends’ actual reports of binge drinking. it also employed a prospective, 3-month design. similar to past work, results suggested that prior binge drinking was a strong predictor of future binge drinking behavior (white et al., 2008). importantly, results are consistent with prior research (leibsohn, 1994; read et al., 2005; white et al., 2008) and provide evidence that both peer selection and socialization effects may account for some of the binge drinking behaviors reported by students during their college transition. the college transition is typically characterized by numerous opportunities for substance use (pandina et al., 2010). one pathway to college students’ binge drinking may be through the selection of friends who have similar past binge drinking experiences as themselves. our results also yield preliminary evidence to suggest that new college friends may influence the maintenance of binge drinking behavior. this finding is consistent with prior studies that have found that emerging adults are influenced by the behaviors of their friends (allen, porter, & mcfarland, 2006; cohen & prinstein, 2006). while experimental alcohol use is considered to be normative during the first year of college, friendships that form around and facilitate binge drinking are concerning and deserve attention. study results can be further interpreted through the lens of social learning theory (slt). according to the slt of alcohol, social reinforcement and modeling are central concepts for understanding binge drinking during the college transition (borsari & carey, 2006). the college transition provides an ideal social environment to facilitate alcohol use. in the context of slt, peers serve as models for binge drinking and simultaneously provide social reinforcement. binge drinking facilitates contact and acceptance among peers, provides pleasant shared experiences, and increases intimacy, closeness, and support among newly forming friendships (borsari & carey, 2006). thus, individuals transitioning to college who have already experienced the positive social aspects associated with binge drinking may select peers with similar past experiences and mutually engage in binge drinking as a means to develop a close friendship. indeed, previous studies have shown that incoming college students appear to binge drink to make friends rather than to cope with negative affect (reifman & watson, 2003). as a friendship continues to develop, peers may maintain binge drinking behaviors as both members of the dyadic relationship experience similar positive reinforcement for binge drinking and drink as a means to maintain shared behaviors and beliefs. implications for prevention results suggest that a tiered approach to alcohol prevention may be effective. given that past drinking behaviors were associated with future binge drinking, interventions designed to address the health risks associated with binge drinking among incoming college students are indicated. recent research suggests that psychoeducational alcohol prevention programs on college campuses hold promise in the shortterm. in a randomized clinical trial that included 30 universities, the use of an online, internet-based alcohol misuse prevention program, referred to as “alcoholedu for college”, was associated with a significant reduction in the frequency of past-30 day binge drinking in the fall semester upon course completion (paschall, antin, ringwalt, & saltz, 2011). however, these results did not persist into the spring semester, highlighting the potential need for booster sessions or other prevention approaches. the results of the present study suggest that incorporating peer related factors into alcohol prevention programming may prove to be fruitful. peers’ drinking prior to college matriculation was found to predict binge-drinking behaviors during the first few months of college, above and beyond past drinking history. thus, programs that promote physical health but also teach peer alcohol resistance skills during the first few weeks of college may help combat binge drinking on college campuses. peerled prevention programs or the use of well-respected peer actors in online materials may also help increase the salience of prevention programming. for those students who do not respond to universal (or broad) prevention efforts, and form mutually supportive social relationships around binge drinking, selective or indicated prevention programming peer influence and college binge drinking 54 may be warranted. a number of studies have found that peer-led interventions utilizing motivational interviewing techniques with college students have been successful in reducing alcohol use (larimer, cronce, lee, & kilmer, 2004; tevyaw, borsari, colby, & monti, 2007). future development and work in the area of peer-led interventions appears warranted. limitations and future directions though the present study uniquely builds upon existing literature in the area of peer influences on college student drinking behavior, it also has a number of limitations. data at both time points were collected from a small subset of incoming first year students, limiting generalizability. efforts to enroll all incoming first year students for participation in future research in this area would be beneficial. despite assurances of confidentiality, it is also possible that students under-reported their alcohol use given that they were under the legal drinking age. alternative explanations for the binge drinking behaviors in the current sample should also be considered. drinking behavior was only measured between two friends in this sample. the influence of other peers, or non-interpersonal factors, was not assessed in this study. for example, students’ greek affiliation, a known influence on binge drinking (mccabe et al., 2005) was not assessed. although the majority of students (> 75%) at the university where this study was conducted live on campus their first year, it is possible that students living on campus may drink more than students that live off campus or vice versa. further, some studies have shown that for males, having a roommate who was a binge drinker in high school is related to increases in drinking behaviors in college (duncan, boisjoly, kremer, levy, & eccles, 2005). future research would benefit from examining these alternative explanations and other potential reasons that friendships may form other than around binge drinking behaviors. another important issue in this study was the attrition rate from t1 to t2. students with the highest binge drinking rates at t1 were the least likely to complete the follow-up survey at t2. the final sample for analysis included mostly females and less frequent binge drinkers compared to the t1 sample. importantly, even among this small sample, peer influence mechanisms still accounted for a significant portion of the variance in binge drinking behaviors. future research with more frequent binge drinkers might find stronger peer influence effects. specifically, it would be useful to examine whether frequent binge drinkers are more strongly affected by peer influence than individuals without a history of binge drinking. it would also be important to study individuals who are abstainers to understand continuities and discontinuities in their college drinking behaviors (hersh & hussong, 2006). it is also important to note that the current study only included participants who made new best friendships over the course of the first three months of college. thus, study participants may be higher in various types of socially facilitative personality traits, such as extroversion, compared to excluded individuals. finally, this study used a single item to measure binge-drinking behaviors at both time 1 and 2, which temper conclusions. future research would benefit from using validated measures of binge drinking behaviors. conclusion this study offers further evidence to suggest that peer influence processes are relevant for understanding binge drinking on college campuses. the current study improves upon prior research methodology by examining actual peer reports of substance use behaviors rather than estimations by the study participant. results highlight the potential benefit of using developmental theories, methods, and ecologically valid time points to understand peer influence effects on college binge drinking. references allen, j. p., porter, m. r., & mcfarland, f. c. 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(2006). increases in alcohol and marijuana use during the transition out of high school into emerging adulthood: the effects of leaving home, going to college, and high school protective factors. journal of studies on alcohol, 67, 810–822. miller, prinstein, esposito-smythers 20 the pertinent prenatal period: a secondary analysis examining the relationship between prenatal maternal anxiety and child language development at 18 months prenatal anxiety, an issue impacting pregnant persons with a prevalence ranging from 21% to 25% (field, 2017), could potentially play an important role in shaping child language development. while few studies have examined the links between anxiety and language development, existing studies suggest that greater anxiety is associated with poorer development (ibanez et al., 2015). in studies that have examined prenatal anxiety as an independent variable, maternal mental health tends to be discussed broadly without consideration for distinct aspects of prenatal mental health (e.g., anxiety versus depression; rogers et al., 2020). moreover, there has been a focus on child cognitive outcomes such as memory or learning rather than language development (keim et al., 2011). one prominent study exploring the association between prenatal mental health, as encompassed by depression and anxiety, and children’s cognitive outcomes found that prenatal anxiety was significantly associated with lower scores on assessments of cognition (ibanez et al., 2015). in this study, the macarthur communicative development inventory (cdi) was used to assess language as a cognitive domain, and it was observed that higher levels of prenatal anxiety were associated with lower cdi scores in children (ibanez et al., 2015). however, this study did not disentangle the influence of anxiety from that of depression. additionally, the cdi is based entirely on maternal reports, which may introduce outcomes such as social desirability bias or the inability to accurately attribute differences in reported vocabulary skills to true differences in skill, in addition to the possibility that more anxious mothers may simply report differently than non-anxious mothers. additionally, two studies investigated the trajectory of maternal prenatal anxiety throughout pregnancy and developmental outcomes in 1-year-old infants (irwin et al., 2020; keim et al., 2011). these studies examined prenatal anxiety as an independent variable but did not control for varying mental health disorders that are highly comorbid. both studies found that higher prenatal anxiety was associated with lower scores on assessments of cognition. specifically, irwin et al. (2020) found that increasing maternal anxiety across pregnancy was associated with lower receptive language, also known as the “input” of language. next, a study conducted by rogers et al. (2020) aimed to assess whether maternal prenatal depression and anxiety were adversely associated with varying developmental skills in children during the first 18 years of life. they found that prenatal anxiety was associated with poorer language abilities in early childhood, as measured through a composite, without controls for varying mental health disorders. in a study that controlled for confounding mental maternal mental health is thought to be an important factor that may shape child development as early as the prenatal period. prenatal maternal mental health has been linked to both physiological and factors that are theorized to explain the links between mental health and child language development. whereas some past research has examined the associations between prenatal mental health and child language development, most have examined broad measures that include both anxiety and depression. given that there are distinct mechanisms by which these aspects of maternal mental health are hypothesized to impact development, this study aims to parse the association between anxiety and child language development specifically. this study utilized data from a longitudinal prospective study to examine the associations between prenatal anxiety and child language development at 18 months in 167 families. we conducted a series of three regression models beginning with a simple linear regression examining prenatal anxiety and language development, followed by two models, first adding demographic covariates, then including prenatal depression. we did not find associations between maternal anxiety and child language development; inadvertently raising the question of when and by which mechanisms maternal mental health may or may not impact aspects of child development, which are crucial answers to be discerned in order to determine the most effective way to support pregnant mothers and their children throughout the prenatal period. keywords: prenatal anxiety, language development, maternal mental health, child outcomes melanie lucia esterine department of counseling and clinical psychology, teachers college at columbia university, new york, ny usa graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 21 esterine health comorbidities, brouwers et al. (2001) showed that high prenatal anxiety during late pregnancy was uniquely associated with lower attention-related process skills at three weeks, one year, and two years. this finding may lend insight to investigations of language acquisition, given that attention-related processes are thought to be related to language acquisition and processing abilities (de diego-balaguer et al., 2016; kannass & oakes, 2008). finally, a pertinent study conducted by clifford et al. (2022), which examined the association between postnatal maternal mental health and children’s expressive language (i.e., output of language) at approximately one and a half years of age (mage = 17.03 months), found that postnatal maternal anxiety was negatively related to child language production scores, as reported by a parent. in this study, prenatal anxiety is not the independent variable; however, its relevance lies in the dependent variables falling within the domain of language. researchers have theorized that both physiological and psychological processes could underlie the associations between prenatal anxiety and postnatal child development. physiological issues have been proposed as one mechanism by which prenatal anxiety could shape development. notably, greater prenatal anxiety has been associated with poorer fetal development, including reduced fetal head circumference (lewis et al., 2015), with slower or decreased fetal head growth during gestation associated with language difficulties in children two years of age compared to their typically developed peers (villar et al., 2021). research has also found that extremely high levels of prenatal anxiety may restrict blood flow and oxygen to developing fetal organs (hobel & culhane, 2003). restricted blood flow in particular can cause maternal vascular malperfusion, a placental abnormality, which has been linked to poor language development (straughen et al., 2017). these findings highlight physiological pathways through which prenatal anxiety may implicate a child’s language abilities. it is also possible that prenatal anxiety forecasts or precedes less developmentally supportive parenting behaviors. research has demonstrated prenatal anxiety to be a distinct predictor of postnatal mood disturbance (blackmore et al., 2016), which has the potential to negatively influence child development, including language development, through the possible presence of these less developmentally supportive parenting behaviors. the family stress model, originally introduced by conger et al. (1992), suggests that parental psychological distress, including anxiety, can lead to parenting practices that may negatively impact child development (masarik & conger, 2017). developmentally unsupportive parenting practices may include insensitivity (newland et al., 2013); reduced time and quality of time spent with children (iruka et al., 2012); and harsh, punitive, and over-controlling behaviors (emmen et al., 2013) that increase the risk of child abuse or neglect (warren & font, 2015). furthermore, maladaptive maternal behaviors and affect, as encompassed by diminished mental well-being, yield a less stimulating environment for children as it relates to the home language environment (i.e., the language that happens in the home, including the words that the child hears and reciprocal back-and-forth parent-child conversations; clifford et al., 2021). research has suggested that the quality of a child’s early home language environment is a crucial predictor of their later linguistic skills and cognitive development (dailey & bergelson, 2022; romeo et al., 2018). it is the exposure to more words and engagement that yield more successful linguistic developmental outcomes, such as the ability to learn vocabulary faster, exhibit increased processing speed, and produce overall stronger language (gilkerson & richards, 2009; hart et al., 1997; hurtado et al., 2014). examining these kinds of developmental outcomes around 18 months of age is crucial, given the rapid growth in vocabulary skills that happens around this time (kuhl, 2010). despite much theory suggesting various pathways through which prenatal anxiety could impact child language development, research on the associations between these constructs is limited. child language development is important to understand, given the crucial insight it may provide into other aspects of child development, such as cognitive and social abilities (anderson & freebody, 1981; gertner et al., 1994). objectives and rationale the present research aims to examine the association between prenatal anxiety and child language development at 18 months of age. relatively few published studies have examined the association between prenatal maternal mental health and language development, let alone the specific association between prenatal anxiety and language at 18 months. an important consideration for correlational research on 22 the pertinent prenatal period memory, and cognition. this study was approved by the teachers college institutional review board (irb), and all participants provided written informed consent after being briefed on the study’s purpose and procedures. they were also informed that they could refrain from specific measure collection or withdraw at any point. participation was voluntary, though participants were compensated with differing cash amounts based on the time point. participants were recruited in new york city through social media, community events, and prenatal clinics. an intentionally racially and socioeconomically diverse sample was recruited for participation. recruitment for this study occurred in two waves, with a pause due to the covid-19 pandemic. thus, 93 mothers were recruited in the first cohort (before the pandemic) and 116 were recruited in the second cohort (after the height of the pandemic). in this study, we used data from both cohorts. before enrollment in the study, mothers were screened over the phone to ensure that they met inclusion requirements, including that they were 18 years or older, were at least 35 weeks along in their pregnancy, and had no knowledge of fetal neurological or developmental issues. upon successful enrollment in the study, all 209 mothers completed the prenatal visit. after the child was born, further inclusion criteria were enforced for subsequent participation. these criteria included the child’s gestational age being greater than or equal to 37 weeks with no known neurological or developmental issues at birth. 205 mother-child dyads met these criteria. participants were invited to participate in visits occurring from approximately every six months after birth through their child’s third birthday. in the current research project, we examined data from families who completed both the measure of prenatal anxiety and the measure of child language development at 18 months. the total number of mother-child dyads with complete data was 65 for cohort one and 104 for cohort two. two mothers failed to complete demographic measures used as covariates in the analyses. thus, my final analytic sample comprised 167 participants. table 1 presents descriptive statistics corresponding to demographics and covariate variables. prenatal anxiety prenatal anxiety was measured by the beck anxiety inventory (bai). the bai is a 21-item questionnaire that helps in rating anxiety levels. it is a self-report this topic is the susceptibility to omitted variables bias (duncan et al., 2004). given this possibility, examining the links between prenatal maternal anxiety and child development with a full set of controls for potential confounders may yield a better sense of whether these associations reflect bias or a true association. it is important to understand that although various mental health disorders may be comorbid with one another, they present with different symptoms, require different therapeutic interventions, and–in the case of parent-child dyads–signify different implications for the child (rogers et al., 2020). insofar as this correlational work could lay the foundation for testing whether interventions that target maternal mental health have positive effects on child language development, establishing whether these associations are robust is an important first step. by focusing specifically on prenatal anxiety, we can hone in on this construct as it relates to child language development. furthermore, by controlling for numerous potentially confounding variables, including prenatal maternal depression, this research may strengthen the current research on this topic. not only does the present research hope to lay the framework for possible interventions for mothers struggling with mental health, anxiety in particular, but it also strives to do so for children who may be susceptible to some of the unintentional consequences prenatal anxiety may bring. by distinguishing the potential implications of prenatal anxiety from those of prenatal depression and narrowing the scope, we enhance our understanding and ability to develop tailored interventions aimed at the prevention of any adverse developmental outcomes that may surface in the presence of prenatal maternal anxiety. hypothesis the present research hypothesizes that higher levels of prenatal maternal anxiety are associated with lower levels of expressive and receptive language skills in children as measured at 18 months. methods participants the mothers included in the current research were originally recruited for participation in a longitudinal study known as buddy, a study examining associations among various sociocultural factors, early experiences, and child development, particularly language, 23 esterine measures. these correlations attained a rounded value of 0.93 with significance (lena foundation, 2022). the lena snapshot has proven to be efficacious as it relates to monitoring the progress of language development as well as helping to identify the probability of language delay (lena foundation, 2022). especially given the multilingual nature of the participants recruited for buddy, it is crucial to mention that the lena snapshot has demonstrated limited validity in multilingual contexts. covariates prenatal depression prenatal depression was measured by the patient health questionnaire depression scale (phq-8). the phq-8 is an 8-item scale used as a diagnostic and severity measure for depression (kroenke et al., 2009). it is a self-report questionnaire that implements a likert scale with responses for items ranging from zero (“not at all”) to three (“nearly every day”). the questionnaire asks respondents to consider the presence of the items’ corresponding symptoms during the previous two weeks (arias-de la torre et al., 2023). the items correspond to symptoms outlined in the dsm-iv as diagnostic criteria for major depressive disorder. sample items for this measure include “i am sad all the time and i can't snap out of it" and "i am so sad or unhappy that i can't stand it”. the phq-8 is scored by summing the respondents’ scores to each of the items, with total scores closer to zero representing lower levels of depression and total scores closer to 24 representing higher levels (arias-de la torre et al., 2023). the tool displays high internal consistency reliability (α = .82) and construct validity (pressler et al., 2011). for the purposes of buddy, the phq-8 was administered as opposed to the phq-9, which includes a ninth question on suicidal ideation, due to the study’s desire to focus on the core aspects of depression while avoiding potential issues that may arise with item nine in non-clinical settings. demographic variables demographic variables included child sex, child age at lena snapshot completion, mother’s race/ ethnicity (with white mothers as the reference group), years of formal education completed by the mother (i.e., maternal education), and family income. data analysis plan to examine the associations between maternal prenatal anxiety and child language development, we assessment developed in 1988 that asks about common anxiety symptoms and their impact over a week (rung, 2024). the questionnaire assesses short-term symptoms, primarily those that are physical. sample items include: “numbness or tingling” and “unable to relax”. for each question, there is a uniform set of four answer choices with scores ranging from zero to three. as a result, overall scores ranged from 0 to 63 characterized by grouping as follows: 0 to 7 = minimal anxiety; 8 to 15 = mild anxiety; 16 to 25 = moderate anxiety; and 26 to 63 = severe anxiety (rung, 2024). while the bai is not a diagnostic tool, this score can help mental health professionals determine the severity of anxiety. the measure shows high discrimination (between anxious and non-anxious persons) in clinical populations and high internal consistency (α = .93) and test-retest reliability as measured over a week (ricc = .84; oh et al., 2018). however, it is important to note that the measure shows limited discriminant validity against depressive disorders (oh et al., 2018). language development child language development at 18 months was measured by the language environment analysis (lena) snapshot. the lena snapshot is a 52-question, parent-completed questionnaire that measures a child’s expressive and receptive language skills (lena foundation, 2022). sample items from the lena snapshot include “does your child spontaneously produce sentences that are 10 or more words in length?” and “does your child understand concepts like ‘least’, ‘most’, and ‘first’?” the questionnaire is norm-referenced to a sample of typically developing children who participated in a natural language study by its creators (lena foundation, 2022). the lena system uses an algorithm to automatically score responses and compares the score to the normative dataset of the language development of other monolingual, north american english-speaking children at that age. following this, the system generates a standard score that estimates the child's developmental language age, placing them at below or above their true age (lena foundation, 2022). the assessment has strong test-retest reliability, acquiring a correlational value of ~.93 over two years (lena foundation, 2022). this tool has also been correlated to various standardized language and cognitive assessments, including the cognitive adaptive test and the preschool language scale 4th edition, both the expressive and receptive 24 the pertinent prenatal period sults, a high positive correlation was observed between prenatal anxiety and depression, which likely impacted the results attained by the third regression, which included all the covariates. analyses first, we ran a linear regression model to examine the relation between prenatal anxiety and language development at 18 months without the inclusion of any covariates. the model results are presented in table 4, alongside all of the results produced by my analyses. the model’s standard deviation indicated a small negative association (sd = -0.06), indicating that a one standard deviation increase in maternal anxiety was associated with a .06 reduction in language development. in raw units, this corresponded to a reduction of -0.15 units on the measure of language development. however, importantly, this association was imprecise and not statistically significant (p = .43), indicating that the association is not statistically distinct from a correlation of zero. to examine the extent to which this small association was biased by child and family characteristics, we then ran a model that controlled for the following variables: child sex, child age at lena snapshot, mother’s race and ethnicity, maternal education, and income. the association between anxiety and language development became slightly larger but remained imprecise and statistically non-significant. despite this slight increase, the first and second regression analyses produced consistently small estimates that hovered around 0, suggesting a near zero effect. although the association remained statistically non-significant, interestingly, in this second regression analysis, the direction of the β value flipped from negative to positive (β = .03). on the other variables included in this regression model, notably, two attained statistically significant coefficients, child sex (β = .20, p = .01) and mother’s race when specified to be black (β = -.20, p = .03). the last regression model we ran included the previously mentioned covariates in addition to prenatal depression. the inclusion of depression in the model substantially changed the association between prenatal anxiety and children’s language development. indeed, the association increased from near zero in earlier models (β = .20) and became nearly statistically significant by conventional standards (p = .06). this pattern of results looks a lot like what we might expect if suppressor effects were at play, leading me to be suspicious ran a series of three regression models using spss v29 (ibm corp). first, we ran a simple linear regression model to test the relationship between prenatal anxiety and language development. next, we conducted a multiple linear regression model to account for demographic covariates: child sex, child age at lena snapshot completion, mother’s race/ethnicity, maternal educational attainment, and family income. finally, we ran a multiple linear regression model in which we included prenatal depression in addition to the demographic covariates introduced in model two. we tested this final model to probe the unique association between prenatal anxiety and child language development while holding constant the influence of prenatal depression, given the robust high correlation between depression and anxiety. results descriptive statistics beginning with some discussion on descriptive statistics of the sample, the sample for the present study was relatively diverse. 44% of mothers in the sample identified as white and 55% identified as nonwhite, while 40% identified as hispanic or latino and 59% as not. as for family income and maternal education, the range for these variables was vast, though both distributions did skew towards the right (i.e., the higher end of the spectrum). on average, child age at lena snapshot completion was 18 months, and the total score on the phq-8 had an average of five (m = 5) with a left-leaning distribution (i.e., the lower end of the spectrum) representing lower levels of prenatal depression for the mothers in the sample, on average. regarding the bai and prenatal anxiety, the average score was approximately nine (m = 9) with the data skewing left as well, representing lower levels of prenatal anxiety for the mothers included in the present study. lastly, the total lena snapshot score (i.e., child language development) skewed right toward higher scores and greater language abilities with an average score of 104 (m = 104). table 3 shows the correlations among variables included in my analyses. of note, a low negative correlation was observed between prenatal anxiety and language development, and a moderate negative correlation was observed between prenatal depression and language. interestingly, in the context of the effect it had on re25 esterine analyses in this study, yielded null results. in the context of this particular study, one important consideration is the small sample size. the small sample size of 167 participants can pose a myriad of limitations for data analysis and interpretation. for starters, smaller sample sizes make it more difficult to ascertain the validity of a found effect, especially small effects. this is attributed to the lower statistical power often achieved by smaller sample sizes. small sample sizes also yield unreliable results due to low generalizability, making it difficult to accurately attribute results to the broader population. in the second regression analysis, we similarly found a statistically nonsignificant association between prenatal anxiety and child language development. however, as previously noted, a peculiar change occurred with the standardized coefficient value for this association from the first analysis to the second– the direction of this value shifted from negative to positive. though we should be careful not to heavily interpret these coefficients, given that they were both very close to zero, this hypothetical interpretation opposes current literature in the field, highlighting the need for continued research. on top of this, it raises the question of whether there could be cases in which the experience of anxiety confers advantages to parent-child interactions that support child development. however, again, ultimately the estimate from this model was quite small and suggestive of no association. interestingly, in this second regression, we did observe two statistically significant associations. an association was found between child sex and language development, a finding that aligns with a substantial amount of literature in the field, depicting significant gender differences in language acquisition spanning from early childhood through adolescence. though empirical evidence is not robust and findings are mixed, numerous studies highlight a female advantage in various aspects of language acquisition in early childhood (clarke-stewart, 1973; heister, 1982). we also observed a negative association between maternal race when identified as black and child language development. this finding raises concern that warrants further examination, given its illustration of a vulnerable population that may benefit from interventions geared towards the promotion of early childhood language development. this association has been observed in other literature, such as cho et al. (2007), about the estimate. such effects will be discussed further; however, they tend to occur with highly correlated variables when simultaneously input as predictors. of note, there was an observed negative association between maternal depression and child language (β = -.25, p = .02) as well as an association between child sex and child language (β = .20, p = .007). and, as mentioned earlier, there was a strong positive correlation between prenatal anxiety and prenatal depression (r = .70). discussion overall, this study found little evidence to suggest an association between prenatal anxiety and child language development at 18 months of age. in the first analysis, which most closely replicated existing literature due to its refrain from controlling for covariates, opposing results to current literature were observed. for example, ibanez et al. (2015) explored the associations between prenatal depression and anxiety with children’s cognitive outcomes without controlling for depression. in contrast to the current study, they found that prenatal anxiety was significantly associated with poorer cognitive development, as characterized by language, at three years old (ibanez et al., 2015). results also conflict with those of rogers et al. (2020), which aimed to assess the association between prenatal depression and anxiety with various developmental skills, including language, during the first 18 years of life. again, in this study, there was no control for the covariate prenatal depression, yet researchers found that prenatal anxiety was associated with diminished language abilities. this pattern is consistent with other prominent studies such as irwin et al. (2020) and clifford et al. (2022), which found higher prenatal anxiety to be associated with poorer receptive communication skills and postnatal maternal anxiety to be associated with child expressive language, respectively. the antithetical nature of these results alone emphasizes the need to continue conducting research within this realm to better understand the implications of prenatal mental health on child language development and other facets of child development at large in order to design and implement tailored interventions geared towards positive outcomes for mothers and children as needed. one can hypothesize many reasons why this first analysis, and ultimately all of the 26 the pertinent prenatal period to lead to difficulties in detecting small effects and unreliable results. it is also worth noting the two-cohort study design necessitated by the pandemic. as previously mentioned, participants were recruited at two different time points due to the pandemic, resulting in two cohorts. recruitment for cohort one began before the pandemic and was interrupted once restrictions were imposed. under “normal” circumstances where participants are recruited at different time points, a study faces the risk of the “cohort effect”, which is described as the variation in characteristics of a group of people over time based on a shared experience (caruana et al., 2015). this effect is all the more applicable in this study where participants of cohort two were recruited after a shared experience as life-changing as the covid-19 pandemic. the cohort effect implies that different experiences attributed to a given period can impact the perceptions and responses of a participant in a research study (i.e., economic circumstances; caruana et al., 2015). meaning that participants of cohort two may showcase attitudes and behaviors that are highly attributed to their shared exposure to and experience with the pandemic. this phenomenon can ultimately introduce bias into the research because it signals a possible distortion of observed trends attributed to differences in shared life experiences that may have independently implicated the results. additionally, the lack of consistency in the child’s age at which mothers completed the lena snapshot serves as a limitation. considering the correlation between prenatal anxiety and age at snapshot completion is low (r = .1), this limitation would be more pertinent if there were some sort of correspondence between prenatal anxiety and child age at snapshot completion, such that mothers with higher levels of prenatal anxiety were systematically completing the lena snapshot at a different time than those with lower levels of prenatal anxiety. however, it remains an important factor to consider. the target age for the current study was 18 months; however, mothers with children as young as 16 months and as old as 21 months filled out the snapshot for the 18-month time point, contributing to the data the current study used. though the mean age at snapshot completion was approximately 18 months (m = 17.98), the standard deviation was 0.895, signaling that the data is rather spread out. this standard deviation– though not exorbitantly high–is notable given that, as mentioned previously children’s vocabuwhich observed that at three years old, white children of white mothers had a lesser likelihood of presenting with language delays than non-white children and mothers (the majority of them black). the consistent nature of this association highlights an exceedingly real equity issue that needs to be addressed to attain more positive outcomes for all children, regardless of their race or their mother’s race. lastly, in the third linear regression, though it yielded a statistically insignificant relationship between total prenatal anxiety and language development, a notable change was observed in the estimate attained for the prenatal anxiety–child language development relationship. the p-value for this relationship changed significantly from the second analysis (p = .72) to the third (p = .06). this change, although there is a lack of association, represents a marked increase in the predictive power of prenatal anxiety. this compelling finding signifies what this research hypothesizes to be a suppressor effect induced by the control of prenatal depression. a suppressor effect in a regression occurs when controlling for a variable increases the predictive power of the model, as observed here. this represents the possibility of a rather complex relationship between prenatal anxiety and child language development that is somehow mediated by the presence of prenatal depression, should said relationship exist. moreover, in this regression model, two statistically significant associations were observed: one between child sex and language development and another between prenatal depression and language development. the former of the two was also noted in the previous regression; however, the latter is specific to this regression, given that prenatal maternal depression was introduced here. a negative association between prenatal depression and child language development at 18 months was observed, representing a relationship characterized by a diminishing of language abilities in the presence of higher prenatal maternal depression. this coincides with existing literature which has found that at 12 months, children of mothers who were diagnosed with major depressive disorder while pregnant showcased lower language abilities compared to the control group (o’leary et al., 2019). limitations myriad factors limit the conclusions of the current study. as previously mentioned, the small sample size is a large limitation of the current study for its potential 27 esterine studies may account for the inability to interpret correlation as causation. lastly, the current study is limited in its failure to account for or consider pregnancy-specific anxiety (psa). though often conceptualized interchangeably with prenatal anxiety, psa is a unique phenomenon (langille et al., 2023). psa is common, affecting 2040% of women during pregnancy (araji et al., 2020). it differs from trait anxiety in that psa is an affective state in which a pregnant person feels worry, fear, or nervousness surrounding matters related to their pregnancy such as their prenatal health, the baby’s health, labor and delivery, and parenting (dunkel et al., 2022). it is important to consider these phenomena distinctly considering they have distinct clinical impacts (langille et al., 2023). conclusion despite the limitations mentioned above, the current study serves as a significant step in understanding the role that maternal mental health may play in child development, especially as it pertains to prenatal mental health and child language outcomes. moreover, it contributes to the literature surrounding the importance of distinguishing between the ramifications of varying clinical disorders, which are crucial given their differences in treatment. though the current study did not provide evidence that prenatal maternal anxiety influences child language development at 18 months, this null hypothesis suggests a need to achieve greater clarity into its true impact, given that these findings oppose current literature. the implications of improperly understanding the effects of prenatal anxiety, or maternal mental health, on child development are such that we remain incapable of providing adequate resources to children who may be at a disadvantage or to mothers who may be unaware of possible consequences. it also provides thoughtful insight into other associations present within this realm such as maternal race and child gender’s seeming to influence child development as well. by means of attempting to answer a question and shed light on prenatal mental health, the current study raises new questions regarding patterns and relationships that may exist in the sphere of the mother-child matrix. it’s important to understand the implications that may arise for child development based on prenatal maternal mental health to know how to best support pregnant mothers and their children not only during pregnancy but at other stages as lary is characterized by rapid growth at 18 months of age, with studies showcasing that infants may add up to 10-20 new words to their vocabularies daily (fenson et al., 1993; reznick & goldfield, 1992). it is important to note that in the current study we controlled for child age, which addresses this concern. the data was also limited by the measures used to capture the independent and dependent variables–the beck anxiety scale and the lena snapshot. both measures relied on parent reporting, which introduces the potential for social desirability bias, where individuals answer questions in a way that might make them seem more “acceptable” (paulhus, 2017). one specific limitation of the lena snapshot includes what may be perceived as a limited scope, given that the snapshot primarily focuses on expressive and receptive language, failing to capture other parts of language, such as metalinguistic awareness and higher-order language skills (lena foundation, 2022). additionally, currently, there is limited validity for multilingualism with the snapshot questionnaire, given that responses are compared to norms established by monolingual, north american english-speaking children. this fails to account for the nuances which multilingualism adds to language development and acquisition. a large portion of the study’s participants, mothers and children alike, fall into this demographic, raising a concern regarding the accuracy of language abilities as captured by lena snapshot scores. a specific limitation of the beck anxiety inventory (bai) is its low discriminant validity in distinguishing between symptoms of anxiety and depression (muntingh et al., 2011). this raises a concern for the present study’s aim to isolate the effects of anxiety, as bai scores may not accurately capture anxiety independent of depressive symptoms. the study’s correlational design also limits its implications for drawing causal inferences. while we had causal theories about the links between maternal anxiety and child development, it’s impossible to discern whether a causal relationship exists due to the lack of experimental manipulation in correlational research. indeed, a range of confounding variables–including those that we did and did not control for–could have biased any observed associations between the constructs in our study. though no significant association was observed in the present study, this limitation impacts all studies conducted without random assignment. thus, it is important to consider how future 28 the pertinent prenatal period this nature, within the same vein as the aforementioned recommendation, would be to control for more covariates, such as prenatal stress. it is important to note that the study whose data the current study used also measured maternal stress at the prenatal time point. to advance the mission of dissecting varying facets of mental health (i.e., depression vs. anxiety vs. stress, etc.) in order to further understand their differences and implications, it is important to account for as many variables as possible, including prenatal stress. future studies could assess the association between prenatal mental health and child outcomes by comprehensively accounting for different components of the former. to date, in the domain of child language development, research has found that the level of prenatal stress can account for variance in 2-year-old toddlers’ productive and receptive language abilities (laplante et al., 2004), showcasing the ability of prenatal stress to dictate child language development in some capacity. differentiating aspects of maternal mental health and understanding their possible implications for not only children but also for mothers is incredibly pertinent. this is particularly evident given the intersection between research and understanding as well as intervention and policy. for the sake of best supporting these communities, it’s essential to appreciate the intricacies of factors that may affect them. ultimately, the current study contributes to an under-researched area of child psychology and development. although the findings do not necessarily demonstrate a cause for concern, it is essential to continue researching in this domain to identify opportunities for action. references anderson, r. c., & freebody, p. 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(2015). housing insecurity, maternal stress, and child maltreatment: an application of the family stress model. social service review, 89(1), 9–39. https://doi. org/10.1086/680043 32 the pertinent prenatal period table 1 descriptives (demographic variables) note. n = 304 note. this table shows descriptive statistics for the demographic variables. the total participant count for the current study is 167 children/families, as stated in the last row in the table. maternal age is reported in years. family income is reported in usd. maternal education is reported in years. child age at lena (language environment analysis) snapshot completion is reported in months. family income was log-transformed. 33 esterine table 2 descriptives (iv & dv) note. lena is representative of language environment analysis. 34 table 3 correlation matrix note. bolded correlations indicate statistically significant correlations (p < .05). construct names rather than measure names are used in the matrix. the pertinent prenatal period 35 table 4 correlation matrix esterine note. bolded correlations are significant of highly correlated variables. only correlations relevant to the current study and the overarching literature are included in the matrix. construct names rather than measure names are used in the table. * covariate included – covariate not included 18 the impact of childhood cancer on family functioning: a review tamaki hosoda feinberg school of medicine, northwestern university family functioning can influence the adjustment of children with cancer. in order to provide effective interventions for the family, it is important to recognize how family functioning, including parental adjustment and distress, can change during the course of treatment. upon review of current literature, some variations in findings in family functioning due to childhood cancer were found. while some families showed resiliency (a non-disorganizing impact), others showed signs of impairment throughout the treatment (a disorganizing impact). moreover, some families even exhibited improvement (an organizing impact). in addition, it was found that such outcomes were related to different research methodologies (i.e., quantitative, qualitative, cross sectional, longitudinal). based on these methodological distinctions, this review attempted to seek links between specific research designs and particular results in order to delineate a clearer picture of the dynamic transitions within families and their function over the course of childhood cancer treatment. considering an overall trend of family functioning associated across studies of varied methodologies, this review speculates that while families with high family functioning might receive appropriate social resources and strengthen their internal bonds during the course of treatment, families with low family functioning might experience difficulties coping with adverse events and fail to reestablish a new pattern of family functioning. this review also indicates that such changes in family functioning occur on both practical (e.g., reassignment of family role) and existential levels (e.g., exploration of the meaning of illness) in the context of childhood cancer. the impact of childhood cancer on family functioning due to remarkable advances in childhood cancer treatment, the five-year survival rate for all cancer sites (including leukemia, cancer of the brain and other nervous system, renal tumors, and other cancers) has increased to 79% (jemal et al., 2006). this improvement in the survival rate causes long-term repercussions on the lives of children and family (mccubbin, balling, possin, frierdich, & bryne, 2002). mccubbin et al. (2002) argue that recurrent admissions, invasive treatments for the child, role shifts within the family, and the uncertainty of prognosis can be stressful for the family, thereby debilitating family functioning. additionally, kinahan et al. (2012) indicate that physical disfigurements, especially cranial and spinal deformities, and hair loss due to treatments, on childhood cancer survivors might have significant psychological impacts. such physical disfigurements might increase the risks of developing anxiety, depression (kinahan et al., 2012), and more negative self-image (jamison, lewis, & burish, 1986), thereby impairing child patients’ quality of life. given that these physical characteristics might remind the family of the child’s cancer, they could also have a psychological impact on the family (björk, wiebe, & hallström, 2005; quin, 2008). impact of childhood cancer over the treatment phases alderfer and kazak (2006) describe the impact of childhood cancer on families through the four phases of treatment: diagnosis, treatment initiation, illness stabilization, and the end of treatment. diagnosis phase. because common childhood cancer symptoms, such as fatigue and joint pain, are often overlooked in the diagnosis phase, parents often wait days or weeks before taking their children to a hospital. this delay may increase a sense of guilt in the parents. when parents do visit physicians, they often see their children undergo painful, invasive diagnostic procedures. meeting with unfamiliar multidisciplinary professionals and receiving an immense load of information about the illness may overwhelm parents and increase their anxiety (alderfer & kazak, 2006). similarly, siblings may also feel that their lives are disrupted due to the illness, as they worry about the survival and health of their ill brother or sister. at the same time, the siblings may be, or feel, somewhat excluded by their families because parents’ attention tends to focus on the ill children and those siblings may not receive sufficient information about the illness from their parents, preventing them from having a complete and accurate understanding of the experiences of their ill brother or sister. this may be a scary correspondence concerning this article should be addressed to tamaki hosoda, northwestern university, feinberg school of medicine, 710 n. lake shore drive, chicago, il 60611. email: tamakihosoda2014@u.northwestern.edu. graduate student journal of psychology 2014, vol. 15 copyright 2014 by the department of counseling and clinical psychology teachers college, columbia university 19 hosoda feeling for those children (havermans & eiser, 1994). treatment initiation phase. in the treatment initiation phase, families’ daily lives may begin to revolve around treatment. parents see their children manifest side effects (e.g., nausea, rashes, poor appetite) and begin or continue painful treatments (e.g., surgery, chemotherapy, radiation therapy), which might cause families anxiety and feelings of guilt as the experience of watching the child suffer takes its toll on parents’ psychological wellbeing (enskar, carlsson, golsater, hamrin, & kreuger, 1997). illness stabilization phase. during the illness stabilization phase – generally weeks or months after diagnosis, although relapse and severe side effects may occur – treatment begins to be more fully incorporated into families’ new daily life patterns (alderfer & kazak, 2006). the end of treatment phase. at the end of treatment – usually months or years post-diagnosis – intense treatment is replaced by periodical follow-up visits. during this period, the families’ overall burden may decrease. however, this often causes mixed feelings in parents, namely anxiety at the same time as feelings of joy (katz & jay, 1984). through the course of treatment, families may increase their dependency on medical care and staff, preventing them from facing the fear of relapse. therefore, the end of treatment can make families feel that they have lost the sense of security and protection that they enjoyed while their children were under constant care, causing more anxiety (alderfer & kazak, 2006; katz & jay, 1984). in addition, families have to flexibly recreate their everyday life pattern without the regularity of the previous cancer treatments. since families may have by this point successfully incorporated treatment regimens into their lives, including diet restrictions and limited physical activities, changing these patterns could also be challenging (ostroff, ross, & steinglass, 2000). even after the completion of treatment, the fear of death, relapse, and lasting negative side effects, such as growth disorder and infertility caused by treatment, can persist in the minds of families (byrne et al., 1987; hutchinson, willard, hardy, & bonner, 2009; ostroff et al., 2000; vannatta, salley, & gerhardt, 2009). thus, families’ experiences may change dramatically during the course of treatment because each phase of childhood cancer treatment has a different and significant impact on their functioning. family functioning and childhood cancer treatment since health care providers have frequent contacts with the family over the course of treatment, especially during hospitalizations or intense treatment, they may often see childhood cancer’s impact on the family. for example, the demands of treatment might force the parents to change their jobs in order to be available for their child’s frequent hospital visits, or to seek a relative’s support for siblings’ care. likewise, the potential disruption in the balance of family relationships could lead to an eventual divorce (kupst & schulman, 1988; mccubbin et al., 2002). concerns about financial difficulties might also increase as the treatment is prolonged, placing further strain on family functioning (kalnins, churchill, & terry, 1980; kupst & schulman, 1988; mccubbin et al., 2002). upon seeing such familial problems through the treatment, health care providers often mistakenly link worsening family relationships (e.g., divorce) or parental distress (e.g., depression) to childhood cancer, rather than truly grasping the underlying complexities of such issues (cadman, rosenbaum, boyle, & offord, 1991). it is important for health care providers to appropriately consider family functioning in addition to physical symptoms, since it may influence current and later psychological adjustment of ill children and their treatment in both direct and indirect ways. (drotar, 1997; katz & jay, 1984, kazak et al., 2011; pelcovitz et al., 1998; pless, roghmann, & haggerty, 1972, trask et al., 2003; wallander & varni, 1998). for instance, when the family is cooperative and has open communication concerning the illness, the child might be better able to acknowledge the situation (dimatteo, 2004; sobo, 2004). on the other hand, if psychosocial problems in the family (e.g., neglectful childcare, parental depression) deter the parents from regularly attending hospital visits and seeking medical consultation, pediatricians might not be able to smoothly proceed with treatment (sobo, 2004). moreover, when the child of such parents sees other parents visiting their own children, he might feel lonely or jealous, potentially 20 impact of childhood cancer on family: review worsening the existing relationships between him and other pediatric patients. in addition, if parents fail to understand complicated medical regimens, such as food restrictions, the treatment may not proceed in an appropriate manner (dimatteo, 2004; sobo, 2004). there is a lack of research investigating the effect of parental mental health problems on children diagnosed with cancer. nevertheless, one could speculate that excessive anxiety and fear might drive the parents to share information about their child’s poor prognosis with other parents, unsettling other parents and creating a negative environment for both other pediatric patients, their families, and the health care providers. as such, health care providers should consider family functioning and appropriately introduce psychological treatment to the family, as well as patients, not only as addition to the physiological treatment they administer, but as part of the same regimen. limitations of research serious limitations exist among previous studies exploring the impact of childhood cancer on family functioning. specifically, the use of heterogeneous methodologies makes a comprehensive examination of research findings difficult (grootenhuis & last, 1997). first, the utilization of different psychometric measures may affect the research outcomes by limiting the ability to generalize across studies. while some researchers utilize quantitative research with different psychometric scales, moreover, others employ qualitative research methods, such as interviews. a further important limitation is that most previous studies are limited by small, site-specific sample sizes (i.e., fewer than 50 participants) (drotar, 1994; pai et al., 2007). another issue affecting the generalizability of previous research can be found in the discrepancies concerning variables (e.g., the types of cancer, existence of ongoing treatment, and amount of time following diagnosis) that may influence the specific research findings (kupst, & schulman, 1988). for example, families with on-treatment or off-treatment status may have or have had different experiences (cadman et al., 1991; hutchinson, willard, hardy, & bonner, 2009; sawyer, antoniou, toogood, rice, & baghurst, 2000; sloper, 2000). yet most studies under review do not take such information into consideration in examining their outcomes. other factors limit the generalizability of existing studies. for example, the decision to incur reversible and/or irreversible physical disfigurement (e.g., weight or hair loss, cranial or spinal deformities, amputation of limbs) or impairments (e.g., thyroid dysfunction, infertility, growth disorder) can pose significant stress on the patient and their family (alderfer & kazak, 2006; kinahan et al., 2012; long & marsland, 2011; oberfield & sklar, 2002; patenaude & kupst, 2000; vannatta et al., 2009). the studies reviewed here do not take account of these decisions. likewise, many researchers point out that the availability of social support from workplaces and professionals, including psychologists, social workers, and child psychiatrists, may affect family functioning. (ferrel, rhiner, shapiro, & dierkes, 1994; fife, norton, & groom, 1987; kupst & schulman, 1988; mccubbin et al., 2002; speechley & noh, 1992). while some studies include such information, others do not (pai et al., 2007). these limitations should be taken into account in the examination of research outcomes. among relevant studies, some variations in findings can be found. while some families show resiliency, others show signs of impairment throughout the treatment (long & marsland, 2011; mccubbin et al., 2002). different research designs may affect these results. yet there is a lack of research that seeks links between specific research designs and particular results. in order to fill this gap, this review examines the effects of varied research methodologies on study outcomes in order to depict a clearer picture of the dynamic transitions within families and their function over the course of childhood cancer treatment method a literature search was conducted using psycinfo, pubmed, and web of science with the following search terms: “childhood cancer,” “family functioning,” “parents,” “psychological adjustment,” and “distress.” the titles and abstracts of studies concerning families experiencing childhood cancer published from 1980 to 2012 were reviewed. in order to identify relevant sources, citations of reviewed studies were also investigated. in the review, research dealing 21 with the psychosocial issues of child, parent, sibling, and family related to childhood cancer were available. among these studies, the following inclusion criteria were used: (a) the sample of pediatric patients of age 18 or younger; (b) patients with any types of cancer (e.g., leukemia, brain tumor); (c) studies written in english; (d) studies focusing on family functioning, especially parental experiences. the following exclusion criteria were used: (a) studies focusing on the experiences of patients or their siblings; (b) studies focusing only on fathers, not parents or mothers; (c) studies focusing on gender differences of parents; (d) studies focusing on treatment approaches; (e) studies focusing on parental bereavement following patients’ death; (f) studies focusing on marital quality without the inclusion of family functioning. using these criteria, 30 studies (18 quantitative studies and 12 qualitative studies) were included for the review. review impact of childhood cancer: methodologies among previous studies, three types of family functioning outcomes were found: disorganizing (impairing), non-disorganizing, and organizing effects of childhood cancer (mccubbin et al., 2002; pai et al., 2007). to investigate the impact of childhood cancer on family functioning, it is necessary to analyze the components that caused these three different outcome directions in terms of research methods. impact of childhood cancer found in quantitative studies. among quantitative studies, the impacts of childhood cancer on family functioning are discussed in both longitudinal and cross-sectional studies. longitudinal studies. many researchers who used psychometric measures found the signs of impairment in family, including parental poor mental health and worsened relationships among family members. concurrently, their outcomes have multiple variations. in particular, the passage of time following diagnosis can be an important factor leading to varied outcomes (ostroff et al., 2000; pai et al., 2007). that is, many researchers corroborate the argument of pai et al. (2007) that parental distress tends to increase at the point of diagnosis, but gradually decreases throughout a year following diagnosis. during the diagnostic phase, manne et al. (1996) found that the majority of the parents report mild depressive symptoms and these symptoms remain at the same level or are reduced after 6 months post-diagnosis. one year after diagnosis, sawyer, antoniou, toogood, rice, and baghurst (1993) found that although most parental psychosomatic symptoms were attenuated, parents of children with cancer diagnoses still had more symptoms than the control group. fife, norton, and groom (1987) show the overall stability of family functioning through the treatment, after the diagnosis was received. most families maintained their function except during the diagnosis phase and did not experience drastic changes in their family structure (e.g., divorce, separation). simultaneously, fife et al. (1987) found that families with concurrent problems prior to diagnosis (e.g., having a family member in psychiatric care) showed lower family functioning after the diagnosis. within 18 months following diagnosis, on the contrary, sloper (2000) found that the distress level of most parents did not decrease and some parents showed enhanced distress levels related to family cohesiveness and repeated hospitalizations. thus, although most researchers share the argument of definite negative impacts of childhood cancer experiences during the diagnostic phase, divergent family functioning outcomes after this phase were found in different studies. in the illness stabilization phase, while most families may show good adaptation, others may not. during the two years following diagnosis, sawyer, antoniou, toogood, rice, and baghurst (2000) identified the successful adaptation of families. according to them, the psychological adjustment and function of families with childhood cancer gradually improved and became closer to the level of control groups in four years. on the other hand, some researchers identified both good and poor adaptations by families. over the course of 5 years following diagnosis, wijnberg-williams, kamps, klip, and hoekstra-weebers (2006) found that while the distress in most parents was alleviated, some parents who experienced the repeated deterioration of their child’s condition exhibited elevated distress levels. moreover, kazak (1989) suggests that families that were low-functioning prior to diagnosis may adjust poorly to the illness hosoda 22 after the end of treatment. similarly, maurice-stam, oort, last, and grootenhuis (2008) found that although parental psychological distress tends to return to a normal level, families with a passive reaction pattern tend to have higher distress levels than families with an optimistic reaction pattern. thus, while the passage of time seems to attenuate disorganizing effects on family functioning, some families still experience detrimental impact on their function. cross-sectional studies. similar to the aforementioned longitudinal studies, cross-sectional studies, which do not take the passage of time post-diagnosis into consideration, show both good and poor adaptation of parents in response to their child’s diagnosis. dockerty, williams, mcgee, and skegg (2000) found that the parents of children with childhood cancer reported significantly higher distress levels and poorer mental health in comparison with the control group. on the other hand, wright (1993) examined the transition of the parents’ quality of life and found that the parents still perceived their current quality of life to be satisfactory even though they felt that their quality of life had become significantly poorer in the context of the treatment. moreover, cadman et al. (1991) add to the literature by considering the impact of psychosocial services. they conducted a survey of parents whose children had chronic illnesses or physical disabilities and found that the functioning of these families was not different from that of control group parents. based on this conclusion, they warn of the risk that health care providers simply assume that such parents have depressive feelings, which do not always exist. they also explain that parents whose children have such illnesses or disabilities have a greater access to psychosocial services during their children’s treatment. increased access might have attenuated the impact of childhood cancer on family functioning. given the possibility that utilization of psychosocial services might have improved the family’s coping capability, the fact that their function was at the same level with the control group may not necessarily mean that the parents had not experienced depressive feelings or that the family did not need support. it may only mean that they had more resources than families in the control group. impact of childhood cancer in qualitative studies. similar to the quantitative studies under review, qualitative studies revealed variations in family functioning due to childhood cancer. as a variation of disorganizing effects, many qualitative studies acknowledge impairing effects on parental psychology when treatment is prolonged, such as depression (clarke-steffen, 1997; knafl, breitmayer, gallo, & zoeller, 1996; patterson, holm, & gurney, 2004; ward-smith, kirk, hetherington, & hubble, 2005; young, dixon-woods, findlay, & heney, 2002), debilitated family cohesion, or worsened marital relationships (barbarin, hughes, & chesler, 1985). contrary to the quantitative studies, evidence of potential positive effects as well as non-impairing impacts of childhood cancer on family functioning was found among the qualitative studies. for instance, kupst and schulman (1988) found that in the six to eight years following diagnosis, some families experienced significant role transitions (e.g., divorce, remarriage, career changes). yet most families regained their original function and stability despite these transitions. moreover, mccubbin et al. (2002) also found that families showed resiliency by maintaining functional integrity during the treatment phases. additionally, quin (2008) found that one-third of families perceive their child’s cancer experiences positively, by feeling that the family became closer overall and were more likely to ‘live in the present’ in response to the difficult situation. by contrast, just over one-quarter of the participants experienced negative reactions of insecurity and fear. in particular, unlike the quantitative studies, most qualitative studies under review found a change of existential meaning due to childhood cancer experiences. for instance, by interviewing the parents of children with chronic renal failure, type 1 diabetes, or childhood cancer, gannoni and shute (2010) identified positive changes in the realms of self-esteem and assigning meaning to the illness. while experiencing severe distress, parents of children with these illnesses generally improved their self-esteem and were able to assign a meaning to the illness by observing their children’s emotional growth and self-regulated behavior. the parents also described their efforts to strengthen family functioning in order to cope with adverse situations by supplementing the partner’s role (e.g., a parimpact of childhood cancer on family: review 23 ent attends a medical appointment when the partner is too depressed or emotionally exhausted to do so). björk et al. (2005) present a complementary finding. although parents may lose their unconscious belief in immortality when confronted with childhood cancer, by learning about cancer and strengthening their relationships with healthcare providers and family members, they may establish beliefs more applicable to their situation, thereby beginning to regain their control and original capabilities. graves and aranda (2008) indicate that when facing relapse, families may live with both fear and hope, and that hope might not dispel fear. they therefore suggest that health care professionals need not only to help families stay hopeful but also to support them in living with both hope and fear. thus, the difficult circumstances of childhood cancer did not always have negative impacts on family functioning. in many cases, parents found a way to maintain their families, both by developing positive perceptions of their child’s illness and by adjusting the assignment of roles within the family. for example, parents may have intimate conversations and help each other to overcome the difficulty, which could improve their relationship and self-esteem. in this vein, family cohesion and marital relationships can in fact be strengthened by the experience of childhood cancer after diagnosis (barbarin et al., 1985; delden, & grypdonck, 2008; kars, duijnstee, pool, & quin, 2008). when considering positive effects of childhood cancer on family functioning, it is important to examine exogenous factors that may have contributed to such positive results. for instance, in terms of marital relationships, the fear of the child’s mortality may divert the parents from facing their own discord, thereby causing them to evaluate their marital relationships more favorably (barbarin et al., 1985). furthermore, the retrospective nature of qualitative interviews often leads participants to recast their experiences in a more favorable light (mccubbin et al., 2002). therefore, positive changes recorded by some studies should be attributed to the nature of their design, rather than to childhood cancer as such. differences in outcome by methodology. while some quantitative studies show impairing effects on family functioning due to childhood cancer, others show non-impairing effects. acknowledging the impairing effects on family functioning, by contrast, some qualitative studies found that childhood cancer actually has positive effects on family functioning, including the change of existential meaning. in other words, while quantitative studies tend to focus on disorganizing or non-disorganizing effects, qualitative studies tend to focus on organizing effects on family functioning. factors that lead to different family functioning outcomes given the discrepancy of outcomes seen among families, it is important to identify factors which influence consequences in family functioning (long & marsland, 2011). demographic characteristics. interestingly, many researchers indicate that the demographic characteristics of families are not significantly related to family function consequences (robinson, gerhardt, vannatta, & noll, 2007; thompson, gustafson, hamlett, & spock, 1992). for instance, robinson, gerhardt, vannatta, and noll (2007) found that the child’s gender and age were not significantly related to maternal distress levels, although they were associated with the wellbeing of the child and father (i.e., the older the child was, the lower the distress levels of both the child and fathers were). while this study deals with cystic fibrosis, not cancer, thompson, gustafson, hamlett, and spock (1992) also found that demographic characteristics (i.e., children’s age and gender, families’ socioeconomic status) or objective severity of illness were not strongly associated with maternal psychological distress. these findings imply that factors other than demographic characteristics may more affect on the outcome direction of family functioning. psychosocial support. many researchers suggest that psychosocial support for families can contribute to the improvement of parental wellbeing and family’s capabilities (barbarin et al., 1985; fife et al., 1987; hoekstra-weebers, jaspers, klip, & kamps, 2000; kupst & schulman, 1988). for instance, good communication with health care providers as well as within families might contribute to the enhancement of family functioning (shapiro, perez, & warden, 1998). additionally, psychological support from hosoda 24 relatives or friends can help the parents develop a positive interpretation of their child’s illness and reconstruct a new schema (mccubbin et al., 2002), thereby helping them stay hopeful (fife, 1994). health care providers and mental health professionals could also share information concerning the treatment with the family, thereby helping the family to see prospects of treatment and enhance their sense of control of the situation (patterson et al., 2004). existing factors in the family. kupst and schulman (1988) indicate that parental coping skills can be a key component for positive outcomes. such skills might include an ability to seek psychosocial support, as well as the ability to handle the situation by themselves. in addition, within marital relationships, open dialogue, coping skills of other family members, parents’ trait anxiety, freedom from financial difficulties, and the existence of ongoing treatment can also be factors for family coping and functioning outcomes (dockerty et al., 2000; hoekstra-weebers, jaspers, kamps, & klip, 1999; kupst & schulman, 1988; manne et al., 1996; ostroff et al., 2000; sawyer et al., 2000). pre-existing factors in the family. poor adjustment during the diagnostic phase may also predict family functioning after diagnosis (dockerty et al., 2000; manne et al., 1996; ostroff et al., 2000). fife et al. (1987) found that while most families maintained their function except during the diagnosis phase, families with psychosocial problems before diagnosis showed a further debilitation in their function. kazak (1989) also suggests that low-functioning families prior to diagnosis may adjust poorly to the illness after the end of treatment. considering these studies, it can be assumed that family functioning before diagnosis influences its future direction. impact of childhood cancer on family functioning across treatment phases this paper presents a comprehensive picture of the dynamic transitions of family functioning over the course of treatment by linking study outcomes to heterogeneous research methodologies. a review of the literature distinguishes two important perspectives: a perspective that examines the change of family functioning at multiple levels (i.e., practical and existential) instead of a linear level (i.e., disorganizing or organizing) and a perspective that considers family functioning before diagnosis. practical and existential layers although no study explicitly outlined the transitions of family functioning in terms of two layers, practical and existential, the changes within these two layers of family functioning during the treatment phases are seen in our sample of studies. the presence of this thread across studies can lead one to theorize that changes of family functioning may occur both in a practical layer (e.g., divorce or reassignment of family role due to the burden of finance and transportation) and in an existential layer (e.g., exploration of the meaning of illness, emotional growth, restructuring values, self-blame). specifically, research has explored the extent to which childhood cancer impacts family functioning based on a linear perspective (disorganizing, non-disorganizing, or organizing) (pai et al., 2007). some studies indicate that disorganizing, non-disorganizing, and organizing impacts can coexist in different layers. goldbeck (2006) suggests that parents with newly diagnosed chronic ill children can exhibit a mixed psychological state involving depression accompanied by debilitated physical daily functioning, along with a sense of satisfaction with their families. that is, the co-occurrence of a disorganizing impact (depression) and organizing impact (satisfaction) can be found in these parents’ reactions. based on these findings, changes in family functioning can occur in a parallel fashion across practical and existential layers. furthermore, it can also be inferred that illness affects the two layers differently. for instance, deteriorated illness conditions might increase parental burden in the practical layer, whereby family’s capability and self-esteem could be impaired in the existential layer. otherwise, even if the family functioning or parental distress level in the practical layer does not change throughout the course of treatment, the quality of family functioning or parental distress might change if parents positively integrate their traumatic experience into their own lives (fife, 1994). relating to research methodologies, while studies administering quantitative measures emphasize apimpact of childhood cancer on family: review 25 praisal of practical-level changes (disorganizing or non-disorganizing), studies administering qualitative measures focus on appraisal of value-oriented and existential-level changes (disorganizing, non-disorganizing, organizing). more specifically, given the nature of psychometric scales which have narrowly-focused variables (sawyer, 2000), it is conceivable that quantitative research tends to elicits factors in the practical layer. on the other hand, since qualitative research, especially interviews, can allow interviewees to express subtle, personal meaning of life-threatening illness, it may elicit factors in the existential layer as well as in the practical layer. conceivably, even if psychometric scales show a detrimental impact on family functioning due to childhood cancer experiences, the family might also experience a positive impact on their function at the existential level. in short, disorganizing, non-disorganizing, and organizing effects might co-occur at different levels. family functioning and diagnosis although the few aforementioned studies suggest that inherent problems in the family could be predictive for family functioning outcomes (fife et al.; 1987; kazak, 1989), no study explicitly outlined how such pre-existing problems affect outcome directions over the several phases of treatment. olson (2000) attmpts to remedy this gap by proposing a circumplex model, which conceptualizes family life course along three dimensions (family cohesion, family flexibility, and communication). according to this model, while families balanced in those three dimensions can adjust to a challenge by utilizing resources within the family, families lacking that balance may have difficulties coping with a crisis (alderfer & kazak, 2006; olson, 2000). olson’s model does not focus on childhood cancer and therefore does not take the long-term treatment phases into consideration, but it can help explain the dynamic transitions of family functioning. to summarize, while a high-functioning family may seek out social resources and strengthen the bonds within the family during the course of treatment, low-functioning families may experience difficulties coping with adverse events and fail to reestablish a new pattern of family functioning. dynamic transitions in family functioning on the basis of the discussion above, it can be concluded that disorganizing, non-disorganizing, or organizing impacts on family functioning might co-occur in both practical and existential layers throughout childhood cancer. simultaneously, while high-functioning families before diagnosis might tend to enhance their functioning, low-functioning families before diagnosis might be more at a risk of lowering their functioning through childhood cancer experiences. clinical and research implications upon review of the current literature, a discrepancy between family functioning outcomes has been found: some families show resiliency and others show impairment during the treatment phases. in the examination of factors that caused this disparity, two perspectives that were not fully integrated into the previous literature are distinguished: a perspective that examines the change of family functioning at multiple levels (i.e., practical and existential) and a perspective that considers family functioning before diagnosis. based on this conclusion, this study has delineated a clearer picture of the dynamic transitions of family functioning over the course of treatment. that is, while families at risk might reveal their inherent problems in the treatment phases and their relationships might disconnect, consolidated and more functional families might strengthen their existing ties. such changes may occur in the practical and existential layers in a parallel fashion. as suggested in this review, having a comprehensive picture of family over the pre-diagnosis and treatment phases may enable care providers and mental health professionals to deliver better screening and more effective interventions for the family. for instance, even if the parents feel stressed due to financial strains caused by the treatment at a practical level, they might still have found some meaning of their child’s illness and improved their self-esteem at an existential level. an in-depth understanding of the family might help mental health professionals identify such a positive change and equip them to help families to deal with stress due to financial strains. at the same time, not all negative impacts should hosoda 26 be attributed exclusively to childhood cancer. for example, even if the mother shows depressive symptoms in the treatment phases, a pre-existing problem (e.g., relationship with her own parents, domestic violence from her husband) might also have contributed to her depression. a more comprehensive understanding of the family could help mental health professionals identify such a preexisting problem, which may exacerbate the impacts of childhood cancer by itself. as for screening, kazak et al. (2011) suggest the use of the psychosocial assessment tool, a brief screening tool based on obtained parental reports. this tool aims to detect families at psychosocial risk at the point of diagnosis. health care providers and mental health professionals could deepen the understanding of the family by administering such a screening tool or interviewing the family. having a comprehensive picture of family dynamics could also help mental health professionals choose an appropriate intervention. for example, sahler et al. (2005) found that problem-solving skills training was efficacious when mothers with children newly diagnosed with childhood cancer encountered difficulties in medical contexts. moreover, mccubbin et al. (2002) indicate the necessity of strength-based interventions to elicit family resiliency. since there are many intervention options, the identification of the characteristics of a family and what they actually need at a practical level and/or existential level in the pre-diagnosis and treatment phases might allow mental health professionals to facilitate appropriate interventions corresponding to each family. health care providers would also benefit from recognizing the mechanisms of family functioning influenced by childhood cancer experience. even if psychosocial problems in the family (e.g., neglectful childrearing, parental depression) interfere with smooth communication between the parents and health care providers, health care providers are required to communicate with the parents in order to proceed with treatment (dimatteo, 2004; kazak et al., 2011; sobo, 2004). therefore, if health care providers develop a better understanding of family’s characteristics and its problem, this might help them better communicate with parents. furthermore, when health care providers see the worsened relationship between the parents influence the child’s psychological state, they might empathize with the child, which may lead to feelings of self-blame when they cannot help the child (meadors, lamson, swanson, white, & sira, 2009). however, if health care providers recognize that family functioning could improve in the long-term and if they have strategies to mediate such family problems, this might reduce their emotional pain. these observations suggest that better recognition about the mechanism of family functioning will be useful for parents, children, and health care providers. ultimately, understanding family functioning in light of two perspectives perspectives that examines family’s transitions at multiple levels (i.e., practical and existential) and that considers family functioning before diagnosis will better equip care providers and mental health professionals for effective interventions into families with need. further research to examine these perspectives is also needed. references alderfer, m. a., & kazak, a. e. 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(2002). parenting in a crisis: conceptualising mothers of children with cancer. social science & medicine, 55, 1835–1847. doi:10.1016/s02779536(01)00318-5 impact of childhood cancer on family: review     31   graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university a facet-level analysis on the associations between mindfulness and attachment styles angela e. lee-winn university of washington yuet juhn tse university of washington gareth i. holman university of washington jeremy w. luk university of washington practicing mindfulness generally results in improved psychological health, behavioral regulation, and relationship functioning. attachment style describes how children and adults respond to relationship stress. a recent correlational study by shaver, lavy, saron, and mikulincer (2007) demonstrated direct links between facets of mindfulness and attachment styles in a sample of adults who volunteered to participate in a meditation retreat trial. the current study tested if these associations can be generalized to a college sample of 204 undergraduate students who were not involved in a meditation trial. mindfulness and attachment styles in college students. findings highlight the possibility that mindfulness and attachment styles may share common underlying processes. implications for theory and clinical practice of mindfulness are discussed. mindfulness can be defined as the nonjudgmental awareness of what is taking place in the present moment (brown & ryan, 2003; dimidjian & linehan, 2003; kabatzinn, 1994; marlatt & kristeller, 1999). interventions utilizing mindfulness skills training in a clinical setting have been developed (baer, 2003) demonstrating that the practice of mindfulness leads to a variety of positive physical and psychological health outcomes. because its usefulness has largely been established based on treatment outcome studies, little is known about how early life experience and development impacts subsequent levels of mindfulness. understanding the associations between facets of mindfulness and attachment style is one way to address this gap in the literature. this is an important research question because it may highlight the importance of promoting secure attachment style early in life, given its association with higher levels of mindfulness.                                                                                                   angela e. lee-winn, department of psychology, university of washington; yuet juhn tse, department of psychology, university of washington; gareth i. holman, department of psychology, university of washington; jeremy w. luk, department of psychology, university of washington correspondence concerning this article should be addressed to jeremy w. luk, department of psychology, university of washington, box 351525, seattle, wa 98195-1525. email: jwluk@uw.edu. m indfulness as a m ulti-faceted construct mindfulness as a psychological construct has primarily been examined in the context of clinical research. practices associated with mindfulness, such as transcendental meditation, were introduced into western treatments for psychological problems (candelent & candelent, 1975) and substance abuse (shafii, lavely, & jaffe, 1975) as early as the 1970s. in recent years, interests in mindfulness research have grown rapidly in clinical psychology (hayes, follette, & linehan, 2004) and across the disciplines of psychology and neuroscience (davidson & lutz, 2008). research demonstrates that mindfulness is associated with a variety of positive outcomes, including lower stress reactivity, improved mental and physical health, greater relationship satisfaction, improved responses to relationship conflict, and improved self-regulation (brown & ryan, 2003; brown, ryan, & creswell, 2007). in addition, a range of mindfulness practices (i.e., techniques for increasing mindfulness) are associated with improved outcomes for a variety of physical and mental health problems, including depression, alcohol use, and chronic pain (baer, 2003). despite its clinical utility, one persistent issue in the field of mindfulness research is the generation of an adequate operational definition and corresponding measurement methods of the construct. to date, different researchers have defined mindfulness in various ways (e.g., bishop, lau, shapiro, carlson, & anderson, 2004; kabatzinn, 1994; linehan, 1993). moreover, existing mailto:jwluk@uw.edu lee-winn, juhn tse, holman, & luk   32 measurements of mindfulness have focused on self-report questionnaires and the proliferation of self-report measures has complicated assessment and construct definition (see baer, smith, & allen, 2004 for a review). as such, one debate in the field has to do with the overarching question, takes a multi-dimensional facet approach, with facets corresponding to separate dimensions of the mindfulness construct that are derived statistically through factor analysis, rather than based on observation or theory alone (baer, smith, hopkins, krietemeyer, & toney, 2006). the current study defines mindfulness as the awareness of the present moment in a nonjudgmental manner, and recognizes five different facets of mindfulness including: (1) nonreactivity to inner experience, such as refraining from impulsive reactions, (2) observing and attending to sensations, perception, thoughts, and/or feelings, such as paying attention to the intensity/location/duration of bodily sensations or the pitch/volume/tone quality of sounds, (3) acting with awareness, concentration, and nondistraction, undivided attention, (4) describing and labeling with words, emotions nonjudgmentally, and (5) nonjudging of experience, such as refraining from judgments or selfcriticism about having an experience (baer et al., 2006). using the multi-facet approach, this study explores whether individual dimensions of the mindfulness construct have differential associations with different attachment styles. a ttachment styles attachment theory and research developed primarily through the work of john bowlby (1982), a british psychiatrist and psychoanalyst, and mary ainsworth, an american developmental psychologist (ainsworth & bowlby, 1991). bowlby (1982) argued that attachment experience in a variety of contexts (most saliently in relationships) throughout the life span constituting a theory, ainsworth systematically studied individual differences in the attachment responses of infants. she eventually developed a standardized measurement protocol and a corresponding classification system for categorizing normative, (i.e., secure) attachment and dysfunctional attachment (i.e., insecure). the insecure attachment categories were (1) anxious-resistant, where the child exhibited extreme distress upon separation from the primary caregiver/parent and ambivalence towards the parent upon reunion, and (2) avoidant, where the child exhibited low levels of distress upon separation from the primary caregiver/parent and indifference to or avoidance of the parent upon reunion (ainsworth, blehar, waters, & wall, 1978). with the continuation of empirical research, attachment theory has been significantly revised and expanded. for example, shaffer (2007) argued that attachment theory has become the dominant approach to understanding early social development. in addition, the application of attachment theory has been extended to explain different styles of interpersonal relationships among adults (hazan & shaver, 1987; fraley, 2002). subsequent studies have focused on assessment of attachment security along two continuous dimensions of anxiety and avoidance (brennan, clark, & shaver, 1998). these studies have generally found that adults high in attachment avoidance tend to minimize the importance of close relationships and respond to relationship stress by withdrawing and avoiding. in addition, adults high in attachment anxiety tend to be preoccupied with potential abandonment and respond with great anxiety when relationship security and closeness are threatened. on the other hand, securely attached adults (low in avoidance and anxious attachments) respond flexibly and adaptively to relationship stress and report high levels of satisfaction and connection in their relationships. decades of correlational and experimental priming studies have demonstrated that attachment security in adults is related to a range of psychological and health-related variables, including relationship quality, depression and anxiety, somatic symptoms, and work performance (mikulincer & shaver, 2007). relationship between m indfulness and a ttachment styles mindfulness is a state of mind in which attention is directed in an open and flexible way to the present moment (brown & ryan, 2003; dimidjian & linehan, 2003; kabatzinn, 1994; marlatt & kristeller, 1999). in terms of psychological function, mindfulness involves the deployment or regulation of attention to present experience in a manner that is not distorted by negative thoughts, and where the impact of negative emotion is minimized (brown & ryan, 2003; brown et al., 2007). the tradition of mindfulness has also produced a well-articulated set of methods for teaching mindfulness, contributing to the embrace of mindfulness teachings by clinical psychologists (baer, 2003). attachment theory describes a similar set of self and emotion regulatory functions that are situated within a specific interpersonal and developmental context (shaffer, 2007). in particular, secure attachment appears to have specific features in common with a mindful state of awareness. for example, both serve a self-regulatory function in the face of threats, and both involve flexible openness to the moment, rather than preoccupation with threat (as in attachment anxiety) or avoidance of threat (as in attachment avoidance). in addition, secure attachment nurtured by positive parenting practices appears to have much in common with mindfulness, including attentiveness and tempered reactivity (laranjo, bernier, & meins, 2008), mindfulness and attachment styles   33 and suggests a sequence in which mindful parents may produce securely attached children, who in turn may become mindful and securely attached adults and parents. only a few studies have empirically evaluated the relationship between mindfulness and attachment. shaver, lavy, saron, and mikulincer (2007) reported data from 70 experienced adult meditators who participated in an intensive full-time meditation training retreat for three months. attachment anxiety and attachment avoidance predicted all five facets of mindfulness, as assessed by -facet assessment, accounting for 10 to 38 percent of the variance in mindfulness. taken together, attachment avoidance and anxiety accounted for 42% of the variance in the total mindfulness scores. in addition, walsh and colleagues (2009) studied trait anxiety, attachment anxiety and avoidance, attentional control, and mindfulness in two separate correlational studies involving 127 psychology students and university staff members. with the exception of attachment avoidance, mindfulness scores were predicted by trait anxiety, attentional control, and attachment anxiety. finally, in a sample of psychology undergraduates, securely attached individuals reported significantly higher levels of mindfulness than insecurely attached individuals (cordon & finney, 2008). in summary, the relationship between mindfulness and attachment styles has only been studied by a small number of researchers, and not all have explored this relationship on the facet-level. importantly, shaver and colleagues (2007) demonstrated that the strength of the relationship between the two insecure attachment styles and mindfulness varies across different facets of mindfulness in a sample of experienced meditators. the purpose of the current study was to replicate the study by shaver et al. (2007) using a college sample in which students may or may not be experienced meditators. the exploratory hypothesis of this study was to examine whether different facets of mindfulness relate differentially to either an anxious or avoidant attachment style. m ethod participants participants were male and female undergraduates over the age of 18 and of diverse ethnic backgrounds, who were recruited from the psychology human subject pool at a large university located in the pacific northwest of the united states from january 2008 to march 2008. a total of 222 undergraduate students participated in this study. during data analyses, 18 participants were screened out because of invalid or missing demographic information, including age, gender and/or ethnicity. finalized data analyses included 204 participants. general demographics of all participants were the following: 61.8% were female with mean age of 19.38 (sd = 1.60); 45.6% were caucasian, 36.3% were asian, 4.4% were native hawaiian or pacific islander, and 13.7% were mixed or others ethnicities. previous meditation experience was not required to participate in this study. procedure questionnaire packets were distributed to all undergraduate students who agreed to participate. all participants were then given an hour to complete the questionnaires and received extra course credit for their participation. participants were allowed to leave anytime during the experiment and were debriefed following completion. m easures questionnaire packets included demographic questions (i.e., age, gender, and ethnicity), the five facet mindfulness questionnaire (ffmq; baer et al., 2006), and the experiences in close relationships scale (ecrs; brennan, clark, & shaver, 1998). the ffmq was used to measure the five different facets of mindfulness, including the ability to (1) observe, (2) describe, (3) act with awareness, (4) be nonjudgmental, and (5) be non-reactive. this scale, as well as the individual five facets, has shown to be reliable ( . the ecrs was used to measure adult attachment style based around two factors analytically derived from the primary constructs of avoidance and anxiety. results the aim of the present study was to investigate whether different facets of mindfulness correlate with anxious attachment style or avoidant attachment style. to understand the relationships between the five facets of mindfulness and attachment styles, we c correlations. in addition, multiple regression analyses were conducted to evaluate the strength of all five facets combined in predicting attachment styles. pearson's correlations between mindfulness subscales and attachment styles were used (see table 1). mindfulness total score was negatively correlated with both anxious attachment style (r = -.34, p < .01) and avoidant attachment style (r = -.36, p < .01). observe was negatively correlated with avoidant attachment style (r = -.19, p < .01). describe was negatively correlated with avoidant attachment style (r = -.23, p < .01). acting with awareness was negatively correlated with anxious attachment style (r = -.32, p < .01) and avoidant attachment style (r = -.29, p < .01). lastly, nonjudging was negatively correlated with anxious attachment style (r = -.47, p < .01) and avoidant attachment style (r = -.25, p < .01). in addition, the variability of strength among the five facets in association with attachment styles also exists when all five facets were combined into a single model for predicting anxious attachment style and avoidant lee-winn, juhn tse, holman, & luk   34 table 1 pearson correlation coefficients showing links between attachment styles and mindfulness scores attachment styles mindfulness scores anxious attachment avoidant attachment nonreactivity -.13 -.09 observe .12 -.19* describe -.14 -.23* acting with awareness -.32* -.29* nonjudging -.47* -.25* total score -.34* -.36* note. * p < .01. attachment styles. in table 2, multiple regression analysesshow that observe (ß = -.15, p < .05), acting with awareness (ß = -.18, p < .05), and nonjudging (ß = -.19, p < .05) were negatively associated with avoidant attachment style, while only acting with awareness (ß = -.20, p < .01) and nonjudging (ß = -.38, p < .001) were negatively associated with anxious attachment style. in practical terms, both anxious and avoidant attachment styles were associated with absent-mindedness at the present moment and the tendency to judge and self-evalu experience. for avoidant attachment style, it was also sensations and feelings. discussion the purpose of this study was to investigate whether different facets of mindfulness are associated with different kinds of insecure attachment style. the results supported the hypothesis that different facets of mindfulness would be differentially related to attachment styles. to such an extent, the identification of differential relationships between attachment style and mindfulness on a facet level was consistent with the study by shaver et al. (2007). in brief, both anxious and avoidant attachment style were significantly associated with lower mindfulness scores. anxious attachment style was negatively associated with all facets of mindfulness except observe. avoidant attachment style was significantly associated with all facets of mindfulness except nonreactivity. however, findings of the present study differed in the sense that we found weaker associations between mindfulness and attachment styles. in particular, nonreactivity was not significantly related with either attachment style. one possible explanation for this pattern is the differences in participants in the two studies. who were all experienced meditators over the age of 50, we used college undergraduate students who may or may not have previous meditation experience. as non-meditators are often less familiar with accurately describing and labeling their feelings when compared to experienced meditators (thompson & waltz, 2007), it is possible that this difference in the sample partly accounted for the specifically, thompson and waltz (2007) argued that through meditation individuals learn to accept, describe, and label their emotions accurately enabling them to understand and express their emotional experience. they suggested that non-meditators may have a harder time accurately describing and labeling their emotions. this implies that the amount of meditation experience may affect the way participants comprehend the questionnaire items because of the relative lack of experience with meditation. several other limitations should be noted in the study. first, this study relied on the self-report method and may be vulnerable to response bias. second, the data is correlational in nature and no causal relationship can be drawn. third, all participants of the study were undergraduate students and information regarding their table 2 multiple regression analysis predicting anxious attachment and avoidant attachment using f ive facets of mindfulness variable b se p anxious a ttachment nonreactivity -.449 .340 -.089 .189 observe .474 .266 .125 .076 describe -.045 .238 -.014 .852 acting with awareness -.769 .276 -.198** .006 nonjudging -1.099 .201 -.377*** < 0.001 avoidant a ttachment nonreactivity .012 .373 .002 .975 observe -.584 .291 -.151* .046 describe -.250 .263 -.078 .342 acting with awareness -.700 .306 -.175* .023 nonjudging -.562 .219 -.189* .011 note. * p < .05, ** p < .01, *** p < .001 mindfulness and attachment styles   35 previous meditation experiences was not assessed. thus, the generalizability of these findings remains to be tested and future studies should examine the potential effect of prior meditation experiences. despite its limitations, the present study adds to the current literature by demonstrating the relationship between attachment style and different facets of mindfulness. mindfulness and attachment appear to capture related fundamental processes by which human beings self-regulate behavior and emotion. in this way, mindfulness and attachment share much in common. one immediate implication is to consider attachment style and mindfulness practice in clinical research and practice. an important area of future research is to examine if attachment style or level of mindfulness moderates treatment effects. clinicians could then tailor treatments (i.e., using mindfulness) to individuals with different attachment styles. from a developmental perspective, investigating the association between mindfulness and attachment may provide insight into how to raise emotionally healthy individuals from early stages of development. further understanding of the relationship between mindfulness and attachment may suggest more effective ways of promoting long-term positive health outcomes and preventing childhood mental disorders. future research might address whether attachment styles influence mindfulness skills or vice versa using longitudinal research methods. specifically, mindfulness can be perceived on both sides of the attachment transaction. that is, mothers who produce infants with secure attachment should demonstrate mindful qualities and, as the correlational research suggests, infants who demonstrate a secure attachment should subsequently demonstrate higher degrees of mindfulness. these hypotheses should be directly assessed empirically. following this line of theory, intervention researchers have initiated an exploratory study of mindfulness training as an intervention for increasing the chances of secure attachment between infant and mother (bialy, 2006). more generally, this study supports the utility of applying the facet model of mindfulness, as different facets of mindfulness have been shown to differentially associate with attachment styles. the facet structure of mindfulness can be useful when teaching such skills to patients in therapy. furthermore, a facet-level analysis of mindfulness may provide a more accurate and precise account of how mindfulness relates to other psychological constructs in research studies. for instance, evans, baer, and segerstrom, (2009) have demonstrated that the nonjudging and nonreactivity facets of mindfulness were predictive of persistence and self-regulation. further research examining how mindfulness relates to other psychological constructs will inform how to integrate mindfulness training into clinical intervention. references ainsworth, m. d. s., & bowlby, j. 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(2009). predicting individual differences in mindfulness: the role of trait anxiety, attachment anxiety and attentional control. personality and individual differences, 46, 94-99.   93 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university the impact of childhood parenting styles on feelings of embodiment in adolescence abby droeger & joan miller department of general psychology, the new school for social research the human connection between mind and body is an essential component of psychological health. the concept of embodiment, a perceived sense of ownership and awareness that individuals have over their own bodies, has risen to prominence in the field of psychology within the last few decades. despite abundant research linking a lack of embodiment to psychological dysfunction, little is known about the relationship between how development influences embodiment later in life. this study aims to examine the correlation between parenting styles during childhood and embodiment in late adolescence and early adulthood. theories of embodiment embodiment relies on the distinction between body image and body schema. body image is the primarily conscious system of perceptions, emotional attitudes, and conceptual beliefs regarding one’s body. a body schema, however, is the unconscious, automatic sensory-motor capacities and activations (i.e., posture and movement regulation). both concepts describe embodiment, and both are correlated with healthy psychological functioning and a mind-body connection (gallagher & zahavi, 2008). this distinction between body ownership and agency is a useful tool for better understanding the bodily self and psychological dysfunction. the discussion surrounding body schema and body image prompted a classification of two kinds of disturbances of embodiment. the first, based on body schema, affects the subject’s embodied sense of self (i.e., within schizophrenia or depression). the second is related to body image and body awareness (e.g., eating disorders, body dysmorphic disorders, somatoform disorders) (gallagher & vaever, 2004). the mind-body relationship is influential in shaping positive psychopathology (kearney et al., 2022). embodied self-regulation has grown in therapeutic approaches. an integration of a behavioral component or embodied actions has been shown to benefit a greater connection of mind and body. for instance, mindfulness, yoga, and therapy practices such as cbt require an alignment of body and mind (brown, 2003; bryant, 2009). from a clinical lens, a lack of embodiment has been linked to psychological dysfunction and psychopathological disorders such as depression, eating disorders, and schizophrenia, which are often explained as a disturbance of embodiment (fuchs & schlimme, 2009). in general psychiatry, there are two kinds of body awareness disturbances: hyper-embodiment and disembodiment (wilde, 2003). fuchs and schilmme (2009) describe disembodiment in the context of schizophrenia, where patients feel that they no longer inhabit the body or they feel alienated from the body. patients also feel a mechanization of the body, a disintegration of habits, and a sense of detachment or disconnection around others. these researchers describe hyper-embodiment in the context this research project aims to better understand the relationship between parenting styles and feelings of embodiment. embodiment is defined as a perceived sense of ownership and awareness that individuals have over their own bodies, and healthy embodiment is believed to positively impact psychological functioning in children. the parenting styles examined within this study were baumrind’s original three parenting styles: authoritative, authoritarian, and permissive. these parenting styles are based on two dimensions: control and warmth. authoritative parenting has been found to encourage independence while maintaining a supportive environment. for this reason, there is a lot of research that supports authoritative parenting in young children. undergraduate participants were asked to complete a modified version of the parental authority questionnaire and the body consciousness questionnaire. participants were then shown three parent-child interactions related to sleep, food, and bathroom, as well as two potential parent responses to these interactions. participants were asked to rate the level of autonomy and warmth each of these potential parent responses conveyed, as well as which response they preferred, which response they believed that their parents would have chosen, and which response they would choose if they were the parent. due to the empirical research supporting the benefits of authoritative parenting in many aspects of psychological functioning, we predicted a correlation would exist between authoritative parenting and positive embodiment. however, there was no significant correlation found between these variables. a new significant relationship between authoritarian parenting and public body consciousness was found. further research on this relationship is suggested, as well as the development of a better scale for measuring healthy embodiment. keywords: parenting styles, embodiment, body consciousness, authoritative, authoritarian 94 of depression, where patients feel that they cannot escape the body, the body feels oppressive/heavy, and it is an obstacle (fuchs & schilmme, 2009). additionally, individuals experiencing hyper-embodiment describe a loss of the capacity for affective attunement. both bodily disturbances are the result of a disruption in embodiment in terms of body schema, the unconscious, and automatic processes of the body. another psychological dysfunction relating to embodiment dysregulation is the result of a disturbance in body image. body image was first described by paul schilder (1935), who described it as a mental representation of one’s body that is developed by every individual. it has been described as a multidimensional concept relating to other people’s perceptions, thoughts, behaviors, and attitudes about body and appearance (gardner, 1996). eating disorders, such as anorexia nervosa and bulimia nervosa, are thought to develop from a disturbance in body image (glashouwer et al., 2019). a relationship between positive embodiment and lower body image disturbance has been identified (cook-cottone, 2015). for instance, exercise frequency has been associated with higher positive body image (homan & tylka, 2014). piran’s developmental theory of embodiment describes five processes to gaining positive embodiment: (1) feeling “at home” in the body and fostering a positive connection, (2) experiencing agency/functionality of one’s body, (3) perception and awareness of bodily needs (i.e., hunger), (4) self-care in response to perceived internal needs (e.g.. eating when hungry), and (5) embodying one’s body in the first person, as opposed to second or third person (burychka et al., 2021). gaining autonomy in childhood erikson (1950) argued that during early childhood, a conflict arises between our ability to develop autonomy and whether or not we will experience shame and doubt. erikson classifies this experience as an essential developmental milestone. strong resistance to parenting during toddlerhood is considered to reflect a child’s healthy attempts to assert needs and control (erickson, 1963; kopp, 1982). autonomy theories argue that children are motivated to be autonomous during toddlerhood and, therefore will begin to resist control by parents. during the second year of life, a goal-directed action to gain autonomy emerges, and they explore at greater distances from parents, check back in with mothers less, and orient play less toward mothers (eckerman et al., 1975; bronson, 1974). toddlers also begin to desire to complete tasks by themselves and resist being helped (stipek et al., 1992). additionally, young children begin to say “no” as well as other forms of resistance to control (dunn & munn, 1987). rather than being seen as a complete act of defiance, this stage has been demonstrated to be an important milestone in developmental growth. the concept of bodily autonomy has become a more widely discussed topic of political and research interest in the united states within the past decade (kidd et al., 2021). parenting behavior has been shown to impact the likelihood of children developing autonomy (cohn et al., 1986). researchers argue that an environment in which parents raise their children to feel that they can control certain events and assert action, and in which parents avoid powerful external controls, will help to foster autonomy in a beneficial way (crockenberg & litman, 1990). baumrind’s parenting styles baumrind (1971, 1991) identified three parenting styles based on two dimensions: control and warmth. parental control refers to the degree to which parents manage their children’s behavior, ranging from high control with strict rules and demands to low control with fewer rules and demands. parental warmth refers to the degree to which parents accept and respond to their children’s behavior. using these dimensions, baumrind identified three primary parenting styles: authoritative, authoritarian, and permissive. authoritative parents encourage independence while maintaining control and boundaries. these parents are both warm and firm, taking into account the viewpoint of the child. authoritarian parents are highly controlling and demonstrate little warmth, providing strict rules and demands for their children. permissive parents demonstrate warmth but provide very few demands. their parenting is described as indulgent and passive. a fourth parenting style was later added, based on the research conducted by maccoby & martin (1983). this parenting style identifies parents who are neglectful and uninvolved in their children’s lives. according to baumrind’s parenting styles (1991), authoritative parenting has been shown to best recognize and encourage a child’s sense of autonomy (steinberg and silk, 2002). correlations have been found between authoritative parenting and both academic and social competence in school-aged children droeger & miller 95 parenting styles and feelings of embodiment tence (body image). we hypothesize that authoritative parenting will correlate with greater private and public body consciousness, as well as body competence. method participants participants were undergraduate students at the eugene lang college of liberal arts at the new school. non-english speakers were excluded because the survey was conducted in english, and it was important to ensure participants were fully aware and could understand and interpret what was being asked. there were no exclusion criteria related to ethnicity, race, or gender. in total, there were 56 total participants, but not all participants completed every question. fifty-two participants were aged 18-24 years, and four participants were aged 25-34 years. forty-two participants identified as female, four participants identified as male, seven participants identified as non-binary, two participants indicated that they prefer to self-describe (with one identifying as transsexual), and one participant did not complete the question regarding gender identity. recruitment and distribution of the study survey occurred through email to the participants. the recruitment email disclosed that participants would need to complete demographic questions, questions related to different parenting situations, as well as two separate questionnaires. it also disclosed that the study should take approximately 30 minutes to one hour to complete, that participation was completely voluntary, and that participants would not receive any compensation from the researchers. finally, the recruitment email included a link to the qualtrics survey, and individuals who were willing to participate and fit the criteria were instructed to click on the link and complete the survey. if the participants did not fit the criteria, they were excluded from the data analysis. after being recruited, participants completed the study online via the new school’s qualtrics platform. materials and procedure this study examines the correlation between parental authority and body consciousness, intending to better understand how parenting style in childhood influences feelings of embodiment later in life. all participants were recruited via email, and participants who met the criteria completed a qualtrics survey. the survey first asked participants to fill out the following demographic questions: age, gender identity, race/eth(baumrind 1971, 1991). additionally, authoritarian parenting (characterized by high levels of controlling behavior) has been associated with low social and academic competence (p. cowan et al., 1994). mattanah (2005) argues that autonomy in childhood should not be confused with permissive parenting because active autonomy encouragement involves a high degree of parental involvement rather than giving into the child’s every demand. for instance, a parent should listen to the child’s desires, and encourage independent behavior and exploration of the environment rather than giving in to the child completely or demanding complete compliance. current study when children attempt to address bodily needs and wants, they are sometimes met with disapproval. for instance, after dinner, a child tells their mother, “i am hungry,” and they are met with, “no you are not; you just ate”. this approach is often the result of frustration or impatience; however, in early childhood, this response may foster an ignoring of bodily needs. although there is significant research indicating the importance of developing and fostering autonomy, there is little research that focuses on how children use their bodies to control autonomy (ryan et al., 2015). there is a clear and present gap in the literature regarding the influence of autonomous decision-making, supportive parenting, and feeling a sense of ownership and connection to one’s body later in life. for this study, we have chosen three areas of control that children may use to assert their autonomy, all of which involve control over one’s body: eating, bathroom, and sleep. we have defined embodiment as an awareness of one’s internal bodily sensations and public perception of one’s body. lacking embodiment would mean feeling uncertain in one’s body or lacking awareness, which may translate to feeling greater doubt and shame. we aim to demonstrate a correlation between parenting styles in childhood, particularly a sense of autonomy related to control over one’s body and feeling a sense of embodiment later in life. we will use baumrind’s parenting styles (1991) to assess the dimensions of authoritative, authoritarian, and permissive parenting styles that the participants received. we will also use the body consciousness scale, developed by miller et al. (1981), to assess dimensions of private body consciousness (body schema), public body consciousness (body image), and body compe96 droeger & miller nicity, and highest level of education. participants were asked who they considered their primary caregiver(s) through childhood (which we have defined as ages 1-18), mother, father, both, or prefer not to say. they were asked if they were still in contact with their primary caregiver and if they had any children of their own. the survey then described three hypothetical parent-child interactions presenting a conflict between the parent and child in which the child uses bodily control to gain autonomy in the situation (i.e., bodily control relating to food, bathroom, and sleep). participants were then asked how they would respond if they were the parent in each situation. the parent-child interactions were created by the authors to reflect common interactions between parent and child that involve the child’s attempt to gain autonomy over the situation using bodily control. the responses were created to reflect common responses of parents to children, one following more authoritative guidelines (i.e., greater warmth and autonomy) and the other following non-authoritative guidelines (i.e., less warmth and autonomy). the level of authoritativeness for each response was validated by how participants rated their level of warmth and autonomy. the first situation was related to sleep and was presented to the participants in the following description: for the past few weeks, 2-year-old emma has been struggling with taking her nap. every day at naptime, she protests and says she is not tired. she has never had difficulty sleeping on a schedule before, and this has been a new and difficult situation for her parents to deal with. two potential responses to this first situation were presented to participants in the following description: response one: her parents listen when she says she is not tired and let her play longer and take her nap later each day. response two: her parents put her in her crib and leave her to fall asleep, even though she cries and protests. the times when she doesn’t fall asleep, her parents say she must stay in her crib the whole naptime and stick to her sleep schedule. the second situation was related to food and was presented to participants in the following description: james is seven years old. he is a picky eater and doesn’t like to eat any foods that are green. his parents try to get him to eat his vegetables, even when he doesn’t want to. one night his parents gave him broccoli with his dinner, and he asked for something else. two potential responses to this second situation were presented to participants in the following description: response one: when james refuses to eat broccoli, james’s parents ask him to choose which vegetable he wants to replace the broccoli with (i.e., carrots or bell pepper). response two: when james’s parents give him broccoli for dinner, they do not allow him to have anything else and let him know that he cannot have dessert unless he finishes his broccoli. the third situation was related to the bathroom and was presented to participants in the following description: mia is three years old and has been potty trained for one year. even though she is potty trained, she prefers to go to the bathroom at home. sometimes she has accidents at preschool because she does not want to go to the bathroom. two potential responses to this third situation were presented to participants in the following description: response one: her parents say she needs to use the bathroom every day at school. if she does not use the bathroom at school, she does not get a treat when she gets home. if she does use the bathroom at school, she gets to pick out a treat as a reward. response two: her parents say it is okay to have accidents while she is learning to use the bathroom but encourage her to go when she is at school. they give her a stuffed animal to bring with her when she tries to use the potty so that she will feel more comfortable. participants were asked how much each of these responses conveys warmth and autonomy on a 4-point likert scale (1 = strongly disagree; 4 = strongly agree). they were also asked which response they preferred and which response most closely resembled how their parents would have acted. these survey questions were presented to offer a more qualitative approach to better understanding participant’s relationship with their parents and how they view parenting styles. these more qualitative questions also serve the purpose of reminding the participants of some of the experiences they may have faced as children to prepare them to answer the quantitative questions regarding parenting styles. parenting styles 97 were operationalized with the parental authority questionnaire (trinkner et al., 2011), and feelings of embodiment were operationalized using the body consciousness questionnaire (miller et al., 1981). parental authority questionnaire the original parental authority questionnaire (paq; buri, 1991) was developed to measure parenting style as conceptualized by baumrind (1971, 1991). the original paq consists of 30 items, 10 for each parenting style: authoritarian, authoritative, and permissive. this study uses a modified version developed by trinkner et al. (2012), which adapts the scale to examine both parents, rather than the mother and father separately. this modified version also shortens the scale due to time and space constraints. the modified version was developed by selecting four items for each parenting style that all the authors agreed were the best representations of each original parenting style as conceptualized by baumrind. the modified version includes 12 statements (i.e., “my parents feel that children can do whatever they like”; “my parents get very angry if i disagree with them”), with a four-point likert scale (1: “disagree strongly; 4: “agree strongly”). results are averaged for each parenting style, with higher scores indicating greater use of that parenting style. each participant’s score reflects the extent to which their parents used authoritative, authoritarian, and permissive parenting styles. the modified parental authority questionnaire by trinkner et al. (2012) can be found in the appendix. please note that a potential limitation of this questionnaire is that it does not include neglectful parenting as a fourth parenting style. in 1983, maccoby and martin suggested a way of measuring parenting styles using baumrind’s typology and the parenting dimensions: demandingness and responsiveness. they added a fourth parenting style: neglectful. based on this work, baumrind expanded her typology to include the fourth parenting style, neglectful parenting (maccoby & martin, 1983). this has been left out of the parental authority questionnaire, perhaps because neglectful parenting involves no authority or care for a child’s authority at all. further research is suggested to better understand the relationship between neglectful parenting styles and feelings of embodiment. the body consciousness questionnaire the body consciousness questionnaire attempts to modify the psychological dichotomy of public versus private self-consciousness to the body self. this scale is based on a classification of observation of the self into both private aspects (i.e., thoughts, images, memories, motives, and feelings) as well as the public aspects, which can be observed by outside forces (i.e., appearance, manner, style of behavior). private body consciousness is defined as the awareness of internal sensations and, public body consciousness is defined as the awareness of observable aspects of the body (miller et al., 1981). the questionnaire also examines body competence and how effectively participants perceive their body functions. body competence evaluation is positive; those high in body competence endorse items relevant to effective body functioning. this questionnaire properly addresses both disorders of embodiment situated in dysfunction surrounding the perception of body schema and body image. body image is the primarily conscious system of perceptions, emotional attitudes, and conceptual beliefs regarding one’s body. a body schema, however, is the unconscious, automatic sensory-motor capacities and activations (i.e., posture and movement regulation). therefore, in terms of the body consciousness scale, private and public body consciousness are measures of body image, and body competence is an evaluation of one’s body schema. the questionnaire is a 15-point scale with statements relating to all three factors of body consciousness: private, public, and body competence (“i am very aware of my best and worst facial features”; “i am very aware of changes in my body temperature”; “for my size, i’m pretty strong”). participants were given a 5-point likert scale (0: “extremely uncharacteristic; 4: “extremely characteristic”), and results were averaged to compare sample means with the means reported in miller et al. (1981). the body consciousness questionnaire can be found in the appendix. results control analyses validity of parenting response measure we undertook paired samples t-tests to assess whether the sample parenting responses differed, as intended, on the degree to which each reflected more or less authoritative parenting. providing evidence for the validity of the sample parenting responses as a measure, results revealed that warmth and autonomy were greater in the authoritative parenting responses as compared with the parenting styles and feelings of embodiment 98 droeger & miller non-authoritative parenting options (see table 1). warmth and autonomy correlation correlational analyses revealed that warmth and autonomy were significantly correlated with each other in the case of each parenting option (sleep: r (41) =.58, p < .001; food: r (42) =.77, p < .001; bathroom: r (41) = .40, p = .005). the lowest correlation between warmth and autonomy occurred in the case of the bathroom parent-child interaction. additionally, the responses observed in the case of the food parent-child interaction were skewed in that only one participant preferred the non-authoritative option. for these reasons, further analyses focused solely on the sleep parent-child interaction (see table 1). relationship between outlooks on sleep parent-child interaction we undertook correlational analyses on perceptions of the authoritative option for the sleep parent-child interaction (see table 2). in addition to the correlation noted earlier between warmth and autonomy (r (42) = .58, p < .01), we also found a negative correlation between autonomy and the response that the participant would choose if this were their own child (r (42) =.37, p < .05). although this latter effect was not predicted, it may suggest that participants valued warmth over autonomy in this particular parent-child interaction. we also observed a significant correlation between what participants would choose for their own child and what they would prefer for themselves (r (43) =.79, p < .01), as well as between what participants would choose for their own child and the response, they believe their parents would have chosen (r (43) = .36, p < .05) (see table 2). relationship between scale measures and responses to sleep parent-child interaction we undertook correlational analyses examining the relationship between preferred response to the sleep parent-child interaction and the parental authority questionnaire and body consciousness questionnaires (see table 3). as predicted, participants preferred response in the sleep interaction was positively correlated with the authoritative subscale of the parenting scale (r (40) = .37, p < .05), and negatively correlated with the authoritarian subscale of this scale (r (40) = -.40, p < .05). no significant correlations were observed between participant’s preferred response in the sleep interaction and their score on the body consciousness scale. the only other significant correlation occurred between the participant’s scores on the authoritarian parenting subscale and on the public body consciousness scale (r (40) = .35, p < .05) (see table 3). discussion the findings found in all three parent-child interactions indicate that the participant’s perception of the positive relationship between warmth and autonomy is congruent with the characteristics of authoritative parenting. as predicted, the participant’s preferred response in the parent-child interaction regarding sleep was positively correlated with authoritative items and negatively correlated with authoritarian items. additionally, the positive relationship between the response participants would choose for their own child and the response they believe their parents would have chosen is significant in demonstrating the continuity of parenting ideas across generations. within the sleep parent-child interaction, we were surprised to find a negative relationship between autonomy and the response that participants would choose if it were their own child. this may indicate that participants valued warmth over autonomy in this sleep-related interaction. the overall relationship between the parental authority questionnaire and the body consciousness questionnaire was not found to be significant. however, a significant positive relationship was found between the sum of the authoritarian parenting items and the public body consciousness items. this unexpected finding indicates the need for further exploration of the relationship between public body consciousness and an authoritarian parenting style. there were no relationships found between the preferred parenting option and the body consciousness scale. an indication of warmth and autonomy in our parent-child interactions is important in providing support for the authoritative parenting style among participants and across generations. this finding adds to the research supporting warmth and autonomy in conflict related to parent-child interactions. additionally, it advocates for this parenting style in issues related to the child’s bodily decisions. our interactions involved the child aiming to achieve autonomy through decisions involving food, sleep, and the bathroom. all of these require the child to use control over their body to gain autonomy. support for all three parent-child interaction scenarios was found but was most significant in our sleep-relat99 ed interaction. this may suggest strong support for parents to use authoritative parenting styles when dealing with conflict involving sleep-related decisions. participants were more likely to advocate for authoritative parenting involving the sleep interaction and were less convinced about the appropriate way of dealing with the food and bathroom interaction. we have considered a few reasons behind this finding. the sleep-related scenario may be considered as more of an independent task than the food and bathroom scenarios. for instance, a child choosing not to sleep may be considered less of an interference for other individuals around them. a child choosing to forego meals or having the parent cook them something else involves more dependence on a caretaker. similarly, a child only willing to use one bathroom also involves greater dependence on caretakers around them, having to take them home to use the restroom or dealing with school accidents. perhaps participants also believe that the inclination to sleep is something less controllable to the individual. in other words, participants may be more likely to empathize with a child who is physically unable to sleep rather than a child who willingly refuses to use the bathroom or eat a certain food. further questioning of the reasoning behind the participant’s choices is needed to better understand what separates the sleep interaction from the other two. there was also a significant demonstration of parenting ideas supported across generations. within the sleep interaction, what response participants believed their parents would choose, participant’s preference, and what they would choose for their child were all correlated. this information is important as it is indicative of the power of parenting styles to pass down to the next generation. the relationship found between the parental authority questionnaire and the body consciousness questionnaire was overall insignificant. however, the findings demonstrate a significant relationship between authoritarian parenting styles and public body consciousness. we did not hypothesize this finding, but the results agree with previous research and our understanding of authoritarian parenting style. the findings suggest a link between authoritarian parenting and being highly attuned to how you are perceived in the outside world. we suggest that this is due to participants being forced to adhere to strict parenting and high expectations in order to avoid parental criticism. this finding also supports research that indicates children under authoritarian parenting styles are at a higher risk of experiencing levels of body dissatisfaction (salafia et al., 2007). perhaps this research can be better explained by our findings which have suggested authoritarian parenting is correlated with being highly attuned to how others perceive them and their bodies. this may be an indication that hyper-embodiment exists in children who receive authoritarian parenting. we suggest further research to better discover the underlying reasoning for this relationship. study limitations the body consciousness scale did not correlate with an authoritative parenting style. however, this does not mean that a relationship does not exist between body consciousness later in life and authoritative parenting. in all three parent-child interactions related to bodily autonomy, there was a preference for greater warmth and autonomy, indicating that participants did value authoritative parenting when dealing with embodied situations. there was also further indication that parenting styles get passed down through generations. however, the body consciousness scale may be limited in its grasp of healthy embodiment. our findings may suggest a need for a more comprehensive scale for measuring healthy embodiment. the body consciousness scale measures how aware an individual is of their internal bodily sensations and observable aspects of the body, as well as how competent the individual believes their body is. we suggest a limitation within our interpretation of the scale, as we assumed high levels of these measures would indicate healthy embodiment. however, an over-awareness of bodily sensations may be better suited to represent a hyper-embodiment. we suggest that this limitation may be why we did not find a correlation between body consciousness and authoritative parenting. in future research, we hope to develop a scale that better encompasses healthy embodiment. however, this research did correlate authoritarian parenting with public body consciousness. this finding is valuable for future work, as the characteristics of public body consciousness may be better suited to demonstrate hyper-embodiment. we did not find any correlations between parenting styles, private body consciousness, or body competence. this may also be due to limitations within the scale itself or could indicate that there is no relationship between parenting styles and these measures. a further limitation is that we did not inparenting styles and feelings of embodiment 100 droeger & miller vestigate neglectful parenting style. the reason for this is that it is not included in the parental authority questionnaire, and it may be a limitation that we assumed our population did not have neglectful parenting. the research would be strengthened by finding a measure that includes this parenting style. another limitation was found in the lack of complete responses within the qualtrics survey. not all participants completed the entire questionnaire, and this may be due to the length of it. if we had found a way to shorten the survey, we may have had a better response rate. our qualtrics survey may have also been strengthened by making all scenario variables more independent. the sleeprelated scenario, which was the most independent of all three scenarios, was found to have a stronger response to using an authoritative parenting style than the other two scenarios. further research is suggested that examines parent-child interactions that are considered more independent, meaning less interference for other individuals around the child. final limitations included a small sample size and time constraints in completing the project before the school year ended. conclusion this project did not result in the expected findings but was beneficial in contributing to the current knowledge and future directions that we should continue to research. the research provided support for the authoritative parenting 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(2003). embodied knowledge in chronic illness and injury. nursing inquiry, 10(3), 170-176. https://doi.org/10.1046/j.14401800.2003.00178.x 103 parenting styles and feelings of embodiment table 1 mean warmth and autonomy for different parenting options note. sleep refers to the sleep related parent-child interaction. food refers to the food related parent-child interaction. bathroom refers to the bathroom related parent-child interaction. authoritative refers to the response that was designed to be more authoritative. non-authoritative refers to the response that was designed to be less authoritative. warmth refers to the level of warmth participants rated each response. autonomy refers to the level of autonomy participants rated each response. 104 table 2 correlations for sleep parent-child interaction *correlation is significant at the 0.05 level (2-tailed) **correlation is significant at the 0.01 level (2-tailed) note. authoritative autonomy is the response participants indicated had a higher level of autonomy. authoritative warmth is the response participants indicated had a higher level of warmth. participant preference is the response participants preferred. caregiver preference is the response participants believe their caregiver would have chosen. participant choice is the response that participants would choose for their own child. droeger & miller 105 table 3 correlations for parental authority questionnaire, body consciousness questionnaire, and sleep parent-child interaction parenting styles and feelings of embodiment *correlation is significant at the 0.05 level (2-tailed) **correlation is significant at the 0.01 level (2-tailed) note. permissive sum is the level of participant caregiver’s permissive parenting style that participants received on the modified parental authority questionnaire. authoritarian sum is the level of participant caregiver’s authoritarian parenting style that participants received on the modified parental authority questionnaire. authoritative sum is the level of participant caregiver’s authoritative parenting style that participants received on the modified parental authority questionnaire. private sum is the level of private body consciousness that participants scored on the body consciousness questionnaire. public sum is the level of public body consciousness that participants scored on the body consciousness questionnaire. body competence is the level of body competence that participants scored on the body consciousness questionnaire. 106 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university anxiety symptoms in a community during the covid-19 pandemic: a self-reported study the coronavirus (covid-19) pandemic has affected many aspects of people’s lives, including their mental health. to better understand its impact, the current study looked at how demographic features and beliefs about the pandemic influenced anxiety during this time. participants included 221 residents of michigan who predominantly identified as female and white. they completed the adaptation to social stress questionnaire, a 105-item self-report questionnaire developed to assess participant characteristics, ability to adapt to stress and opinions, beliefs, and experiences related to the covid-19 pandemic, and two measures of anxiety (the statetrait anxiety inventory and the generalized anxiety disorder scale). pearson product-moment correlations and independent samples t-tests were used to determine the relationship between anxiety and other study variables. results show that religious affiliation and older age were associated with lower anxiety scores while living in the subjects’ close environment as an infected individual was associated with increased anxiety. interestingly, thinking someone was to blame for the pandemic, being angered by official message regulations, and not thinking lockdown measures were sufficient increased anxiety. this latter finding implies that consistent with clinical theory, our beliefs about events are connected with our emotional experiences. recommendations for clinical practice are noted as it is imperative for clinicians to be consistent and direct regarding any protocol changes that may help minimize client anxiety. lastly, considerations regarding transparent communication from leaders of organizations that are adjusting their policies due to the covid-19 pandemic are discussed. keywords: covid-19, anxiety, michigan, pandemic beliefs, social stress adaptation paige s. erickson1, kathryn r. forche1, emily a. dowgwillo1, carol cronin weisfeld1, marina l. butovskaya2, and valentina n. burkova2, 1department of psychology, university of detroit mercy, detroit, michigan 2center of cross-cultural psychology and human ethology, institute of ethnology and anthropology, russian academy of sciences, moskva, russia while pandemics have caused great human suffering over many centuries (turner, 2020), the covid-19 pandemic may be the most carefully documented worldwide epidemic in history because of advances in healthcare and in worldwide communications. greater attention to mental health issues has been one theme of research on the covid-19 pandemic, and this report attempts to contribute to the literature on mental health effects within the united states, with a particular focus on the state of michigan. the research reported here was conducted in the spring and summer of 2020, when americans were between two peaks in disease/death rates, with vaccines only aspirational. by the fall of 2020, the u.s.a. had approximately 12 million covid-19 cases, compared to about 58 million cases worldwide (john hopkins university of medicine, 2020). this was almost three million more cases than india, a country whose population is more than four times the population of the united states. as covid-19 spread, states varied widely in terms of their response to the epidemic. in response to the pandemic michigan’s governor, gretchen whitmer, issued executive orders restricting commerce and public activity, while the state legislature (controlled by the other political party) opposed her and encouraged citizens to rebel (jaffe & marley, 2022). michigan received a great deal of news coverage, not because of particularly high covid-19 case numbers or death rates in 2020, but because of the strong reactions against the restrictions placed on michiganders by governor whitmer and her public health officials. one of the objections to health restrictions (e.g., mask-wearing, the closing of bars and gyms, discouraging large gatherings, moving schools to online teaching) is that they may protect against infection but create unwanted side effects such as increased levels of domestic abuse, child neglect, anxiety, depression, and other types of mental illness. this assertion is supported by a recent meta-analysis that included 15 studies (11 related to covid-19 and four related to sars and influenza pandemics) on the effects of pandemics on the mental health of people with pre-existing mental illnesses (neelam et al., 2021). all 15 studies found that people with mental illness experienced more psychiatric symptoms during pandemics compared to control groups (neelam et al., 2021). the primary symptoms identified included increased anxiety, depression, and insomnia. researchers hypothesized that the lack of social interaction and difficulty in maintaining a daily routine contributed to these findings (neelam et al., 2021). similarly, marroquín and colleagues (2020) found 107 that the stay-at-home orders that were implemented in march 2020 were associated with more symptoms of depression, generalized anxiety, acute stress, and insomnia (marroquín et al., 2020). these symptoms remained despite individuals’ levels of perceived social support, which suggests that known protective factors (e.g., social interaction) did not eliminate the impact of social distancing (marroquín et al., 2020). anxiety and predictors of anxiety research has shown that women are significantly more likely than men to develop an anxiety disorder at some point during their lifespan (kessler et al., 1994; pigott, 2003; jalnapurkar et al., 2018). the national comorbidity survey (ncs) conducted from 1990 to 1992 found that lifetime prevalence rates for any anxiety disorder were 30.5% for women and 19.2% for men (kessler et al., 1994). various factors are hypothesized to be responsible for the sex differences reported in anxiety disorders, including genetic, neurodevelopmental, environmental, and neurobiological factors (jalnapurkar et al., 2018). more specifically, fluctuations in estrogen and progesterone levels can substantially influence the severity of anxiety disorders (jalnapurkar et al., 2018). furthermore, women have lower gastric acidity, lower body weight, greater percentage of body fat, and lower blood volume compared with men, factors that can affect the absorption and distribution of medications (pigott, 2003). across cultures, the prevalence of generalized anxiety disorder (gad) is higher in females than in males, at approximately a 1.5 to 1 ratio (mackinaw-koons & vasey, 2000). in the united states, specifically, the us national comorbidity survey replication found prevalence rates of 3.6% for men and 6.6% for women (kessler et al., 2005). importantly, these prevalence rates depend partly on age: the sex difference in prevalence rates for gad is highest in adolescence and declines with age at a faster rate for men than it does for women (mackinaw-koons & vasey, 2000). research suggests that age itself is also an important predictor of anxiety, with findings generally pointing to decreasing levels of anxiety as people get older. a literature review by baxter et al. (2013), for example, found that, globally, adults over age 54 were significantly less likely to be diagnosed with anxiety than adults aged 18-54. additionally, anxiety seemed to rise dramatically for younger adults (18-25 years of age) in the usa between the years 2008-2018; for adults 50 years of age and older, it remained steady (goodwin et al., 2020). the researchers hypothesized that poor job prospects and student loan debt contributed to the rise in anxiety for young (emerging) adults. there is cross sectional research evidence, however, that suggests that these findings may occur because older cohorts are less accurate at identifying and labeling symptoms of anxiety and depression (wetherell et al., 2009). other predictors that have been associated with anxiety include spending increased time online (weinstein et al., 2015), living in a european or north american country, and living in a developed rather than a developing country (baxter et al., 2013). conversely, religiosity is associated with lower anxiety, although results suggest that intrinsic religious orientation is more efficacious than simple religious affiliation (shreve-neiger & edelstein, 2004). volunteerism or helping others (waite et al., 1998) and being the recipient of social support (berkman & syme, 1979) also predict lower anxiety. unique anxiety findings under pandemic conditions although it is difficult to separate anxiety reactions to government restrictions from anxiety reactions to the virus itself, this article attempts to better understand the characteristics, behaviors, and beliefs that were associated with anxiety symptoms early in the pandemic. other research has found gender and age to be predictors of anxiety during the pandemic (marroquín et al., 2020; solomou & constantinidou 2020). marroquín and colleagues (2020) found that younger adults, women, individuals with minimal social support, and those who reported being under a stay-at-home order had higher levels of gad symptoms compared to older adults, males, individuals who identified as having social support, and anyone not under a stay-at-home order (marroquín et al., 2020). similarly, solomou and constantinidou (2020) found women of younger age (18-29), student status, unemployment status, prior psychiatric history, and those reporting a greater negative impact of the pandemic on their quality of life were at higher risk for increased anxiety and depression. large-scale studies have yielded similar results; researchers have found increases in anxiety in younger adults in response to the conditions imposed by the covid-19 pandemic (burkova et al., 2021; kowal et al., 2020). a survey done in june 2020 for the us anxiety symptoms in the covid-19 pandemic 108 center for disease control and prevention (czeisler et al., 2020, p. 1049) reported “considerably elevated” anxiety and depression, along with suicide ideation, in young adults aged 18 to 24. moreover, the impact of one’s social support during pandemic conditions may be complex; for example, kowal and colleagues (2020) found that under the physical isolation mandates of covid-19, anxiety was worse for people living alone and for people forced to live in overcrowded conditions. anxiety findings in the state of michigan (usa) the current authors participated in one of the international studies cited above (burkova et al., 2021), contributing data from across the usa that were pooled with other samples to form the usa sample for that 2021 publication. it was serendipitous that several hundred of the volunteers came from the state of michigan. because, as mentioned above, each state had such a different strategy for managing the pandemic, the authors realized that it might be worthwhile to analyze the michigan data separately, paying more attention to some of the demographic data that had already been gathered, in order to better understand contextual factors. hypotheses the aim of this cross-sectional study was to examine the characteristics, behaviors, and beliefs associated with increased anxiety during the covid-19 pandemic. we had six hypotheses and six exploratory goals. under pandemic conditions, the first hypothesis was that our sample would have higher anxiety levels on the generalized anxiety disorder scale (gad-7) and the state-trait anxiety inventory (stai) compared to normative community samples. secondly, we hypothesized that anxiety levels would be higher in older individuals because of their increased risk for severe covid-19-related illness. similarly, the third hypothesis was that anxiety levels would be higher in people with chronic diseases because of their increased risk for severe covid-19-related illness. the fourth hypothesis was that higher anxiety was expected in people who identified others in their close environment who were diagnosed with covid-19. next, our fifth hypothesis was that anxiety would also be positively associated with the female gender. lastly, our sixth hypothesis was that anxiety would be positively associated with an absence of religious affiliation. this research also had several exploratory goals in mind: to assess if higher anxiety was associated with living alone, having children, experiencing changes in financial well-being or lifestyle habits, social networking online, or holding certain beliefs about government officials responsible for providing leadership during the pandemic. method procedure the data analyzed below are part of a large cross-cultural study that examined possible factors that may be associated with self-reported levels of anxiety during the first wave of the covid-19 pandemic (burkova et al., 2021). the larger sample included 15,375 participants from 23 countries which was conceptualized by a team of researchers in russia. they hypothesized the spread of the pandemic, isolation measures, and restrictions would result in increased depression symptoms and would exacerbate the psychological well-being of people worldwide during the first wave of the covid-19 lockdown (burkova et al., 2021). all co-authors of this larger study collected data from their home countries. participants in each country were recruited from various university listservs and social networking sites. as stated above, a significant portion of the sample was from michigan. thus, the current authors chose to perform a separate analysis on the michigan sample to better understand the impact of context. information relevant to the current study is presented below. approval for all procedures was provided by the university’s institutional review board. data were collected from may 19, 2020, through september 16, 2020. participants participants were members of the community recruited via convenience sampling methods (e.g. local postings on university and faculty email listservs, facebook, instagram, nextdoor, and word of mouth). postings provided a brief description of the study and a link to the survey hosted on qualtrics. participants provided informed consent on the online survey form. there were no incentives given for participation. participants were included in the current study if they resided in michigan, were over the age of 18, completed all of the items in the generalized anxiety disorder 7 (n = 217) and/or the statetrait anxiety inventory (n = 200) questionnaire, and provided at least 50% responses to the other survey questions. based on these inclusion criteria, a total of 221 participants were retained in the analyses. of these participants, 27.1% were male and 72.4% erickson 109 were female. regarding ethnicity, 84.2% of the sample identified as white, 5% as african american or black, 3.2% as hispanic or latino, and 1.4% as asian. participants ranged in age from 22 to 80 years (m = 45.60, sd = 16.28). regarding relationship status, 68.3% reported being married or in a committed relationship, while 31.2% reported being single, divorced, or widowed. regarding religious affiliation, 25.3% identified as catholic, 33.5% as christian, 5.9% as jewish, .9% as muslim and 30.8% as not religious. on average, participants completed the survey 13.71 (sd = 4.17) weeks after the michigan stay-at-home order (march 23, 2020). measures generalized anxiety disorder-7 (gad-7; spitzer, kroenke, williams, & lowe, 2006) the gad-7 is a seven-item self-report questionnaire that assesses the frequency of anxiety symptoms over the past two weeks. responses were recorded on a 4-point likert scale from 0 to 3, where 0 is “not at all” and 3 is “nearly every day.” a cronbach’s alpha coefficient of 0.89 was found in a community sample in germany (löwe et al., 2008). construct validity was supported by the relationship between the gad-7 and the phq-2 depression scale, the rosenberg self-esteem scale, the questionnaire on life satisfaction, and the resilience scale (löwe et al., 2008). participants’ scores were then summed to produce a total gad-7 score for each participant. internal consistency was excellent (α = .910). state-trait anxiety inventory (stai; spielberger, 1983) the stai is a 40-item self-report questionnaire comprised of 20 items assessing state anxiety and 20 items assessing trait anxiety. for the purposes of this study, the 20 items that measure state anxiety were used to assess participants’ anxiety at the time of the survey. responses were recorded on a 4-point likert scale from 1 (not at all) to 4 (very much so). participants’ scores were summed to produce a total score for each participant. a cronbach’s alpha coefficient of 0.87 was found in a community sample (balsamo et al., 2013). construct validity was supported by the relationship between the stai and the beck anxiety inventory (balsamo et al., 2013). internal consistency was excellent (α = .952). adaptation to social stress questionnaire (assq; butovskaya & burkova, 2021) the assq is a 105-item self-report questionnaire assessing individuals’ demographic features, ability to adapt to stress and opinions, beliefs, and experiences related to the covid-19 pandemic (burkova et al., 2021; butovskaya et al., 2021; burkova et al., 2022). table 1 contains the relevant questions and response options for the current study. this assq was designed specifically for the larger cross-cultural study that the authors participated in at the beginning of the covid-19 pandemic. all author participants had the opportunity to critique the questionnaire, after which the agreed-upon questionnaire was translated into the local language for each country. the assq included standard demographic questions (e.g., age, gender, occupation, etc.). as of this writing, three articles have been published using the assq (burkova et al., 2021, 2022; butovskaya et al., 2021), and more studies are in progress. more information about the testing properties of the assq will be forthcoming in future research reports. data analysis because the current study was conducted in response to the global covid-19 pandemic, it was not feasible to collect data from a control group. however, to provide a sense of the magnitude of the anxiety present in the current sample, single-sample t-tests were used to compare mean gad-7 and stai scores in the current sample with mean scores on the gad7 and stai from comparable community samples published in the research literature (löwe et al., 2008; spielberger, 1983). to better understand the relationship between anxiety scores and a range of demographic, behavioral, and belief variables, bivariate analyses were conducted. pearson product-moment correlations were used to determine the relationship between anxiety scores and continuous criterion variables like age and number of weeks into the stay-at-home order. independent samples t-tests were used to examine the relationship between anxiety scores and dichotomous criterion variables assessed with the assq. results hypothesis one in order to assess the magnitude of anxiety in our sample and the inability to have a control group, we compared scores from our sample to scores from previously published community samples. the current sample had significantly higher gad-7 scores (m=6.41) than both a german sample (m=2.95; löwe et al., 2008) and a united states pandemic sample (m=5.66; anxiety symptoms in the covid-19 pandemic 110 marroquín et al., 2020) and significantly higher stai scores (m=41.79) than a community sample of working adults in the united states (m= 35.72; spielberger, 1983). importantly, scores on the gad-7 were significantly and positively associated with scores on the stai (r = .760, p <.001) in the current sample, suggesting substantial convergence across anxiety measures. thus, regardless of measure, this michigan sample was more anxious than comparable community samples. hypotheses two, three, and five to better understand these elevated anxiety scores, we examined their relationship with important demographic and behavioral criterion variables. regarding demographics for our second hypothesis, both gad-7 and stai scores were significantly and negatively correlated with age, (r = -.330, p < .001) and (r = -.311, p < .001) for gad-7 and stai respectively. thus, as age increased, anxiety scores decreased. additionally, our third and fifth hypotheses were not supported in that having a chronic illness diagnosis and biological sex were not associated with gad-7 or stai anxiety scores. hypotheses four and six our fourth hypothesis was supported in that having infected people living in your environment (t(214) = -2.53, p = .012) was associated with higher gad-7 scores. our sixth hypothesis was supported by the finding that those who identified as religious reported significantly lower gad-7 scores (t(209) = 2.12, p = .035). exploratory goals in terms of the exploratory goals regarding beliefs, thinking there was someone to blame (gad-7: t(213) = -2.794, p = .00; stai: t(194) = -2.735, p = .007), feeling angry in response to official message regulations (gad-7: t(214) = -2.81, p = .024; stai: t(193) = -2.55, p = .012), and believing that lockdown measures were insufficient (gad-7: t(209) = 2.03, p = .044; stai: t(192) = 2.66, p = .008) were associated with significantly higher anxiety scores. other findings lastly, having a history of volunteering prior to the pandemic (t(213) = -2.16, p = .032) were associated with higher gad-7 scores. conversely, those who changed their daily lifestyle habits and believed that virtual social networking was a valuable opportunity to connect with others reported significantly lower gad-7 scores, t(211) = -2.13, p = .035, and t(200) = 2.40, p = .017 respectively. having children, living alone, and experiencing a change in household income were not associated with gad-7 or stai anxiety scores. additionally, anxiety was not significantly associated with the number of weeks since the stay-at-home order, suggesting that when participants took the survey, it did not have an effect on their scores. a summary of these findings associated with the gad-7 can be found in table 2. discussion as hypothesized, average gad-7 and stai scores were higher in the current sample than comparable scores from community samples prior to (löwe et al., 2008; spielberger & gorsuch, 1983) and during (marroquín et al., 2020) the covid-19 pandemic. however, it is worth noting that the current sample had approximately 20% more females than the compared community samples. thus, it is possible that gender played a role in the observed effects in the current sample. the stai average score exceeded an established clinical cutoff of 40 (emons et al., 2019), suggesting that state anxiety was elevated to a clinically significant degree. these findings are consistent with the increases in anxiety (bareket-bojmel et al., 2020; hyland et al., 2020; moghanibashi-mansourieh, 2020) and other mental health problems found in the current pandemic (hwang, 2020; roy et al., 2020; spoorthy et al., 2020). to better understand this pattern of findings, we examined the association between sample characteristics, behaviors, and experiences with anxiety. in particular, hypotheses related to variables that increased the likelihood of covid-19 infection and severe illness (centers for disease control and prevention, n.d.) were partially supported. specifically, having infected people living in your environment was significantly associated with higher state and trait anxiety. research suggests that people experience a fear of contamination related to covid-19 that is similar to the fear of contamination for other viruses, such as ebola or h1n1 influenza (helleringer et al., 2015; cheung, 2015; kim et al., 2015; knowles & olatunji, 2021). therefore, it is possible that those with infected people living in their environment were not only concerned with the well-being of their loved ones but also anxious about contracting the virus themselves. interestingly, there was not a significant relationship between anxiety and living alone. contrary to our hypothesis, however, a number of factors associated with increased vulnerability to covid-19 were not associated with anxiety erickson 111 as expected. in particular, age was negatively rather than positively associated with anxiety. although unexpected, this finding is consistent with a broader literature that finds that as people age, their levels of neuroticism and negative affectivity tend to decrease (kessler & staudinger, 2010; masten & wright, 2010; yeung & fung, 2007; yeung et al., 2020). thus, age continues to be a strong protective factor even when facing a virus that disproportionately affects older adults. similarly, chronic illness was not significantly associated with anxiety. although past research has found associations between pre-existing conditions and negative mental health outcomes during public health crises (gayer-anderson et al., 2020), it is possible that the shift to working from home that occurred in the early months of covid-19 mitigated many of these negative outcomes. not only are individuals with disabilities more likely to work from home (which allows them to flexibly attend recurring medical appointments and have access to medical equipment), but working from home itself has become easier and less stigmatized as many workplaces were forced to broaden their views on accommodations for workers in the early months of the pandemic (schur et al., 2020). thus, increased flexibility and acceptance of working from home may have contributed to the nonsignificant finding for chronic illness. identifying as religious was associated with lower anxiety in the current sample, consistent with our hypothesis. given that the covid-19 environment is one in which we are physically and socially disconnected from each other, belief in a higher power might help people remain connected to others through community-specific religious activities and events and through an awareness that one is part of something bigger than oneself. this is consistent with the larger literature, which has identified religion and pro-social behavior as protective factors against psychopathology broadly and anxiety specifically (gearing & lizardi, 2009; greenfield & marks, 2004; levin, 2009; peteet 2020; smith et al., 2003). interestingly, individuals who reported a history of volunteering prior to the pandemic endorsed significantly more anxiety than participants who had not volunteered in the past. although altruism as a whole tends to be negatively associated with anxiety (elphick, 2020), research suggests that changes in daily lifestyle habits and identity roles can lead to a loss in well-being and the presence of psychological symptoms (giuntella, hyde, saccardo, & sadoff, 2021; greenfield & marks, 2004) and this is true for altruistic behaviors specifically (feng et al., 2020). given a stay-at-home order was put in place shortly before the data was collected, many altruistic individuals may not have been able to volunteer as they usually would. this may have changed their daily lifestyle, separated them from sources of social support, and had implications for their identity as a volunteer, leading to anxiety. perhaps the most intriguing pattern of results may be seen in the three questions that inquire about the perception of failures in leadership. people who endorsed blaming someone “for the current situation in your country” reported higher anxiety scores on both measures. of the 62% of respondents who felt there was someone to blame, the vast majority identified an entity in national leadership (the cdc, president trump, congress, etc.) who they believed was to blame. further, about half of the sample endorsed feeling angry about official messaging, and 34.7% said that self-isolation measures imposed by authorities were not sufficient. these beliefs similarly predicted higher anxiety. together, these results are consistent with broader research on organizational leadership. in a meta-analysis by costello and colleagues (2019), researchers found that the perception of poor leadership within an organization leads to higher stress; the findings were particularly striking in a dementia care home (vogel et al., 2017), and in nursing homes (willemse et al., 2012). similarly, a study of industrial workers (schmidt et al., 2014) found that leadership perceived as less supportive was associated with higher stress and lower self-perceived health among employees. these findings have been replicated across many occupations, from teaching to the military, in many different countries. as gabriel (2014) wrote: we expect our leaders to lead the way, to show moral courage and to embody and articulate values beyond that of efficiency. we expect leaders to talk to us, to address our concerns and to listen to us….sometimes, we expect our leaders to see clearly, to possess a certain conviction and resoluteness represented by that overused and abused word, vision….we expect our leaders to care – not just in an impersonal manner ‘about’ a project or ‘about’ the bottom line, but ‘for’ the organization and its people, indeed for each and every follower. (p. 319) importantly, these results are consistent with recent work by dhanani and franz (2020), who directly anxiety symptoms in the covid-19 pandemic 112 examined trust in governmental leadership during march, 2020 of the pandemic. their findings suggest that, at that time, there was a significantly higher level of trust in the center for disease control (cdc) than in president trump. moreover, trust in president trump was significantly correlated with misinformation about transmission and symptoms of the virus, as well as angry feelings towards people of asian descent. thus, contrary to prior research identifying mistrust in the government as a barrier to good health behaviors, dhanani and franz (2020) concluded that their findings “suggest that trust in governmental leadership can be a hindrance to health literacy when the messages issued by governmental leaders are at odds with those from public health organizations and emerging evidence-based practices…messaging from governmental leaders in the united states may be impeding effective public health responses to covid-19” (dhanani & franz, 2020, p. 10). together these findings suggest that the absence of clear and consistent messaging from leadership not only makes it more difficult to discern the appropriate course of action but can also directly increase anxiety and mental health symptoms. clinical implications these results have a number of implications for clinical theory and treatment. first, this study highlights that our beliefs about the covid-19 pandemic can impact our emotional response and well-being. this is consistent with a major premise of cognitive-behavioral therapy: our thoughts occupy a position of central importance and largely determine our emotions, behaviors, and experiences (beck institute, 2021). transference-focused psychotherapy, a psychodynamic approach, similarly acknowledges that the way an individual views themselves and others influences their interpretation of their experience and contributes to the development of distressing symptoms (frank yeomans, 2021). thus, existing therapeutic approaches are well-positioned to address mental health difficulties related to this novel coronavirus. the findings also suggest a number of specific therapy recommendations in the current setting. first, being consistent and transparent about changes to protocol and expectations during the pandemic may help minimize client anxiety. this may be particularly true if providers are navigating a shift to telehealth practice or a return to in-person services. given that clinicians are often viewed as an authority, clear communication and consistent information can have a profound impact on clients. additionally, asking about the impact covid-19 has had on patient’s various identities can provide important context for understanding their symptoms. if certain parts of a client’s identity have been lost during the pandemic, processing that loss in therapy may be an important part of addressing patient symptoms. additionally, the results suggest that the associations between symptoms and vulnerabilities to covid-19 may be more complex than predicted and should be understood from the patient’s perspective rather than assumed. thus, approaching patients with a curious, caring, and empathetic attitude is likely to not only strengthen the alliance between the therapist and patient but also provide important contextual information for understanding the patient’s symptoms. not only can these recommendations be helpful in a therapeutic setting, but they can also be implemented across all workplace environments. as many companies transitioned to remote work and are now contemplating returning to in-person, specific health and safety guidelines should be enacted. for example, guidelines regarding the requirement of in-person versus remote work, the (dis)use of masks, covid-19 testing onsite, covid-19 screeners, etc., should be clearly delineated for all employees. furthermore, it would be in leadership’s best interest to facilitate feedback from their employees to ascertain their level of comfort regarding the potential return to in-office work. the findings from this study clearly demonstrate the importance of transparent communication from leaders. limitations and future directions the current study has several limitations. in particular, the current sample consisted primarily of caucasian women from michigan who were recruited through a convenience sampling approach. while this provides insight into a specific demographic, it lacks a holistic view of the population of michigan, which includes diverse racial, ethnic, and socioeconomic backgrounds. consequently, the results from this study are not generalizable to the whole population of michigan. furthermore, the study did not control for potential confounding variables. capturing information regarding psychiatric history could have provided further information regarding the pandemic’s influence on individuals’ anxiety levels. while the political unrest and worsening covid-19 numbers in michigan at the time of data erickson 113 collection provide an interesting sample for study, findings might not be generalizable to other parts of the country where covid-19 numbers and policies differed or to other stages of the pandemic. that said, findings from the current study are largely consistent with prior research on anxiety and mental health during covid-19. another limitation is that this is not an experimental study but, rather, a naturalistic field study. it documents what is happening in the real world, which is a great opportunity for understanding human behavior; however, lacking experimental controls, it provides less evidence of cause-and-effect relationships (miller, 2017). additionally, the current study is part of a larger, global study involving 23 countries. other countries used either qualtrics or google for their online surveys. an attempt was made to get cross-sectional data (different age groups) and diverse populations as much as possible. readers who wish to learn more about the findings from other countries may read the already published articles from this study (burkova et al., 2021, 2022; butovskaya et al., 2021). future research examining these findings in the international sample could help to clarify the generalizability of these findings. further, this study was developed early in the pandemic, when researchers and respondents were unaware of how long the pandemic would last and how costly it would be. consequently, the findings presented are only applicable to the first phase of the pandemic as the results do not capture the perspectives of individuals as the pandemic progressed. to address this limitation, future work should examine whether findings persist over the course of the pandemic. to that end, a second round of data collection is being conducted. questions about epidemiological experience, vaccination, personality characteristics, and unexpected consequences of the pandemic will be examined in the second wave of data collection. conclusions our study revealed factors associated with higher levels of anxiety in a sample of michigan adults. as to be expected, those who lived with someone infected with covid-19 had higher state and trait anxiety. consistent with prior research on anxiety during pandemics, older age and having a religious affiliation were demonstrated to be protective factors against anxiety. furthermore, those who identified as having volunteered prior to the pandemic denied social networking as a valuable means to connect with loved ones and had changes to their daily lifestyle habits reported higher rates of anxiety. a possible explanation is that older adults’ routines may not have been as affected by the pandemic as younger adults due to their retirement status. those who were already communicating with friends online (e.g., social media) may have noticed a smaller shift in their social lives as they still connect with friends, albeit in a slightly different context. however, for those who volunteer, consistent face-to-face contact may have been a primary form of social interaction and/or become ingrained in their routine; thus, the inability to volunteer restricted their means of communication. the findings presented here were from the earlier stages of the pandemic, at a point when no one knew the duration of the stay-at-home orders, thus no shifts to virtual connection were yet established. but as the pandemic continued, more companies, universities, social circles, etc. had to make the adjustment to solely connecting virtually. therefore, it is possible that had the data been collected at a later time in the pandemic, some may have adjusted to the “new normal,” and, consequently, these factors would not have contributed to higher reporting of anxiety symptoms. the results of this study should be interpreted within the context of certain limitations. one important limitation of the current study includes but is not limited to, the lack of representation from diverse racial, ethnic, and socioeconomic backgrounds. accordingly, the results are not generalizable to the whole population of michigan. this study, along with prior studies, demonstrates the negative impact pandemics have on individuals’ mental health. the effects of the covid-19 pandemic are far-reaching and will likely take time to fully understand. the current study adds to the conversation of the mental health sequela resulting from covid-19 and highlights important implications for organizational leaders and clinical practice. references a thought process for developing healthier thinking. beck institute. retrieved july 26, 2021, from https://beckinstitute.org/about/understanding-cbt/ balsamo, m., romanelli, r., innamorati, m., ciccarese, g., carlucci, l., & saggino, a. 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(2007). age differences in coping and emotional responses toward sars: a longitudinal study of hong kong chinese. aging and mental health, 11(5), 579-587. https:// doi.org/10.1080/13607860601086355 anxiety symptoms in the covid-19 pandemic 118 table 1 frequency of adaptation to social stress responses and mean anxiety symptom ratings by group note. m = mean, sd = standard deviation. erickson 119 table 2 group differences in gad-7 and stai anxiety scores note. *p <.05, **p <.01, ***p <.001 anxiety symptoms in the covid-19 pandemic microsoft word manuscript 6_cl.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 effects of child and parent race on reported externalizing and internalizing symptoms: findings from the pacct study shira mattuck teachers college, columbia university a substantial body of research has demonstrated that black children are more likely to be diagnosed with disruptive behavior disorders (dbd) compared with non-hispanic white children and less likely to be diagnosed with affective disorders. several explanations for this phenomenon have been explored in the literature, including the effects of stereotypes, clinician bias, and measurement bias. there is also evidence to suggest that black and non-hispanic white caregivers may report symptoms differently and have different thresholds for determining a behaviour as problematic. the current study aimed to assess whether caregiver race impacted the level of parent-reported externalizing and internalizing symptoms for black and non-black children in a sample of 324 children and adolescents with same and different-raced parents recruited from an ongoing longitudinal study of early childhood adversity. results indicate that non-black caregivers reported significantly higher rates of internalizing symptoms in non-black children. however, there were no significant differences in the reported rate of internalizing or externalizing symptoms in black children, regardless of reporter race. there were also no significant differences between black and non-black children in terms of symptoms overall. these results suggest that there may be meaningful differences in the manner in which black and non-black caregivers report externalizing and internalizing symptoms. these findings are a preliminary analysis and future research should further investigate the role of caregiver race in the determination of childhood diagnoses for black and non-black children. keywords: externalizing, internalizing, child race, parent race previous research has demonstrated that black individuals are diagnosed with certain psychiatric disorders at higher rates than non-hispanic white individuals (garb, 1997). in adults and adolescents, studies have shown that black individuals receive diagnoses of schizophrenia at higher rates than non-hispanic white patients (garb, 1997; kilgus et al., 1995; strakowski et al., 1993; strakowski et al., 1995; olbert et al., 2018). in children and youth, researchers have documented higher rates of externalizing disorders among black children (delbello et al., 2001; lau et al., 2004; nguyen et al., 2007). specifically, black youth are more likely to receive a diagnosis of conduct disorder (cd) than non-hispanic white youth, and less likely to receive a diagnosis of attention deficit hyperactivity disorder (adhd; cameron & guterman, 2007; coker et al., 2016; fadus et al., 2020; feisthamel & schwartz, 2009; flores & lin, 2013; mandell et al., 2007; morgan et al., 2013). however, black children appear to experience similar or greater rates of adhd symptomatology compared to non-hispanic white children (miller et al., 2009). there is some evidence to suggest that the higher rate of cd diagnoses in black youth may be reflective of stereotypes of black children as more aggressive, older, and more culpable for their actions than non-hispanic white children (goff et al., 2014). there is also research that indicates black caregivers may report symptoms differently than white caregivers, and clinicians may receive reports differently as a function of race (bax et al., 2019; cooper-patrick et al., 1999; lau et al., 2004; leslie et al., 2007; mandell et al., 2007; mandell & novack, 2005; vázquez & villodas, 2019). the current study aims to assess whether © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. mattuck graduate student journal of psychology there are differences in the magnitude of externalizing and internalizing symptoms for black and non-black children as a function of caregiver race. this study is unique in that it utilizes data from the ongoing parents and children coming together (pacct) longitudinal study on adverse childhood experiences and includes a large proportion of child and caregiver dyads who are not matched on race. this study represents a first step in disambiguating the effects of child and reporter race on reported externalizing and internalizing symptoms. diagnostic differences based on race differences in the rate of diagnosis of certain disorders based on race was first identified in the research literature in the 1980’s (adebimpe, 1981; adebimpe, 1982; bell & mehta, 1980; bell & mehta, 1981). specifically, adebimpe (1981) reviewed available literature on misdiagnosis of black patients and highlighted the need for clinicians and diagnostic criteria to be sensitive to the symptomatology of black patients. several scholars have demonstrated that black adults and adolescents, especially black men, are more likely to be diagnosed with schizophrenia than non-hispanic white adults (kilgus et al., 1995; olbert et al., 2018; strakowski et al., 1993; strakowski et al., 1995). strakowski et al. (1993) retrospectively analyzed the charts of 173 patients with psychotic disorders discharged from a state psychiatric hospital during a 7-month period. results indicated that black patients were more likely to be diagnosed with schizophrenia than white patients (odds ratio (or) = 5.1), and men were more likely to be diagnosed with schizophrenia than women (or = 1.9). strakowski et al. (1995) further conducted a retrospective chart review of 490 patients randomly selected from 9500 visits to a psychiatric emergency service during a period of one year. the authors found black patients were more likely to be diagnosed with schizophrenia and substance use disorder and less likely to be diagnosed with a personality disorder than similar white patients. black patients were also more likely to be hospitalized. more recently, olbert et al. (2018) conducted a meta-analysis of schizophrenia diagnosis rates in the united states. the authors included 14 studies that used structured diagnostic instruments and 41 studies using unstructured instruments. results indicated that black individuals were diagnosed with schizophrenia at higher rates than white individuals across all studies (or = 2.42), including studies using unstructured interviews (or = 2.43) and in studies using structured interviews (or = 1.77). importantly, studies that used structured interviews did not seem to significantly attenuate the odds ratio as compared to studies that used unstructured interviews. thus, there appears to be a consistent trend in which black adults are diagnosed with schizophrenia at higher rates than non-hispanic white adults. in children, several studies have documented higher rates of diagnosed disruptive behaviour disorders among black children and lower rates of affective disorders as compared to non-hispanic white children (delbello et al., 2001; lau et al., 2004; nguyen et al., 2007). in a retrospective chart review of all adolescents aged 12 to 18 admitted to the adolescent psychiatry unit at cincinnati children's hospital medical center between july 1995 and june 1998 (n = 1001), delbello et al. (2001) found that black males were diagnosed with schizophrenic spectrum disorders at higher rates than black females, or caucasian adolescents overall. black patients were diagnosed with conduct disorder (cd) at significantly higher rates than caucasian adolescents, who were diagnosed more often with alcohol use disorders and major depression. nguyen et al. (2007) examined the impact of race and ethnicity on psychiatric diagnoses for 1189 children and adolescents who participated in a federally funded community effects of child and parent race on reported externalizing and internalizing symptoms graduate student journal of psychology mental health program. the authors found that after controlling for age, gender, functional impairment, and socioeconomic status (ses), black and native hawaiian youth were at higher risk of being diagnosed with a disruptive behaviour disorder (dbd). black, asian american, and native hawaiian youth were also rated as having fewer internalizing symptoms than white youth. this study demonstrates that the higher rates of externalizing disorders in black youth are not accompanied by higher rates of functional impairment and cannot be attributed to other demographic factors such as ses. among the dbds (adhd, cd, oppositional defiant disorder [odd]), research suggests that black children and youth are diagnosed with cd more often than non-hispanic white children and diagnosed with adhd at lower rates (cameron & guterman, 2007; coker et al., 2016; fadus et al., 2020; feisthamel & schwartz, 2009; flores & lin, 2013; mandell et al., 2007; morgan et al., 2013). mandell et al. (2007) analyzed the diagnoses received prior to the diagnosis of autism spectrum disorder (asd) in a sample of 406 medicaid-eligible children. adhd was the most common diagnosis among children who did not receive an asd diagnosis on their first specialty care visit. however, african american children were 2.4 times more likely than white children to receive a diagnosis of cd than adhd. as a possible explanation for these results, the authors suggest that black parents may be more likely to describe their child’s behaviours in a way that emphasizes externalizing symptoms (mandell et al., 2007). in a longitudinal study of 4297 children and caregivers, coker et al. (2016) found that african american children had significantly lower odds of receiving an adhd diagnosis in both fifth grade (or = .40) and tenth grade (or = .42) as compared to non-hispanic white children. similarly, morgan et al. (2013) analyzed rates of adhd diagnosis in a nationally representative sample of 17,100 children involved in a longitudinal study. the authors found african american children were 69% less likely to be diagnosed with adhd than non-hispanic white children. these disparities were already present in kindergarten and extended to at least eighth grade. another study found that among 1173 youth living in residential treatment facilities, only 24.4% of non-hispanic white youth were diagnosed with cd while 34.4% of african american youth had received a cd diagnosis (cameron & guterman, 2007). feisthamel and schwartz (2009) conducted a study of diagnostic rates in a sample of 899 community mental health agency clients ranging from 4 to 85 years of age. clients were assessed by master’s and doctoral level mental health counsellors blind to the research question using the structured clinical interview for dsm-iv (scid; first, spitzer, gibbon, & williams, 1995). european american clients were significantly more likely than their african american counterparts to receive a diagnosis of adjustment disorder (15% vs 7%), while african american clients were significantly more likely to receive a childhood disorder diagnosis, including dbds (20% vs. 12%). in this study, none of the diagnosticians identified as african american. this study demonstrates that the use of a structured clinical interview may not be sufficient to prevent discrepancies in clinical diagnoses based on race. importantly, miller et al. (2009) have demonstrated that lower rates of adhd diagnosis among black children are not attributable to lower rates of adhd symptomatology in this group. the authors conducted a review and meta-analysis of 5 studies on adhd diagnosis and 5 studies of adhd symptoms. results suggest that african american children actually had more adhd symptoms but were diagnosed with adhd only twothirds as often as caucasian children (or = .66), even after controlling for ses. other studies in adult populations have also shown differences in diagnosis based on race when structured or semi-structured clinical interviews were used (neighbors et al., 2003; olbert et al., 2018). neighbors et al. (2003) analyzed data from 665 african american and white mattuck graduate student journal of psychology psychiatric inpatients interviewed by psychiatric residents using a shortened version of the dsm-iii-r symptom checklist (hudziak et al., 1993). african american patients were significantly more likely to be diagnosed with schizophrenia, and clinicians used a different process to link client symptoms to diagnostic constructs for african americans, especially for schizophrenia. taken together, these studies suggest that cd may be overdiagnosed in black children while adhd may be under-diagnosed. these discrepancies appear to persist even when structured diagnostic instruments are used. implications and causes of cd overdiagnosis overdiagnosis of cd in black children may reflect stereotypes of black children as aggressive, violent, and older than non-hispanic white children (goff et al., 2014). in a series of studies using mixed methodologies with university students and police officers, goff et al. (2014) demonstrated that black male children are perceived as less innocent and childlike than white children and elicit a less essential conception of childhood. results also demonstrated that black youth were perceived as older and more culpable for their actions than white youth. the authors further demonstrated that dehumanization of black children through implicit associations between black children and apes predicted actual racial disparities in police officer use of force. rattan et al. (2012) further demonstrated that black adolescent offenders are viewed as more deserving of adult sentencing than identical white offenders. the conception of black youth as older and more responsible for their actions is reflected in the rate of black youth who are sentenced as adults within the criminal justice system. research has demonstrated that black youth are 18 times more likely than white youth to be sentenced as adults and make up 58% of those youth sentenced to adult facilities (poeyamagata & jones, 2007). these findings reflect more general trends in the overcriminalization of black individuals. according to the us department of justice bureau of justice statistics, in 2018 black males were incarcerated at a rate 5.8 times higher than white males. while black people make up approximately only 13% of the us population, they comprised 33% of the sentenced prison population in 2017 (gramlich, 2019). according to the most recently available data from the us department of justice office of juvenile justice and delinquency prevention, in 2017 black juveniles were incarcerated at a rate of 151 for every 100,000 whereas non-hispanic white juveniles were incarcerated at a rate of 26 for every 100,000. stereotypes of black children as aggressive may perpetuate and bolster the reciprocally reinforcing relationship between diagnoses of cd and criminal justice system involvement. cd is one of the most frequent diagnoses given to youth in the criminal justice system (drerup et al., 2008; teplin et al., 2002). teplin et al. (2002) assessed the rate of psychiatric diagnoses amongst a randomly selected, stratified sample of 1829 detained juveniles in cook county, illinois using the diagnostic interview schedule for children version 2.3 (disc; schaffer et al., 1996). the authors found that 37.8% of male detainees met criteria for cd. interestingly, compared with african american juveniles, nonhispanic white juveniles had significantly higher rates of any disorder, any dbd, and cd specifically. in contrast with this finding, more recent research by baglivio et al. (2017) found that among 8763 adolescent males involved with the florida department of juvenile justice, black males were 40% more likely than non-hispanic white males to have received a diagnosis of cd, and approximately 40% less likely to have received a diagnosis of adhd. however, black males were 32% less likely to receive psychiatric treatment. similarly, rawal et al. (2004) found that among a sample of 473 justice-involved youth, effects of child and parent race on reported externalizing and internalizing symptoms graduate student journal of psychology black youth demonstrated greater mental health needs but received lower rates of services. further, teplin et al. (2005) found that white youth were twice as likely to be detected by the criminal justice system as needing mental health treatment than black youth. some research has suggested that white youth who demonstrate conduct problems are more likely to be steered towards mental health treatment while black youth may be relegated to the criminal justice system (atkins et al., 1999; cohen et al., 1990; lewis et al., 1979). in a comparison of youth age 12-15 residing in a state psychiatric hospital or juvenile corrections facility, cohen et al. (1990) found that black youth in the correctional setting had similar scores on the child behavior checklist (cbcl; achenbach & edelbrock, 1983) as white youth in the psychiatric hospital. similarly, westendorp et al. (1986) found that race, but not psychopathology, significantly predicted which youth would be treated in a psychiatric facility and which would be sent to a juvenile justice facility. atkins et al. (1999) has reported similar findings. these findings suggest that the overdiagnosis of black children and youth may be one expression of systemic racial biases in which clinicians and service providers view black youth as inherently more delinquent and less treatable than non-hispanic white youth. mechanisms and moderators of bias emerging evidence suggest that discrepancies in the rate of cd and adhd diagnoses between black and non-hispanic white children may not be accompanied by concomitant symptom levels (miller et al., 2009). there is evidence to suggest that racially based differences in the presentation, interpretation, and/or reporting of externalizing symptoms may contribute to the higher rate of externalizing disorder diagnoses among black children. specifically, clinicians are not immune to racial biases about black patients. studies have shown that health professionals hold both implicit and explicit biases that may affect delivery of care to black patients (fitzgerald & hurst, 2017; institute of medicine, 2002; van ryn et al., 2011). van ryn et al. (2011) found that white health professionals most often have low explicit and high implicit bias towards black patients, who perceive this combination as particularly aversive due to the mismatch between verbal and non-verbally communicated cues. diagnostic bias may also occur as a result of statistical discrimination (balsa & mcguire, 2001), in which clinicians use expectations about the rate of a disorder in a particular population to inform diagnostic decision making. in this way, clinicians who believe externalizing behaviours are more common in black children and adhd less common, may reinforce this discrepancy by conforming to this stereotype in their diagnostic decisions. research has also demonstrated that clinicians who are under conditions of greater cognitive load may experience reduced capacity to regulate implicit biases and may rely more heavily on stereotypes (dyrbye et al., 2019; johnson et al., 2016). there is also evidence to suggest that clinical diagnostic measures used to assess psychopathology may be producing differential diagnoses for non-hispanic white and black children (breslau et al., 2008; eisen et al., 2006; green et al., 2012; johnson et al., 2007; randolph & koblinsky, 2003; zink et al., 2015). instruments designed to diagnose psychopathology are often validated on general population samples and thus may not be as sensitive or specific to psychopathology in minority populations (breslau et al., 2008). as previously discussed, studies that assessed participants using structured or semistructured instruments have also found differences in the rate of diagnoses for certain disorders in black individuals (cohen et al., 1990; neighbors et al., 1999; neighbors et al., 2003; olbert et al., 2018). given the evidence suggesting that black children experience adhd symptoms at similar or higher rates than non-hispanic white children (miller et mattuck graduate student journal of psychology al., 2009), these results suggest that the race of children or reporters may be impacting the diagnostic process at some junction. while clinician and measurement bias may contribute to the overdiagnosis of black children with cd and underdiagnosis of adhd, the description of externalizing symptoms may also vary by reporter race. specifically, there is evidence to suggest that white parents may report externalizing symptoms differently than black parents (bax et al., 2019; lau et al., 2004; mandell et al., 2007; vázquez & villodas, 2019). further, research has also demonstrated that clinicians may receive and interpret reports of symptoms differently as a function of reporter race (cooper-patrick et al., 1999; leslie et al., 2007; mandell & novack, 2005). for example, mandell et al. (2007) found that african american parents were more likely to describe their children's behaviour in a way that emphasized externalizing symptoms. bax et al. (2019) conducted a secondary analysis of children with and without adhd according to teacher and parent symptom report. the authors found that among children with underlying adhd, white children from two parent households were more likely to have received assessment and medication services. studies have also shown that black parents may express greater concerns about the motivations of mental health care providers and the possibility of stigmatization (mishra et al., 2009). additionally, bignall et al. (2015) have demonstrated that black individuals are more likely to normalize psychopathology and make spiritual attributions for mental health issues. there is also evidence to suggest that non-hispanic white and black caregivers may have different thresholds for labelling behaviour as problematic. in an analysis of 4175 youths and their caregivers, roberts et al. (2005) found that the rate of concordance between youth and caregiver report of youth emotional and behavioural problems varied by race. the authors found a higher rate of concordance among european american dyads compared to african americans. european american caregivers appeared to have a lower threshold for labeling youth behaviours as problematic, despite similar rates of youth reported problems across groups. however, in a study of 741 caregivers, vázquez and villodas (2019) found that black parents were more likely to indicate their child needed intervention programs when they reported clinically elevated externalizing problems. thus, black caregivers may have a higher threshold for identifying behaviours as clinically elevated yet may be more likely to endorse the need for intervention when problem behaviours are identified. however, research has demonstrated that clinicians may be more responsive to reports of problem behaviours from non-hispanic white parents (leslie et al., 2007), which may contribute to the discrepancy between black and non-hispanic white youth in service utilization and treatment receipt. despite documented findings indicating that black and non-hispanic white caregivers may report symptoms differently, studies have not yet disambiguated the effects of parent and child race in the reporting of internalizing and externalizing symptoms. elucidating the specific effects of parent race on reported symptoms is difficult as most studies use samples in which parent and child dyads are primarily biologically related, and thus matched on race. the current study is unique in that it utilizes a sample from an ongoing longitudinal study on adverse childhood experiences. experimental groups in this study are characterized by a high proportion of children who were adopted. as such, many children and guardian pairs are not of the same race. this discrepancy will allow for an analysis of the effects of reporter race on the reported internalizing and externalizing symptoms in both black and non-black children. effects of child and parent race on reported externalizing and internalizing symptoms graduate student journal of psychology this study aims to examine whether differences exist in the magnitude of externalizing and internalizing symptoms for black and non-black children that are moderated by caregiver race. this study utilizes data from the longitudinal study on adverse childhood experiences and includes a large proportion of child and caregiver dyads who are not matched on race. this sample presents a unique opportunity to analyze the effects of caregiver race on reported symptoms for black and non-black children. this study represents an initial step in disambiguating the effects of child and reporter race on reported externalizing and internalizing symptoms. hypotheses the hypotheses for this study are twofold. the first hypothesis is that there will be differences in the rate of internalizing and externalizing symptoms for black and nonblack children overall such that black children will have higher parent-reported externalizing symptoms than will non-black children. the second hypothesis is that parent race will moderate the level of internalizing and externalizing symptoms for both black and non-black children such that the level of symptoms for black and non-black children will be influenced by the race of the parent reporter. methods procedures data were obtained from the first phase of the ongoing parents and children coming together (pacct) longitudinal study led by dr. nim tottenham (irb-aaar1888) on the effects of early adverse childhood experiences on psychosocial and neurobiological outcomes. all procedures were approved by the columbia university institutional review board. caregivers gave written informed consent and assent was obtained from child participants. trained research assistants with master’s level education in either psychology or social work collected self-report questionnaire data from reporters at inperson visits. while the race of the research assistants may be an important variable in influencing symptom reports, this data was not available for the purpose of this study. participants were compensated $175 usd for each child that participated in an in-person visit. children also received 4 hours’ worth of community service and a video file with neuroimaging from their visit. participants the current study included four experimental groups and one control group. experimental groups consisted of children with prior histories of international institutional care (previously institutionalized; pi), domestically adopted children (domestically adopted; da), children with disrupted caregiving (disrupted caregiving; dc), and children who have experienced international foster care but not institutionalization (international foster care; ifc). the control group was composed of children who had always been with the biological parent(s) and had never experienced prolonged separation from the primary caregiver. there were 324 participant dyads in this study, consisting of a unique child and a reporter. data was available for 71.29% (n = 231) children and 67.59% (n = 219) reporters. data on self-identified race was missing for 93 (28.7%) children and 105 (32.4%) reporters. some reporters had multiple children enrolled in the study. age at the time of data collection ranged from 6-12 years old (m = 8.84, sd = 2.03). of the child participants, 52.6% (n = 169) were female and 28.7% children (n = 93) reported their race as african american or black. of the children in this study, 30.86% (n = 100) reported their race and ethnicity as nonhispanic white. of the reporters in this study, 25.93% (n = 84) reported their race as african american or black while 52.16% (n = 169) reported their race as non-hispanic white. participant dyads were matched on race between child and reporter in 54.01% (n = mattuck graduate student journal of psychology 175) cases. reporters consisted of biological parents, adoptive parents, foster parents, and/or legal guardians. measures externalizing and internalizing symptoms were measured using the parent report version of the child behavior checklist for ages 4-18 (cbcl; achenbach, 1991). the cbcl is a 113-item parent report questionnaire scored on a three-point likert scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). reporters were asked to choose the response that reflected their child’s behavior in the past six months. the cbcl has 8 subscales, grouped into three categories including the two categories of internalizing behaviors (withdrawn, somatic complaints, and anxious/depression), and externalizing behaviors (delinquent and aggressive). the final three subscales are social problems, thought problems, and attention problems (achenbach, 1991). the current study analyzed the computed t-scores for the internalizing and externalizing scales. the cbcl has good psychometric properties with high internal consistency within scales (internalizing, a = .90 and externalizing, a = .94), inter-rater reliability (internalizing, r = .72, externalizing, r = .85), and stability (internalizing, r = .80, externalizing, r = .82) and has normed comparison data (achenbach, 1991). the cbcl has also demonstrated good content, criterion-related, and construct validity (achenbach, 1991). data was analyzed using ibm spss v.27. based on parent reported demographic data, children and reporters were coded as black or non-black. t-scores for the externalizing and internalizing subscales of the cbcl were computed using manualized protocols provided by the authors (achenbach, 1999). results child and reporter race effects first, a repeated measures anova was used to assess whether dichotomized child and reporter race, and their interaction, were associated with the difference in t-scores on the externalizing cbcl subscale from the internalizing cbcl subscales. the repeated measures anova was used to elucidate whether child or reporter race was significantly associated with differences in cbcl t-scores. there were no significant main effects of child race (f(1, 301) = 1.06, p = .304) or reporter race (f(2, 301) = 1.08, p = .340) on differences between externalizing and internalizing t-scores. there was a significant interaction of child race and reporter race on the difference between externalizing and internalizing t-scores (f(1,301) = 5.53, p = .019), such that non-black children who had non-black reporters had higher internalizing scores than non-black children with black reporters (t = -2.48, p = .014), while we did not find a significant effect of reporter race on cbcl difference scores for black children (t = .85, p = .397). child/reporter race match effects next, a repeated measures anova was used to assess whether dichotomized child race, child/reporter race match, and their interaction, were associated with the difference in tscores on the externalizing cbcl subscale from the internalizing cbcl subscales. child/reporter race match was established by scoring whether the self-reported race for the child and caregiver dyad was congruent. there was no significant main effect of child race on the difference between externalizing and internalizing scores (f(1, 302) = .26, p = .606). there was a trend level main effect of child/reporter race match on the difference between externalizing and internalizing cbcl subscale t-scores (f(1, 302) = 3.75, p = .053). the interaction of child race and child/reporter race match was not significant (f(1, 302) = .02, p = .902). effects of child and parent race on reported externalizing and internalizing symptoms graduate student journal of psychology discussion the present study aimed to assess whether there were differences between externalizing and internalizing symptoms for black and non-black children that varied as a function of reporter race. we anticipated that black children would have higher reported externalizing symptoms than non-black children and that this finding would be moderated by reporter race. results support the hypothesis that there are differences in the manner in which black and non-black parents report internalizing and externalizing symptoms for non-black children. however, the current study did not find significant differences between black and non-black children on the level of reported externalizing and internalizing symptoms overall. the hypothesis that there would be differences in reported externalizing and internalizing symptomatology between black and non-black children was not supported by the results of this study. results indicated that there was a significant interaction of child race and reporter race on the difference between externalizing and internalizing symptom reports. results indicated that non-black caregivers with non-black children reported significantly higher internalizing symptoms than black caregivers with non-black children. we did not find a significant difference between internalizing and externalizing symptoms for black children as a function of caregiver race. further, we analyzed whether congruency in child and caregiver race was associated with differences in the rate of internalizing and externalizing symptoms. we did find a trend level effect of child/reporter race match on the rate of internalizing and externalizing symptoms. the interaction of child race and child/reporter race match was not significant. given the resources often necessary to adopt or foster children, there may be systematic socioeconomic or demographic differences between the groups in which children were not matched with their caregivers on race and the control group in which reporters were biological parents. this difference may be driving the trend level effect of child/reporter race match that was observed in this study. these results add to the body of literature suggesting that reporters of different races may have higher or lower thresholds for labelling youth behaviour as clinically significant (roberts et al., 2005). however, non-black caregivers of non-black children only reported elevated levels of internalizing symptoms and not externalizing symptoms. results are partially in accordance with findings from roberts et al. (2005) who found that european american caregivers had lower thresholds for labelling their child as having emotional and behavioural problems. while the authors of that study described their measures as intending to capture “emotional and behavioural problems”, the five-item tool they used may have more effectively captured internalizing symptoms as compared with externalizing symptoms. the measure utilized by roberts et al. (2005) probed overall mental health, life satisfaction, happiness, and role strain, which may be more closely associated with typical internalizing symptoms. this may explain why we did not find elevated rates of externalizing symptoms reported by non-black caregivers of non-black children. results did not indicate differences in the rate of externalizing or internalizing symptoms for black children depending on reporter race. given the differences in sample size between black (93 children, 84 reporters) and non-black (138 children, 135 reporters) groups in this study, analyses may have been underpowered to detect differences between reporter ratings for black children. the majority of research in this area has focused on differences in the rate of diagnosis and not symptomatology. as previous mattuck graduate student journal of psychology research has described, black children appear to have similar rates of externalizing symptoms as non-hispanic white youth, yet are diagnosed at different rates (cohen et al., 1990; miller et al., 2009). thus, the finding that black and non-black children did not have different levels of reported symptoms may reflect findings from this literature. the current study compared the magnitude of caregiver-reported externalizing and internalizing symptoms for black and non-black children. however, most studies that have assessed differences in the rate of diagnosis have compared black children with nonhispanic white children. several studies have demonstrated that diagnostic trends in the underdiagnosis of adhd and overdiagnosis of dbds may also occur in hispanic and native hawaiian youth (baglivio et al., 2017; cameron & guterman, 2007; fadus et al., 2020; garb, 1997; nguyen et al., 2007). however, this trend appears to be inconsistent across studies. for example, nguyen et al. (2007) found that both black (or = 2.76) and native hawaiian (or = 2.05) youth involved in a community-based treatment program were more likely than non-hispanic white youth to be diagnosed with a dbd. hispanic youth in this study were not more likely to receive a dbd diagnosis than non-hispanic white youth. similarly, baglivio et al (2017) found that among youth in a juvenile justice residential placement, black male youth were significantly more likely than white youth to receive a diagnosis of cd. however, both black and hispanic male youth were less likely than non-hispanic white youth to receive an adhd diagnosis. in contrast, cameron and guterman (2007) found that among youth in residential treatment facilities, both hispanic and african american youth received cd diagnoses at higher rates (43.3% and 34.4%) than non-hispanic white youth (24.4%). given these findings, the inclusion of hispanic white children, asian american children, native hawaiian/pacific islander children, american indian and alaska native children, and children of more than one race in the “non-black” group may have obscured differences in symptom magnitude between black children and non-hispanic white children in this study. the inclusion of these children may explain why differences were not observed between black and non-black children on the measure of externalizing and internalizing symptoms overall. limitations there are several limitations to this study. first, data on self-identified race was missing for 93 (28.7%) children and 105 (32.4%) reporters. it is possible that the exclusion of these missing data points may have impacted the results of the current study. many of the missing data points were associated with participants who had study visits at the beginning stages of this longitudinal study. this trend is likely due to initial issues in the implementation of study procedures at the start of data collection, rather than participant factors. however, there may be systematic differences between participants with missing data and those who have data available. thus, results of this analysis should be interpreted with caution. second, there were differences in the number of black and non-black participants both for children and reporters. these differences in sample size may have contributed to underpowered analyses that were unable to detect differences in reporter ratings for black children. finally, children and caregivers in the experimental groups in this study may not be representative of the general population in regard to socioeconomic variables. as previously discussed, the adoption process requires significant financial and personal resources. thus, participant dyads who were not matched on race in this study may be graduate student journal of psychology effects of child and parent race on reported externalizing and internalizing symptoms systematically more socioeconomically advantaged than children and youth involved in other studies on parent-reported symptomatology. a systematic analysis of these factors was beyond the scope of the current study but deserves consideration. future directions future projects could compare the rate of externalizing and internalizing symptoms for black children compared only to non-hispanic white children. while the current analysis used parent-report measures and did not include clinician assessed measures, the ongoing longitudinal project from which data for this study was derived used trained master’slevel research assistants to diagnose participants using the kiddie schedule for affective disorders and schizophrenia (ksads) semi-structured interview. future research could investigate whether there were differences in the rate of cd diagnosis compared to adhd in this sample and whether this is associated with differences in symptom frequency, duration, and severity as reflected in clinician note-keeping during the interview. these findings may aid researchers in identifying whether differential rates of diagnosis are moderated by parent race. additionally, there is some research to suggest that diagnostic discrepancies may affect black youth differently depending on gender (baglivio et al., 2017; delbello et al., 2001; goff et al., 2014). given these findings, future research may benefit from analyzing whether there are differences in reported internalizing and externalizing symptoms as well as differences in the rate of cd and adhd diagnosis for this sample depending on both race and gender. conclusion this study represents a unique investigation into moderating effect of caregiver race on reported externalizing and internalizing symptomatology in black and non-black children. while the majority of research on this topic has utilized samples in which child and caregiver race was matched, this study utilized data from an ongoing longitudinal study in which a large portion of the child and reporter dyads were not biologically related and differed on self-reported race. findings suggest that there are differences in the ways in which black and non-black caregivers report child symptoms that are dependent on race such that non-black reporters may indicate higher rates of internalizing symptoms in non-black children. these results represent an important first step in identifying the processes and junctures through which discrepancies in the rate of externalizing disorders in black children are produced. this research is integral to the equitable and appropriate treatment of both black and non-black children and youth in health care and criminal justice settings, and the critical awareness that clinicians and researchers must have of the potential impact of caregiver race on reported symptomology. further research is necessary to elucidate the mechanisms through which diagnostic discrepancies between black and non-black children are created. acknowledgements the authors declare no conflict of interest associated with the publication, and no significant financial support for this work that could have influenced its outcome. references achenbach tm (1991) manual for the child behaviour checklist/4±18 and 1991 profile. burlington, vt: university of vermont, department of psychiatry. achenbach, t. m. 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(eds) guide to psychological assessment with african americans. springer, new york, ny. 23     graduate student journal of psychology copyright 2010 by the department of counseling & clinical psychology 2010, vol. 12 teachers college, columbia university engaging in the hookup culture: a self-discrepancy perspective elizabeth victor duke university this study examined the hypothesis that self-concept discrepancies predict engagement in casual sexual behavior, or hookups. one hundred seventy two undergraduate men and women completed questionnaires assessing their level of self-discrepancy and their hookup participation. contrary to the study hypothesis, findings indicate that participants high in actual-ideal self-discrepancy are less likely to engage in hookups. gender, age, and actual-ought self-discrepancy did not predict hookup culture participation. differences between ethnic groups in hookup participation are also discussed. a new phenomenon has changed young adult and adolescent sexual relationship development, as clear boundaries and stages appear to no longer define dating relationships (stanley, 2002). in fact, glenn and marquardt ( proper operational definition for the term hooking up, young people are left with an inability to forecast what physical behaviors are expected from their partners or whether there is a possibility for a future committed relationship. casual sexual encounters, or hookups, according to contemporary college students, can refer to a wide variety of sexual behaviors ranging from kissing to vaginal sex, and usually occur between two people who are either strangers or brief acquaintances, typically last only one night, and occur between partners who are not in a committed relationship (flack et al., 2007; paul, mcmanus, & hayes, 2000). in addition, bogle (2008), as well as england, shafer, and fogarty (2007), reported that hookups typically involve moderate to heavy alcohol consumption and that most college students report not believing their hookup will lead to a future committed relationship. fifty to 75% of college students report engaging in at least one hookup in the past year (glenn & marquard, 2001; paul, mcmanus, & hayes, 2000). the increase of casual sexual encounters continues to stir controversy for both sexes as females and males struggle to find their role in the hookup culture. such encounters have serious health risks leading both psychologists and education policy makers to try to better understand the factors leading to participation in the hookup culture. past research has examined this type of casual sexual behavior during adolescence through a cautionary or disease-related lens (e.g., levinson, jaccard, & beamer, 1995), suggesting that                                                                                                   the author would like to thank erel shvil, mphil, dr. robert thompson, dr. david rabiner, and dr. wilkie wilson for their guidance and support in completing this research project, as well as lori kwapil for her efforts in data analysis and collection. correspondence concerning this article should be addressed to elizabeth victor, 638 mag nolia st, aiken, sc 29801. email: ecv2111@columbia.edu. individuals at increased risk for unwanted pregnancy and contraction of sexually transmitted diseases (stds), including hiv, as individuals are less likely to know about sexual history (dailey, 1997). self-discrepancy theory and the hookup culture little research has been conducted on why some young adults choose to engage in casual sexual activity, while others strive for committed romantic relationships with one perso self-concept may offer some explanation for these differences. self-discrepancy theory (sdt; higgins, 1989) provides a useful frame in which to examine the relationship between casual sexual-decision making and self-concept among young adults. sdt is concerned with how discrepancies in self-perceptions relate to heightened emotional states (i.e., anxiety, stress, and anger). higgins (1987) defined self-concept in terms of three domains: (1) the actual self, or one's representation of the attributes that self, or one's representation of the attributes that one would like to possess; and (3) the ought self, or the attributes that one believes one should possess. in other words, sdt seeks to understand how a person describes themselves in three ways: how they think they actually are (to themselves and to others in their social network), how they would like to be, and how they think they ought to be. according to higgins (1999), when discrepancies involve the domains of the self, emotional vulnerabilities can be heightened (i.e., anxiety, stress, and anger). for example, if a person arrogant, but then lists humble a elevated levels of depression-related feelings. furthermore, a person that uses selfish then lists compassionate experience anxiety-related feelings. discrepancies between how one actually is (the actual self) and how one would ideally like one to be (the ideal self) represent the absence of positive outcomes. in contrast, discrepancies between the victor     24 actual self and how one believes he or she should or ought to be (the ought self) represent the presence of negative outcomes (boldero & francis, 2005). for instance, actualideal discrepancy is hypothesized to lead to feelings of depression or low self-worth, while actual-ought discrepancy is hypothesized to lead to feelings of anxiety or preoccupation with moral behavior. in addition, higgins reports that actualglobal self-esteem (higgins, 1999). the level of discrepancy between these self-concepts varies between individuals. some people do not have a large discrepancy between their actual self-concept and their ideal self. these people are presumed to be more motivated and to have greater self-esteem in comparison to those with high actual-ideal discrepancies (strauman & higgins, 1987). for example, in researching selfdiscrepancies as predictors of chronic emotional distress, people characterized by an actual-ideal discrepancy reported considerable depressive (i.e., dejection oriented) symptoms, but fewer anxiety/ paranoid (i.e., agitationrelated) symptoms (strauman & higgins, 1987). in addition, these findings have been tested outside of normative populations. in a study of undergraduates suffering from major depressive disorder, dysthymia, or an anxiety disorder, those with depressive disorders were found to have significantly higher actual-ideal discrepancies, while anxious participants had significantly higher actual-ought discrepancies , 1993). however, there has been increasing debate about whether depression and anxiety. previous studies have reported that predictive of self-esteem levels in comparison to studies examining personality types or behavior patterns (mcdaniel & grice, 2008). factors associated with hookup culture participation take part in the hookup culture during college. once a person leaves their home and parents to venture off to college, he or she may encounter significant social pressure that will influence his or her future actions in an effort to feel accepted by his or her peers. given the risk of casual sexual decision-making, it is important to explore what variables might predict engagement in casual sexual encounters. this study will address gender, ethnicity, and self-discrepancy as factors that might be associated with engaging in hookups. many previous studies have found that males report hooking up more often than women (grello et al., 2003; manning, longmore, & giordano, 2005); however, others have noted a convergence in males and females sexual attitudes and activities (herold & mewhinney, 1993; feldman & cauffman, 1999; paul et al., 2000). most recently, owen, rhoades, stanley, and fincham (2010) found similar numbers of men and women engaging in hookups. furthermore, simpson and gangestad (1991) found variance both within and between the sexes. for example, they found that women who indicated more positive attitudes toward casual sex were more likely to report engaging in such behavior than women with negative attitudes, and with more partners than their male counterparts. few documented studies examine age or racial differences in hookup engagement (paul et al., 2000), as most studies draw conclusions from largely white undergraduate samples (desiderator & crawford, 1995; grello, welsh, & harper, 2006). previous literature has primarily found differences only in asian american samples who tend to report less involvement in hookups (feldman, turner, & araujo, 1999; markus & kitayama, 1991). whereas davis and colleagues (2007) reported that there were no racial differences found in intentions for future casual sex or attitudes toward safer sex, owen et al (2010) found that students of color were less likely to engage in casual sexual behaviors. weinberg and williams (1988) found that african americans reported more permissive attitudes toward casual sexual behaviors. due to the insufficient amount of previous research concerning this factor of hookup participation, this study will explore potential racial differences in hookup participation. a ims of cur rent research this study will investigate casual sexual encounters through the lens of sdt. the study will evaluate whether -discrepancy levels as defined by selfdiscrepancy theory (higgins, 1989) are predictive of hookup culture participation. both actual-ought and actualideal discrepancies will be assessed to better understand the study using the concept of self-discrepancy to further understand hookup culture. specifically, it is expected that a high level of self-discrepancy (either in actual-ideal or actual-ought discrepancies) will predict hookup culture participation. particularly, since a low actual-ideal discrepancy (ai) is typically associated with increased selfesteem, it is reasonable to assume that high ai will be predictive of high involvement in the hookup culture. consistent with most previous studies, it is expected that males will engage in more hookups and have a greater number of partners compared to their female peers. furthermore, whites are expected to engage in more hookups compared to their peers of other ethnicities. this study will be the first to investigate how a theory of self concept can be used to better understand hookup participation. the investigator is particularly interested in understanding casual sexual relationships taking place during late adolescence, a period generally associated with identity development. the results of the study might better inform college counselors and others in how to provide support for college students, including helping students combat peer pressure (specifically with regard to casual sexual relationships), and mitigating possible tension self discrepancy theory and hookup participation   25 between developing value systems in contrast to established family-of-origin values and ideals. m ethod participants male and female undergraduate students attending a mid-sized private university in north carolina were psychology department subject pool website and through on-campus fliers. since the study was administered in early august 2008, most freshmen would have only been college students for a few weeks and thus were not included in the study. junior undergraduates were not recruited for the study because a disproportionate number of juniors at the university study abroad during their fall semester and therefore the juniors on campus may not be representative of the typical class. the study sample included 172 students, ages 18-24 (m = 19.65, sd = 1.82) who volunteered to participate in the study. participants were primarily female (n = 119, 69%) and sophomores (n = 113, 66%). one hundred twelve (65%) of the participants were caucasian, 32 (19%) were asian american, 14 (8%) were m easures 1986). this measure was designed for the purpose of -discrepancy score(s) between their actual-ideal and actual-ought self attributes. although individual standpoint and the standpoint of a significant other (mother, father, close friend, etc), this study only interest with regard to late adolescent sexual decisionmaking. a well-utilized technique for learning about a participant's most highly accessible self-state attributes (or how a participant feels, thinks, and describes oneself) is to use the free-response listing technique found in this questionnaire (strauman & higgins, 1987). participants were asked to indicate 10 attributes (adjectives) that describe each of the following: 1) the type of person they actually are; 2) the type of person they believe they ideally would like to be; and 3) the type of person they believe they should or ought to be. as per higgins (1987), discrepancy scores were attributes between their three selves (i.e., actual self, ideal self, and ought self). a thesaurus was used to determine if certain words were synonyms (matches) or antonyms table 1 participant characteristics factor n % sd m possible range gender (n = 172) female 119 69% male 53 31% ethnicity (n = 172) caucasian 112 65% african american 14 8% asian american 32 19% other 14 8% class year (n = 172) sophomore 113 66% senior 59 34% hookup participation (n = 172) yes 98 57% typical level of involvement 171 .99 3.95 1-5 furthest level of involvement 170 1.24 4.59 1-5 number of sexual partners 109 8.67 6.69 0-50 alcohol consumption frequency 128 1-5 yes 81 63% .99 3.47 2-5 no 47 37% blackout frequency 81 .76 1.42 2-5 drug use frequency 130 .76 1.29 1-5 no 74 43% notes /anal once before or during a hookup were included. victor     26 (mismatches) between their actual self attributes and their ideal and ought self attributes. synonyms received a -1, while antonyms received a +2. first, the actual-self total score was determined by identifying any synonyms or antonyms in the list of 10 words. if a synonym or antonym was found, the first word was kept, but the antonym or synonym of the word was crossed out. therefore, a participant could have an actual-self total score of -10 to +20, depending on how many synonyms or antonyms were listed. this same process was used for the ideal and ought self-lists to get a total score for each list. next, all the remaining words listed in the actual self were compared to all the remaining words listed in the ideal and then, ought self. for instance, if a participant wrote lazy as an actual self-attribute and then wrote diligent as an ideal selfattribute, the participant would be given a score of +2. however, if a participant wrote hard working in the actual self list and listed diligent in the oughtself list, he would receive a -1 score. each pair of words was given a score and then all the points were tallied at the end to produce an actual-ideal and actual-ought discrepancy score. if a word was found in the actual-self to be neither a synonym, nor an antonym, the word receives no point and the coder continues to the next word. participants also received points based on the degree of match or mismatch, which participants indicated on a 1-4 likert scale (1= slightly describes an attribute i possess to 4= extremely describes an attribute i possess) for each word they listed. for example, if a word in the actual-self list was synonymous with an ideal-self attribute but differed in extent by more than one point (e.g., the participant gave the actual-self word a 1 score, while the ideal-self a 3 score), it was scored as a mismatch of degree, giving the participant a +1 score. if the two words were not mismatched by at least 2 points, no points were awarded. each actual-ought and actual-ideal discrepancy score was then calculated by summing the weights for all matches and mismatches pertaining to that pair of self-states (scott & o'hara, 1993; strauman & higgins, 1988). therefore, an individual received two final discrepancy scores: an actualideal discrepancy score and an actual-ought discrepancy score. the possible range of scores for each discrepancy was -10 to +20. the more negative a final score, the indicating that he or she may be prone to increased anxiety and depression levels. for this study, the range for the actual-ideal discrepancy was -8 to +8 and for the actual-ought discrepancy, scores ranged from -8 to +6. based on these scores, participants were placed into three levels of selfdiscrepancy, both for their actual-ideal and actual-ought for logistic regression analyses, scores were recoded into a positive continuum in order to more easily interpret the findings. the psychometric properties of the selves questionnaire have been investigated in various studies. reliability data have included an interrater reliability coefficient range from .80 to .87 (higgins et al., 1985; strauman & higgins, 1987). interrater reliability for the current study was .87. hookup culture survey. this measure, designed for the purpose of this study, assessed hookup participation, level of involvement in the hookup culture, alcohol/drug use before and during hookups, and affective reactions to hookup participation. the first section assessed hookup, whether or not the individual engages in hookups, and the individu sexual involvement in the hookup culture. the second section of the survey assessed how illicit drugs and alcohol may moderate the relationship between hookup culture involvement and subsequent negative affect. the third section of the study asked participants to indicate the extent to which they experience certain negative (i.e., distress, regret, guilt, and shame) and positive (i.e., security and confidence) emotions after choosing to participate or not to participate in hookups. participants were also asked about types of social consequences (i.e., less romantic options and more time/resources for social networks) they may have experienced due to involvement or lack of involvement in the hookup culture. only the first section of the questionnaire was used for data analysis in this paper, as future papers intend to examine the role of alcohol/drug abuse and the mental health outcomes of hookup behavior. at the end of the survey, participants were given space to provide any open-ended comments or details they wished to reveal that were relevant to the study. procedure individuals wishing to participate in the study completed anonymously an online survey. participants were able to access the website at any time on a computer of their choice. the entire survey took no longer than 45 minutes to complete. participants began the survey by viewing a consent form and then filling out part 1 of the modified selves questionnaire (msq; higgins, bond, klein, & strauman, 1986). next, participants completed the hookup culture survey. all participants responded to questions about demographics, level of sexual involvement that they define as a hookup, and their engagement in the hookup culture; however, participants answered a different set of questions based on their response to the question of whether or not they participated in the hookup culture. participants either received one hour of class credit by the psychology subject pool coordinator or entered into a drawing for one of six $50 cash prizes. when the study ended, six names were randomly drawn from a collection of all non-subject pool participants and given $50 cash prizes. of the participants, 117 students were entered into the drawing and 55 students were given 1 hour of credit for an introductory psychology course. self discrepancy theory and hookup participation   27 results descr iptive statistics hookup participation. this study surveyed 172 sophomore and senior undergraduates. sixty-five percent (n = 112) were caucasian (see table 1 for descriptives). fifty-seven percent (n = 98) indicated that they have participated in the hookup culture. the average number of hookup partners was 6.69 (sd = 8.67) and the mode was 1 partner. since participants were asked to indicate their own definition of a hookup, it should be noted that each person indicated their participation in hookups based on their personal definition. when defining a hookup, 12% (n = 21) involvement, while 65% (n = 1 as the minimal level. only 13% (n = 23) of the students n = n =1) is a colloquial american expression that is synonymous with french kissing, defined as open-mouth kissing that involves definitions, typical level of intimacy was categorized into three groups based on level of sexual involvement and potential risk-taking opportunity (e.g., low condom use, risk of std infection): high intimacy, or engagement in oral and/or vaginal sex; medium intimacy, or petting; and low intimacy of those participating in the hookup culture, 48% reported that they typically make out during a hookup and 38% reported having anal or vaginal sex at least once during a hookup. sixty-three percent (n = 81) of participants reported using alcohol at least once during or before a casual sexual encounter. self-discrepancy. of the 172 participants, 13% reported low actual-ought (ao) discrepancy, 68% reported medium levels of ao discrepancy, and 19% reported high levels of ao discrepancy. participants generally reported higher levels of actual-ideal ai discrepancy than ao discrepancy. thirteen percent reported low ai discrepancy, 56% reported medium ai discrepancy, and 31% reported high ai discrepancy. gender , e thnicity, and hookup participation to test the hypothesis that gender differences exist in hookup participation, (specifically that men will be more likely to engage in hookup culture), a chi-square test of independence was conducted. gender differences were not significant, 2(1) = 0.947, ns. gender differences for ao and ai self-discrepancy levels were also not significant, ²(1) = .067, ns; and ²(1) = .880, ns, respectively. to test the hypothesis that whites would engage in more hookups than their ethnic minority counterparts, a chisquare test of independence was conducted. hookup participation differed significantly by ethnicity ( 2 = 0.002, p < .01), suggesting that white undergraduate students in their sample are more likely to engage in hookups than undergraduates of other ethnicities. because minority subsamples were collapsed due to small sample size, we could not explore group differences. however, the significant difference in ethnicity may be due to the responses of asian americans individuals. these individuals responded almost exactly opposite of their caucasian and african american counterparts. for instance, 72% (n = 23) of the asians reported not participating in the hookup culture. these individuals constitute almost one-third of the subsample choosing to forgo participation in the hookup culture. logistic regressions logistic regression analyses were conducted using spss 18.0. separate logistic regression analyses were conducted using gender, ethnicity, actual-ideal selfdiscrepancy, and actual-ought self-discrepancy as predictors of participation in hookups (a binary dependent of yes or no) (see table 2). inc low actual-ideal self-discrepancy significantly predicted greater hookup participation (see table 2). no other results were significant. to control for combined effects, an additional logistic regression was conducted combining all the predictor variables (age, gender, and ethnicity) into the model with actual-ideal self-discrepancy (see table 3). results indicate that actual-ideal self-discrepancy predicts whether one will participate in hookups or not, above and beyond the other variables (b = -0.13; 95% ci 0.78 0.98). in addition, ethnicity also predicted hookup participation above and beyond the other variables (b = -0.33; 95% ci 0.52 0.99), such that whites were more likely to engage in hookup culture than their ethnic minority counterparts. discussion the goal of this study was to investigate the variables ther or not to participate in college hookup culture. specifically, this self-discrepancy theory can be used as a tool for better understanding engagement in the hookup culture. it was observed that ai discrepancy scores were predictive of hookup participation. the results were particularly victor     28 discrepancy scores actually served as a protective factor for engaging in hookups. there are many assumptions as to why this outcome occurred. it is possible that young adults entering college want to be a part of what they believe the majority of students are taking part in. in this case, engaging in the hookup culture may be seen as a way to gain social acceptance (levinson, jaccard, & beamer, 1995). for example, some researchers believe that normative sexual standards on campus may cause some students to feel that they must conform to personal and social expectations and behavior to engage in casual sex (delamater & maccorquodale, 1979). these perceived normative standards may dictate what individuals believe to be the accepted rate and level of physical intimacy expected during hookups within a particular campus culture, despite maticka-tyndale, 1995). therefore, students may feel that which may entail engaging in casual sexual relationships. therefore, individuals who engage in hookups are aligning their actual self and ideal self, which leave them feeling more secure and less anxious or depressed. given that low ai discrepancy is asscociated with high self-esteem (mcdaniel & grice, 2008), it is likely that those who particpate in hookups would report high self-esteem before ever engaging in such casual sexual behaviors.   although this study did not find an association between actual-ought self-discrepancy and hookup culture participation, many interesting descriptive statistics were observed. more than half of participants reported engaging in at least one hookup and 38% reported engaging in vaginal or anal sex at least one time during a hookup. these findings point to the magnitude of hookup culture engagement and the potential for unsafe sex leading to sexually transmitted infections and unintended pregnancies. l imitations the primary limitation of the study is the concerns about the validity and reliability of the self-report methods. although students were given complete anonymity, selective self-monitoring of positive aspects (strecher et al., 1986) and temporal distance from the described events may impact recall (downey et al., 1995). furthermore, the sample is from a highly selective private university in the southeast, which may not be representative of colleges across the country, both in terms of ethnicity and socioeconomic status. it is important to also de-bunk previous findings that the majority of casual hookups occur between strangers or brief acquaintances. since the university students involved in this particular study attend a small, private college, hooking up may not be as anonymous or casual as it typically is on other college or univerisity campuses. further research is needed to understand what differences exist between the hookup cultures of small liberal arts colleges versus larger, public colleges or universities. finally, since the majority of the sample was caucasian (65%), few conclusions can be drawn about other racial and ethnic participation. future research directions despite the limitations of the current study, it marks the first integration of self-discrepancy theory with sexual relationship development in late adolescence. further research is needed to establish whether self-descrepancy theory can be used to predict why some young adults table 2 logist ic regression analysis predict ing hookup part icipa tion from actual -ideal (ai) sel f discrepancy, actualought (ao) sel f discrepancy, gender, and ethnici ty. predictor b se exp(b) 95% ci for exp(b) ai self discrepancy -.15* .06 .87 .76 .96 ao self discrepancy -.11 .07 .90 .78 1.04 gendera -.12 .33 .85 .44 1.64 ethnicity -.37* .15 2.25 .51 .93 note. hookup participation (dependent variable) coded as yes = 1, no = 0. adummy coded as men = 1, women = 0. * p < .05. table 3 mul tivaria te model predict ing hookup part icipa tion from actual -ideal (ai) sel f discrepancy, controll ing for age, gender, and e thnicity. predictor b se exp(b) 95% ci for exp(b) ai self discrepancy -.13* .06 .88 .78 .98 age .00 .35 1.00 .75 1.34 gendera .01 .17 1.01 .50 2.02 ethnicity -.33* 2.93 .72 .52 .99 note. hookup participation (dependent variable) coded as yes = 1, no = 0. adummy coded as men = 1, women = 0. * p < .05. self discrepancy theory and hookup participation   29 choose to engage in casual sexual behavior, while others parents, and education policy makers could then begin to develop prevention strategies to reduce risky sexual decision making. steps could be made to target certain students at risk for engaging in hookups. furthermore, if sdt is helpful is understanding hookup participation, clinical researchers could then investigate how sdt might mediate the relationship between engagement in certain sexual behaviors and psychological outcome effects (i.e., regret, self-esteem, shame, and confidence). by understanding the role of self-concepts in young adult decision-making, we can better understand why people engage in certain sexual behaviors and the effects of engaging in these behaviors on mental and physical health. references bogle, k. a. 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(1988). black sexuality: a test of two theories. journal of sex research, 25, 197218.   4848 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university interference effects on procedural memory: an assessment of problem-solving task performance samuel a. birkholz1, eric e. hessler2, & michael root3 1, 2 department of psychology, university of minnesota duluth, 3 department of psychology, minnesota state university moorhead three experiments were conducted to assess interference effects acting on procedural task learning and performance using the tower of hanoi puzzle. in experiment 1, participants in the no-interference group completed the tower of hanoi faster than the retroactive interference groups, with no differences between the types of tactile interference. these results indicate that retroactive interference may hinder procedural task performance but does not differentiate between consolidation and retrieval. experiment 2 addressed retroactive interference placement by manipulating the delay prior to the interference task. interfering with only consolidation or recall did not produce interference effects, but qualitative feedback regarding emotion raised questions about the effects of affect induction. experiment 3 attempted to address the influence of a proactive and retroactive affect induction technique but did not produce a dichotomous happy versus neutral effect. overall, the series of experiments conducted provides a conceptual replication of some previous research while contradicting other findings. this research not only extends our current understanding but also highlights the need to continue to explore factors that may influence the practice or acquisition of novel procedural tasks. keywords: procedural learning, interference, affect, memory, tower of hanoi memory refers to the ability of an organism to store, retain, and retrieve information over time (atkinson & shiffrin, 1968; baddeley & hitch, 1974; cowan, 1999). it is a complex process that involves multiple brain regions and neural networks (for review, see squire et al., 1993). there are several types of memory, including working memory, short-term memory, and long-term memory. working memory refers to the cognitive system responsible for temporarily holding and manipulating information in the mind to perform complex cognitive tasks, while long-term memory refers to the storage and retention of information over a prolonged period, ranging from minutes to years, that is retrieved when needed (cowan, 2008). long-term memory is further divided into different subtypes, such as episodic memory, semantic memory, and procedural memory. procedural memory is the type of memory that enables us to learn and recall skills and procedures necessary for daily life, from simple actions such as brushing our teeth to complex activities such as playing an instrument or driving a car. this type of memory is critical for our ability to perform tasks efficiently and accurately without conscious effort or thought. it is also involved in the acquisition of new skills and the refinement of existing ones, making it essential for personal and professional development (squire et al., 1993). comparing procedural memory to other types of memory procedural memory is often implicit, meaning it operates outside of conscious awareness and without deliberate effort (squire et al., 1993). when performing a skilled task, the individual is not necessarily aware of every step involved in the process, but rather, their body and mind learn the sequence of movements and actions through repetition and practice (fitts, 1964). this type of memory is often referred to as muscle memory since the movements become autonomous and are often performed with little or no conscious thought (for review, see packard & knowlton, 2002). another key feature of procedural memory is its resistance to forgetting (squire et al., 1993). once a skill or procedure has been learned and stored in procedural memory, it can be retrieved and executed with little effort or conscious thought, even after years of disuse. this is because procedural memory is primarily stored in the basal ganglia, cerebellum, and motor cortex regions of the brain, which are involved in motor control and movement planning (packard & knowlton, 2002). this is in stark contrast to episodic and semantic memories. episodic memory is a type of long-term memory that involves storing and retrieving personal experiences, events, and episodes (baddeley, 2000). examples of episodic memory include remembering one’s first day of school, a family vacation, a significant life event, or simply how to complete a puzzle. episodic memory. involves conscious effort and is associated with the hippocampus and related brain regions (tulving & markowitsch, 1998). another trademark of episodic memory is that it is declarative, meaning that it involves conscious recollection. this is a similarity that 49 assessing interference effects episodic and semantic memory share (tulving, 1999). compared to episodic memory, semantic memory involves the storage and retrieval of general knowledge and information about the world rather than specific events (for review, see tulving, 1999). semantic memory is associated with the neocortex and related brain regions, and it differs from other forms of memory in that it is more abstract (for review, see allen & fortin, 2013). however, extensive research indicates that episodic and semantic memory is prone to interference (eakin & smith, 2012; flaisch et al., 2016; wohldmann et al., 2008; yang et al., 2013). interference in different forms of memory various factors can influence the accuracy and reliability of stored information. one such factor is interference, which can disrupt the encoding or retrieval of information, leading to memory errors or loss (unsworth et al., 2013; for review, see robertson, 2012). interference can be broadly classified as proactive and retroactive. proactive interference (pi) is where previously learned information interferes with the encoding or retrieval of new information, while retroactive interference (ri) is where newly learned information interferes with the rehearsal or retrieval of previously learned information. for example, imagine trying to remember a previously learned list of items but then learning a new list of similar items. the new list may retroactively interfere with the retrieval of the old list, making it more difficult to remember. unsworth et al. (2013) conducted a series of experiments to understand how pi and ri affect memory recall for word lists. in experiment 1, participants recalled words from either one or two lists. both interference types caused lower recall, more intrusions (incorrect items recalled), and longer recall times. the hypothesis that participants might search both lists simultaneously but eliminate intrusions before recall was tested in experiment 2. participants recalled words from both lists, resulting in roughly equal intrusions from lists 1 and 2. rejecting intrusions was harder, and clustering indicated contextual cues helped recall. experiment 3 examined recall with varying set sizes. recall of lists 1 and 2 was worse than control lists. recalling both lists had worse results than recalling only one, replicating the "only effect" where combining lists led to larger search sets. participants still included irrelevant items, causing interference. finally, experiment 4 used distinct categories for each list. recall outcomes were similar for all three lists, suggesting distinct categories focused on participants' search and reduced interference, resulting in comparable recall without intrusions. unsworth et al.’s (2013) results also might suggest that the effects of ri vary depending on the type of information being retrieved. for example, ri may have a greater effect on semantic memory than episodic memory. another factor that has been well documented to influence the extent of ri in humans (osgood, 1946; wickelgren, 1965) and non-human primates (medin et al., 1980) is the degree of similarity between the old and new information. the greater the similarity, the more likely it is that ri will occur. a third factor is the amount of time that has elapsed since the new information was learned, with more recently learned information being less susceptible to ri (reyna, 1995). yet, these patterns of results might be limited to declarative forms of memory. the mechanisms underlying ri in procedural memory are not fully understood. however, studies suggest that ri may affect different stages of procedural memory processing, including encoding or acquisition, consolidation, and retrieval (for review, see robertson et al., 2004). acquisition refers to the initial learning of a new motor skill. studies have shown that ri can impair the acquisition of procedural memory. for example, in brashers-krug et al. (1996), participants learned to compensate for velocity-dependent forces on a manipulandum and were immediately tested on a second task. learning the second task within a short time period interfered with the retention of the first task. however, this ri was gradually reduced with the increase in the time interval between the two tasks. the study provides evidence that human motor memory is transformed rapidly with time and in the absence of further practice, in addition to providing evidence that ri occurs in tasks that rely heavily on procedural memory. this means that learning a new motor task can interfere with the consolidation of a previously learned task, making it more difficult to acquire the new task. this also suggests that ri may interfere with the encoding or consolidating new motor skills, lead ing to memory errors or loss. however, brashers-krug et al. did not differentiate between consolidation and retrieval. similar results are reported by friedman and korman (2016). in their study, participants completed a finger opposition task where they touched their 50 birkholz et al. thumb and another finger in a specific sequence. they first did four test trials and then 10 training trials with the sequence shown on the screen. then, half of the participants did an interference training session with a different sequence. all participants were tested again 24 hours later on the original sequence and a different sequence with both hands. analyses suggested that ri prevented delayed gains in correct sequences but not accuracy and that two types of processes contributed to procedural learning: one sensitive to interference (consolidation) and one independent (recall). yet, similar to brashers-krug et al. (1996), friedman and korman (2016) did not attempt to interfere with the recall or retrieval process independent of other stages. retrieval refers to the process of accessing and using previously learned information. when further scrutinized, brashers-krug and colleagues’s (1996) results also appear to suggest that ri may not affect the retrieval of procedural memory, but their methods do not address this directly. more recent research has shown that ri can interfere with the retrieval of a previously learned task, possibly across memory types, making it more difficult to execute the previously learned task. gagné and cohen (2016) used a randomized controlled trial to investigate how interference between memory systems affects skill acquisition. participants were assigned to one of four groups, each receiving a different combination of verbal and motor interference tasks during a finger-tapping sequence learning task. the authors used various measures to assess performance, including reaction time, accuracy, and the number of correct sequences produced. participants were tested on the task immediately following the learning phase and again 24 hours later. only the control group showed offline improvement, and introducing a visuospatial task before motor recall eliminated the gains, thereby suggesting interference between memory systems during subsequent motor recall. this suggests that various factors may cause ri and that ri may also negatively impact some of the retrieval processes of previously learned motor skills. within other types of memory, the idea that other factors such as similarity, time, and the amount of practice influence performance is not new, but these are not the only possible contributors to performance. emotion and memory emotional state can influence our ability to learn different types of information, including a new procedural skill. procedural memory is closely linked to the brain's motor system, which is also involved in processing emotions (packard & knowlton, 2002). studies have shown that emotional arousal can enhance memory formation and retention. for example, labar and phelps (1998) found that emotionally arousing words resulted in better memory retention than neutral words. the authors suggested that emotional arousal enhanced the consolidation of semantic memory. conversely, rimmele et al. (2011) found that participants who were exposed to negative emotional stimuli reported better memory retention than those who were exposed to neutral stimuli, even though their performance was actually worse. these mixed results suggest that our understanding of how emotion interacts with memory is lacking, especially within procedural memory paradigms or when emotion is evoked using different methods regarding pi, yang et al. (2011) induced positive affect in participants by giving them candy as a token of appreciation. participants’ memory was then tested using wordand operation-span tasks, presented in increasingly difficult order. the wordand operation-span tasks were 10 trials each, with two trials at each set size ranging from three to seven presented in random order. an increase in positive affect appeared to moderate memory improvements for words and numbers. although similar anecdotal (e.g., an athlete reporting that feelings influence performance) and empirical evidence suggest similar effects may exist within procedural memory (steidl et al., 2006), our understanding is far from comprehensive. however, one study does find an effect of emotion on procedural skill learning within offline consolidation processes. javadi et al. (2011) recruited 99 participants who were divided into nine groups, with each group having a combination of retention type and emotional content conditions. participants completed a mirror-tracing task where stimuli included faces that were negative, positive, or neutral in expression, with a significant difference between the valence scores of positive and negative images but no significant difference in the arousal scores. the experiment was composed of two sessions (training and testing) with either a 12or 24-hour retention interval. participants also completed a finger-tapping task, which was used to evaluate alertness. the results suggest negative content during encoding improves later performance on the mirror-tracing task 51 assessing interference effects more than neutral or positive content. in fact, participants who learned with negative images had greater skill improvement over time compared to those who learned with neutral or positive images. another relevant but secondary finding suggests that alertness does not play a role in performance differences, which might suggest that physiological arousal is not as important as other factors. although the most basic forms of pi and ri are not widely disputed, there is still some debate on the effects of emotion on learning, as the research findings have not always been consistent. research has found positive and negative emotional states may enhance learning (javadi et al., 2011; labar & phelps, 1998; yang et al., 2011). however, other studies have found that negative emotional states may hinder learning (flaisch et al., 2016; rimmele et al., 2011). furthermore, interactions between variables such as level of skill expertise and affective tone have not been widely examined outside of video game literature (weinreich et al., 2015), leaving gaps in the literature that should be addressed by basic research. overall, while there is some debate on the effects of emotion on procedural learning, it is clear that emotional states can impact the learning and retention of procedural skills. the exact nature of this impact, and whether it is positive or negative, may depend on various factors, such as the type of task, the individual's level of expertise, and the specific emotional stimuli involved. more research is needed to fully understand the complex relationship between emotion and procedural learning. to this end, we report on a series of three experiments conducted to (a) replicate the existing literature that demonstrates ri can directly impact procedural learning and performance, (b) clarify the importance and independence of the consolidation and recall processes within procedural paradigms, and to (c) explore the specific impact of unexpected rewards on novel procedural task acquisition and performance. experiment 1 experiment 1 attempted to replicate previous literature that establishes ri within procedural paradigms (brashers-krug et al., 1996; friedman & korman, 2016; gagné & cohen, 2016; robertson et al., 2004). we used the tower of hanoi as the target procedural memory task (see figure 1), because it requires learning a specific set of rules and steps (vakil & heled, 2016) which can be taught instead of used as a measure of problem-solving. we expected that peg puzzles (see figure 2) would produce the most interference due to their similarity to the tower of hanoi (osgood, 1946; wickelgren, 1965). ring puzzles (see figure 3) are less like the tower of hanoi and were not expected to cause the same level of interference, but interference was still expected to occur compared to the writing control task. therefore, the hypotheses for experiment 1 were as follows: 1. ri that occurs between learning the tower of hanoi and the final performance test was expectedto cause completion time (s) to increase significantly within the peg and ring interference groups when compared to the no interference control group. 2. participants in the ring interference group were expected to complete the task faster than participants in the peg interference group when retested on the tower of hanoi. method participants one hundred eight participants (30 men, 78 women; 18–50 years of age) were recruited via a bulletin board flyer and received course credit for their participation. data from one participant in the ring group were excluded because they could not complete the post-interference tower of hanoi task. data from one participant in the peg group were removed due to a pre-interference completion time that was over three standard deviations from the mean. data from two more participants (one peg group, one ring group) were excluded for having a post-interference completion time that was over three standard deviations from the mean. therefore, data from 104 participants were included in the final analyses (see table 1). materials the tower of hanoi (see figure 1) required participants to move a tower of discs from a start peg to a target peg. there were two rules for moving the discs: (a) only one disc could be moved at a time and (b) a larger disc could not be placed on a smaller disc. the tower of hanoi task varies in difficulty based on the number of discs used. the minimum number of moves the puzzle can be completed in is calculated using the equation f(x) = 2n-1, where f(x) represents the fewest number of moves and n equals the number of discs. typically, the puzzle consists of three pegs and three disks. difficulty increases as the number of discs increases. to make the task moderately difficult, the tower of hanoi task 52 birkholz et al. used in this study consisted of three pegs and four discs. successful completion of the tower of hanoi requires a set procedure that must be carried out in a specific order. the specific sequence extends the task beyond motor memory and forces participants to use spatial problem-solving skills and procedural memory. some participants in the study worked with either three different peg puzzles or eight different ring puzzles, each with a unique goal and set of rules. the three peg puzzles (see figure 2) were the in-line puzzle (left panel), the elimination puzzle (center panel), and the addition peg puzzle (right panel). the in-line puzzle required participants to move pegs so that they switched sides, while the elimination puzzle involved removing all but one peg from play by jumping one over another to an open spot. the addition peg puzzle required filling all holes but one by tracing preset lines between them, with the caveat that a move could not be made if it led to a previously filled slot. for the ring puzzles (see figure 3), participants had to disconnect two linked metal pieces by twisting, sliding, or pulling them apart, using similar strategies for each puzzle. completion times in seconds were recorded using a stopwatch. procedure first, each participant learned how to complete the 4-disc tower of hanoi puzzle with verbal, written, and visual instructions. written instructions were given to each participant and read aloud, briefly outlining the objective and rules of the task. the visual instructions (see figure 4) were provided in the form of an animated .gif (karwath, 2005), and by one researcher demonstration. the discs were color-coded by size. once the animation began, the discs moved from the start peg, following the best sequence possible (a total of 15 moves) to complete the task. the video lasted approximately 30 s and was replayed six times for each participant. after the instruction, participants were allowed two min to practice the tower of hanoi without the animation. this training method is modified slightly from vakil and heled (2016). participants then ran through the tower of hanoi another time, completing it as quickly and efficiently as possible. out of view of the participant, the researcher recorded the completion times (s) and the total number of moves made. following the practice phase, participants were randomly assigned to complete one of the three tasks: writing control, ring puzzles, or peg puzzles. during a 10-min period, control participants wrote a detail-oriented description of the events of their day. if they finished early, they were instructed to write a detailed description of their favorite place on campus. participants in the ring and peg puzzle groups solved as many of their respective puzzles as possible within 10 min. for both of those groups, puzzles were introduced verbally and in writing, with one visual demonstration by the experimenter. participants repeated puzzles if they completed all of them within the 10-min period. immediately following the interference task, tower of hanoi’s performance was assessed again using the same method described for the pre-interference assessment. results homogeneity of variance was not violated for before interference completion time (p = .776) and completion time data appeared to be normally distributed. an initial analysis of variance (anova) comparing completion times between groups before interference showed the effect of the interference group was not significant, f(2, 101) = 0.496, p = .611, η2 = .010, suggesting that performance did not differ across groups prior to completing their respective interference or control task. performance on the tower of hanoi was then examined using a series of 3 (interference group: control, ring puzzle, peg puzzle) x 2 (test trial: before interference, after interference) mixed anovas on the dependent variables completion time and number of moves (power = 1.0). homogeneity of variance was not violated for after interference completion time (p = .615), before interference number of moves (p = .287), or after interference number of moves (p = .158). both of the main effects of interference group, f(2, 101) = 3.225, p = .044, ηp 2 = .060, and test trial, f(1, 101) = 17.587, p < .001, ηp 2 = 0.148, were significant on completion time. the interference group x test trial interaction was also significant on completion time, f(2, 101) = 12.883, p < .001, ηp 2 = 0.203. none of the main effects were significant on the number of moves, which suggests that all participants not only learned the puzzle but retained the steps equally well. interpretations of the significant effects on completion time are provided below. a series of t-tests using tukey’s correction were used to follow up on the significant main effect of the interference group. the control and ring puzzle groups were significantly different (p = .038). completion time was longer in the ring puzzle group (m = 53 assessing interference effects 23.914, sd = 6.807) than in the control group (m = 20.472, sd = 6.077), regardless of test trial. no other comparisons were significant. the significant main effect of test trial indicated that completion time was longer after interference (m = 23.420, sd = 7.609) than before interference (m = 21.080, sd = 5.503), hinting that at least one group’s performance changed. simple effects were run to follow up on the significant interaction effect and to further explore both within and between-group differences. the simple effects of test trial at ring puzzle, f(1, 101) = 22.61, p < .001, r = .44, and peg puzzle, f(1, 101) = 16.82, p < .001, r = .32, were significant. completion times were longer after completing the ring and peg puzzles than before completing them (see figure 5). in contrast, the simple effect of test trial at control was not significant, meaning there was no difference in completion time before and after performing the control task. simple effects also indicated that differences were driven by completion times being different across groups following their respective tasks, f(2, 101) = 7.92, p = .001, while no differences were observed in completion times before the conditions deviated, f(1, 101) = .500, p = .611. experiment 1 discussion previous research has shown the potential for ri in procedural memory (brashers-krug et al., 1996; friedman & korman, 2016; gagné & cohen, 2016; robertson et al., 2004). experiment 1 aimed to examine the effect of interference tasks on the retrieval of procedural memory of the tower of hanoi puzzle. results showed that the writing control group completed the tower of hanoi puzzle faster than the peg and ring interference groups after the respective interference tasks. however, the peg task, which was subjectively more similar to the tower of hanoi than the ring task did not produce larger interference effects. notably, the results also suggested that the level of interference did not affect the participant’s total number of moves. these results support hypothesis 1, but hypothesis 2 was not supported. experiment 1, like other research, did not compare the effects of consolidation and retrieval on ri (brashers-krug et al., 1996; friedman & korman, 2016). experiment 2 was conducted to investigate the importance and potential independence of these processes in procedural memory and skill acquisition. experiment 2 javadi et al. (2011) focused on retrieval as the point of action for ri. another important process potentially affected by ri is the consolidation of newly acquired memories (brashers-krug et al., 1996; friedman & korman, 2016). consolidation aids in memory retention by organizing material in working memory and preparing it for transfer into long-term memory (squire, 1986). without the consolidation process, memory would not transfer. this study aims to address the effects of ri on the differentiable processes of consolidation and retrieval by examining both potential points of action within the same ri paradigm as experiment 1. using the tower of hanoi again as a target task, our hypotheses for experiment 2 were as follows: 1. immediate forms of interference were expected to produce the greatest performance decline due to the learner’s inability to consolidate newly learned information (brashers-krug et al., 1996; friedman & korman, 2016). 2. delayed interference, acting directly before retrieval, was expected to have no performance-inhibiting effects due to allowing consolidation to complete automation of the procedural task (javadi et al., 2011). 3. participants in the control group were expected to perform better than participants in any other condition when retested on the tower of hanoi. method participants one hundred and thirty-two participants (51 men, 81 women; 18–30 years of age) were recruited via the university’s online research recruitment website and received research credit for their participation. four participants were removed from the analysis due to not following the rules for completing the tower of hanoi puzzle, data from two more participants were removed due to incomplete data collection, and data from six more participants were removed due to their initial test completion time (s) being over three standard deviations from the mean. therefore, a total of 120 participants were included in the final analyses (see table 2). materials the same 4-disc tower of hanoi puzzle that was used in experiment 1 was used in experiment 2. in 54 birkholz et al. the interference conditions, participants worked with ten different ring puzzles instead of eight. completion times in seconds were recorded using a stopwatch. procedure the progression for experiment 2 was similar to experiment 1 with a few minor modifications. each participant learned how to complete the 4-disc tower of hanoi puzzle following the same procedure as in experiment 1. participants were then instructed to complete the tower of hanoi again, completing it as quickly as possible and in as few moves as possible. out of view of the participant, the researcher recorded pretest completion time (s) and total number of moves. following the practice phase, participants were randomly assigned to complete one of the three conditions. during a 13-min period, no interference participants wrote a detail-oriented description of the events of their morning. if completed before time expired, they were asked to describe their favorite location at the university. participants in the immediate interference group solved as many ring puzzles as possible within 10-min immediately following the pre-test, then had a three-min waiting period. participants in the delayed interference group waited three minutes after the pre-test, and then were instructed to solve as many ring puzzles as possible within 10 minutes. ring puzzle instruction was the same as in experiment 1. immediately following the experimental phase, tower of hanoi’s performance was assessed again using the same method described for the pre-test assessment. results the pre-test number of moves between groups was examined to gauge similarity in levels of mastery across groups. homogeneity of variance was violated (p = .001) but completion times appeared to be normally distributed and the achieved power was .999. a kruskal-wallis h test indicated the median pre-test number of moves did not differ across conditions, χ2(2) = 0.594, p = .743. homogeneity of variance was also violated for pre-test completion times (p = .029) and non-parametric tests were used for all subsequent analyses. a kruskal-wallis h test suggested that neither pre-test, χ2(2) = 0.061, p = .970, nor post-test, χ2(2) = 0.150, p = .928, completion times differed across groups, meaning the groups performed the tower of hanoi similarly before and after any intervention. within-group performance between pre-test and post-test completion times was examined using a series of wilcoxon signed-rank tests which suggested a significant difference within the immediate interference group (z = -2.197, p = .028, r = .571), with median post-test completion times (mdn = 19) being faster than median pre-test completion times (mdn = 21). all other comparisons were not significant. exploratory analyses conducted after removing all participants whose pre-test completion times were over three standard deviations from the mean of experiment 1’s before interference completion times yielded the same overall result, except that no significant difference was observed in the immediate interference group when comparing median pre-test completion times to median post-test completion times. experiment 2 discussion experiment 1 indicated procedural memory performance can decline when ri tasks are introduced. experiment 2 did not reveal the same findings when a three-min waiting period was added either immediately after the pre-test or immediately before the post-test. offline performance gains were observed within the immediate interference group while performance did not change within the control and delayed interference groups. these gains might be explained by offline practice, but previous research has only observed these gains within consolidation, suggesting that interfering with retrieval seems to, at least initially, cancel out these gains (gagné & cohen, 2016; javadi et al., 2011). this highlights the importance of work implicating retrieval as an important yet separate mechanism within procedural memory performance and skill acquisition, suggesting that retrieval is less susceptible to ri than previously reported (javadi et al., 2011). experiment 2 suggests ri acting on the consolidation process apart from the retrieval process yields different results as compared to acting on both processes. however, another important factor was highlighted during the debriefing process. many participants noted that the ring puzzles elicited frustration. experiment 2 did not quantify emotion as a possible variable acting on performance, but feelings of frustration may have inadvertently enhanced ri within experiment 1 as other experiments have shown (flaisch et al., 2016; rimmele et al., 2011; weinreich et al., 2015). however, participants did not provide similar informal feedback after complet55 assessing interference effects ing experiment 1. experiment 2 may have also inadvertently introduced boredom or decreased motivation, factors that have been found to influence both learning and memory (moore et al., 2014), although this is contrasted by research suggesting alertness does not impact procedural performance (javadi et al., 2011). the mixed results warranted further research to address why ri did not occur and to examine potential influences of emotion observed in previous research (javadi et al., 2011; steidl et al., 2006). experiment 3 previous research across memory types has implicated emotion as a factor that moderates performance (flaisch et al., 2016; javadi et al., 2011; labar & phelps, 1998; packard & knowlton, 2002; rimmele et al., 2011; yang et al., 2011), with interventions ranging from emotionally-valenced images or word lists and the receipt of an unexpected gift. however, the research discussed earlier suggests that affect induction has mixed results and the effects are observed as both pi and ri. experiment 3 was designed to address the implications of positive affect induction via receipt of an unexpected gift either before (pi) or after (ri) learning a novel procedural skill. we hypothesized the following: 1. positive affect such as joy or happiness was expected to improve test performance regardless of placement (javadi et al., 2011; yang et al., 2011). 2. improvements in performance were expected to be accounted for by an improved ability to learn the task (yang et al., 2011). 3. changes in alertness were not expected to impact skill acquisition or retrieval (javadi et al., 2011). method participants seventy-eight participants (33 men, 45 women; 18-24 years of age) were recruited. participants received general psychology course credit and a $10 amazon. com gift card for participation. data from two participants were removed after the manipulation check analysis due to worsening completion times during practice. data from one outlier was removed within the delayed gift group based on the first timed test immediately following the practice phase being greater than three standard deviations from me mean. data from three more participants were removed due to incomplete data collected, and therefore up to 72 participants were included in the final analyses (see table 3). materials the tower of hanoi was also used in experiment 3. however, participants learned the 3-disc procedure. a transfer task was added which utilized the 4-disc procedure that was used in experiments 1 and 2. the positive and negative affect schedule expanded form (panas; watson & clark, 1994) measured self-reported state affect during the experiment. participants rated to what extent they agreed with statements with either positive or negative connotations. higher scores on either positive affect words or negative affect words correspond to either higher positive affective tone or higher negative affective tone respectively. within the general dimension portion, 10 responses were coded as general positive affective words while 10 others were coded as general negative affective words. positive and negative emotionally charged words were broken down further into subgroups and categorized to analyze these additional dependent variables: joviality, attentiveness, sadness, fatigue, and surprise. these subgroups were identified logically as pertinent to this study while other subgroups such as fear, hostility, and shyness were excluded. procedure each condition’s specific procedural sequence is depicted in figure 6. one control group first completed the panas. next, these participants were taught how to complete the 3-disc tower of hanoi puzzle with verbal, written, and visual instructions. written instructions were read aloud and given to each participant briefly outlining the objective and rules of the task. visual instructions were provided in the form of one researcher demonstration. after instruction, all participants were allowed five minutes to practice the tower of hanoi. the number of practice trials and successful completions during practice were recorded. completing the puzzle or restarting marked the beginning of a new practice trial. initial test performance on the tower of hanoi puzzle was measured (s) out of sight of the participant. the total number of moves was not counted as participants were allowed more practice time, and this should only have increased puzzle mastery. immediately following learning and initial testing participants read a psychology magazine for five minutes. immediately following, participants 56 birkholz et al. were retested on the hanoi puzzle. following the second testing phase, transfer was tested using the 4-disc version of the tower of hanoi with no instruction. after the transfer measure, participants were awarded a $10.00 amazon.com gift card. another control group followed a similar process except they did not complete panas before learning the tower of hanoi. instead, participants in this group completed the panas after learning instead of a five-minute waiting period. one experimental group followed the same process as the first control group except participants were awarded a $10.00 amazon.com gift card before completing the panas. a second experimental group followed the same process as the second control group except participants were awarded a $10.00 amazon.com gift card before completing the panas. results panas a series of 2 (affect: positive, neutral) x 2 (placement: before learning, after learning) independent groups anovas were used to examine the following dependent variables: general positive, general negative, joviality, attentiveness, sadness, fatigue, and surprise. homogeneity of variance was not violated for any of the affective variables and the distributions appeared to be normal. the achieved power was not as high as in other analyses but was sufficient: .817. results indicated a significant main effect of placement on attentiveness, f(1, 71) = 6.441, p = .013, ηp 2 = .087 (see figure 7). on average, attentiveness was higher after learning (m = 14.971, sd = 3.339) than before learning (m = 13.216, sd = 2.583) free of the affective condition. no other main effects or interactions were significant. practice each participant was required to complete at least two of the practice trials being analyzed for their data to be included in the practice trial analyses. five participants were excluded from all practice trial analyses (two from control group 1, two from control group 2, and one from experimental group 1), leaving up to 67 participants for analyses of the practice phase while achieving power = 1.0. a 2 (affect) x 2 (placement) x 2 (practice: practice two, practice three) mixed anova was conducted to examine completion time differences between practice trials and across conditions. homogeneity of variance was not violated for either practice two completion time (p = .325) or practice three completion time (p = .077), and sphericity was assumed. practice had a significant main effect on completion time, f(1, 58) = 5.189, p = .026, ηp 2 = .082. there was also a significant affect x practice interaction, f(1, 68) = 4.18, p = .040, ηp 2 = .071 (see figure 9). no other main effects or interactions were significant. simple comparisons were conducted to follow up on the significant interaction. results indicated the positive groups’ times differed significantly from one practice trial to the other f(1, 60) = 10.90, p = .002, r = .39, with practice three (m = 16.469, sd = 5.486) being faster than practice two (m = 19.231, sd = 9.964; see figure 8). no other simple comparisons were significant. a power function (y = kxn; r = .635, sd = .233) and a quartic function (y = ax4 + bx3 + cx2 + dx + e; r = .753, sd = .166) were calculated for each participant’s practice period, and the quartic function was determined to have a better-fit coefficient. a 2 (affect) x 2 (placement) anova was conducted as a precaution to ensure function fit was not different across conditions, resulting in no significant main effects or interaction. the derivative of each quartic equation was taken and solved at the points equal to the second, third, and fourth practice trial times. these derivatives gave the rate of change for each participant’s power curve at each point. the rates of change were analyzed using a 3 (practice: practice two, practice three, practice four) x 2 (affect) x 2 (placement) mixed anova to examine changes in completion time (s). homogeneity of variance was not violated within practice two (p = .095), practice three (p = .094), or practice four (p = .092). the main effect of practice, f(2, 126) = 10.311, p < .001, ηp 2 = 0.141, on rate of change was significant. pairwise comparisons for the main effect of practice indicated changes in completion time differed between practice two and practice three (p = .006), practice two and practice four (p = .006), and practice three and practice four (p = .007). respectively practice two completion times changed fastest (m = 0.577, sd = 0.1.525), then practice three (m = 0.378, sd = 1.015), and practice four (m = 0.280, sd = 0.761). no other main effects or interactions were significant. finally, a 2 (affect) x 2 (placement) independent groups anova was used to examine potential differences in the number of attempted practice trials between groups. unsuccessful trials were in57 assessing interference effects cluded in the analysis. homogeneity of variance was not violated (p = .706), and neither the main effect of affect nor placement on the number of attempted practice trials was significant. in addition, the affect x placement interaction was not significant. test and transfer a 2 (affect) x 2 (placement) x 2 (timed trial: first test, second test) mixed anova was used to examine differences in performance between conditions and across timed trials. homogeneity of variance was not violated for timed trial completion times (p = .947), and achieved power was 1.0. there was a significant main effect of placement, f(1, 68) = 4.339, p = .041, ηp 2 = 0.060, with completion of the panas before learning resulting in slower average test completion times (m = 7.740, sd = 1.608) than when the panas was completed after learning the tower of hanoi (m = 6.996, sd = 1.579) regardless of affective condition. no other main effects or interactions were significant. the main effect of placement was explored further using a series of independent sample t-tests comparing the first and the second test completion times based on panas placement being either before or after learning, which indicated the significant main effect was due to a difference in the second test completion times, t(70) = 2.100, p = .039, d = .495, with later panas placement resulting in faster completion times (m = 7.021, sd = 1.509) than early panas placement (m = 7.773, sd = 1.529). no difference arose between the first test completion times. a 2 (affect) x 2 (placement) independent groups anova was used to examine the dependent variable of transfer time. homogeneity of variance was not violated (p = .369), and there were no significant effects. experiment 3 discussion previous research has used an unexpected gift of candy to induce a higher momentary positive affect before completing a task (yang et al., 2011). in this study, a $10 gift card was used. it appears that the manipulation failed to produce the desired effects but there were notable changes in attentiveness. however, these changes are limited to after learning how to complete the tower of hanoi. this suggests that the intervention did not have a significant impact on attentiveness, but instead simply engaging in learning a novel puzzle might have caused the increase. in turn, the improvements observed across practice trials between the positive and neutral affective groups might be attributable to non-significant differences in initial practice performance. this post hoc explanation is supported by the evidence suggesting that no group exhibited greater practice trial-to-practice trial performance changes. therefore, the affective results of this study are largely inconclusive. that being true, it appears that the panas placement between the first and second tests may have facilitated performance in some way, but the extent and specific mechanisms of this influence are also unclear. granted, all groups were able to master the 3-disc version of the puzzle, but transfer performance may have been better if a variable training method was used (vakil & heled, 2016). overall, the changes in attentiveness are particularly interesting and will be covered in greater detail within the general discussion. general discussion this series of experiments had three main objectives: (a) replicating existing literature demonstrating the impact of retroactive interference (ri) on procedural learning and performance, (b) clarifying the significance of consolidation and recall processes within procedural paradigms, and (c) exploring the influence of unexpected rewards on procedural task acquisition and performance. experiment 1 replicated prior research on ri in procedural memory using the tower of hanoi task and various puzzles. our first hypothesis was supported that both interference groups would perform worse than the control group. the amount of interference in the peg and ring groups was similar when participants were retested on the tower of hanoi, which was contrary to our second hypothesis. however, experiment 1 did not differentiate between consolidation and retrieval processes. experiment 2 aimed to clarify the impact of interference on the consolidation and retrieval processes in procedural memory performance. we hypothesized that immediate interference would lead to the largest performance decline, while delayed interference would have no effect. however, the results were not consistent with that hypothesis. we observed that emotions such as frustration and boredom might have influenced performance, which led to conducting experiment 3. experiment 3 did not yield the expected effects, though the interpretation of the results paralleled that of experiment 2, except for the intriguing differences in alertness observed 58 birkholz et al. before and after learning the tower of hanoi puzzle. affect induction previous research has found that we can induce different affective states using various methods (flaisch et al., 2016; javadi et al., 2011; labar & phelps, 1998; packard & knowlton, 2002; rimmele et al., 2011; yang et al., 2011). while experiment 3 utilized an intervention based on previous work, we assumed that participant affect would be impacted by the surprise receipt of a $10 gift as compared to a small piece of candy (yang et al., 2011). given the results, we must acknowledge that there may be a reason why this particular intervention is not commonly used or reported (zhang et al., 2014). this may explain why the methods used in experiment 3 did not produce a clear positive and neutral dichotomy. future replication of experiment 3 should use a different method to change participant affective tone. zhang et al. (2014) tested four different commonly used affect induction procedures (recall with music, guided imagery, visual images with music, and embodiment) and found that all are effective in inducing both pleasant and unpleasant affective changes. however, some procedures are more effective than others. viewing evocative photographs while listening to music and recalling an affectively salient event while listening to music were the most effective in inducing a pleasant affective tone, while viewing evocative photographs while listening to music was the most effective in inducing unpleasant affect. overall, these results suggest that combining evocative images with music is a powerful way to manipulate affective states, while all four methods are equally effective in modifying arousal. using these methods before learning the tower of hanoi, or imposing an effective strategy post-learning, might increase the likelihood of achieving the desired effect. this would provide further insight into if the placement of emotionally-valenced interference impacts various stages of procedural skill acquisition and performance. alertness and procedural memory previous research found that alertness was not a factor in procedural performance changes (javadi et al., 2011). however, the definition of alertness matters. previous literature defines ‘alert’ or ‘alertness’ in many ways, but we believe the following definition, modified and adapted from oken et al. (2006) and shapiro et al. (2006), is both recurrent in the literature and appropriate for this discussion. alertness refers to a heightened state of readiness or vigilance corresponding to the ability to maintain focus and attention on a task or situation. javadi et al. (2006) used a self-report questionnaire and a finger-tapping task to measure alertness, whereas in experiment 3, we used the panas. another main difference is that in experiment 3, we tracked changes in performance across the acquisition stage. this allowed us to determine what mechanisms might be driving overall performance differences if they arose. the differences in the results of experiment 3 and those reported by javadi et al. (2011) warrant further exploration into how the construct of alertness interacts with procedural skill acquisition. in experiment 3 we observed that alertness appeared to increase after participants’ engagement in learning how to complete the tower of hanoi. we cannot attribute these changes to the monetary intervention, and therefore conclude that there is some other relationship between alertness and learning a procedural skill. this brings us back to the definition of alertness, and how previous research has linked it to changes in performance. much of the early research exploring the role of alertness on memory defined alertness as needing sleep or not (aguirre et al., 1985; gorissen et al., 1997; rogers & rosenberg, 1990). however, contemporary research has expanded our understanding of alertness to include momentary fluctuations that influence both attentional control and memory processes (debettencourt et al., 2018, 2019; keene et al., 2022). we also better understand the neuroanatomical structures responsible for modulating alertness (ross & van bockstaele, 2021; van egroo et al., 2022). however, there are still gaps in our understanding of the results of experiment 3. to date, there appears to be little or no research that systematically examines the influence of alertness on procedural memory processes. however, we might be able to glean some insight from other memory domains such as long-term memory encoding and working memory. within these systems, vigilance, or the ability to maintain focus on a given task, can be measured using response time and pupillometry. faster response times in decision-making tasks and larger pupil size compared to an individual’s baseline are predictive of errors. in turn, errors suggest that not enough attentional resources are being allocated to the task. to clarify the relationship between vigilance and working memory, adam et al. (2015) used 59 assessing interference effects the whole report change detection paradigm. participants were presented with a memory display, followed by a test array, and had to indicate whether it was the same or different. instead of the standard same/different response, participants were presented with a 3 x 3 matrix of colors and had to select the individual color that appeared at the same location as in the original display. the researchers used a lapse model and an attentional control model to explain fluctuations in performance and found that the attentional control model best explained working memory performance. these findings suggest that attention lapses contribute to individual differences in working memory capacity. further evidence to support an attentional control explanation was reported by debettencourt et al. (2019). participants completed a task in which they had to identify if an array consisted of colored circles or squares by pressing a button. the circles appeared more frequently than the squares, causing errors to occur when participants had to switch to identifying the squares. to measure the relationship between vigilance and working memory, a whole-report color task was added to the task at random intervals. results showed that attention lapses, identified by faster reaction times, were related to errors in working memory. similar observations are made in long-term memory. debettencourt et al. (2018) had participants complete a task where they identified indoor or outdoor scenes and then performed a recognition memory test with 200 images. sustained attention was measured using the average reaction time over the previous three trials and was found to predict memory performance. infrequent images preceded by faster reaction times in the initial decision-making task were less likely to be remembered in the surprise long-term recognition memory task than those preceded by slower reaction times. this suggests that an individual’s level of vigilance during encoding affects which memories are formed. these recent studies might also give us insight into the results from experiment 3, and at least give us an idea of why increases in alertness appear to coincide with procedural skill acquisition. when alert, individuals are more attentive and able to process information more efficiently, which can lead to better retention and retrieval of information. additionally, alertness can lead to increased motivation (neigel et al., 2017), which may encourage individuals to engage in more deliberate and focused practice, leading to improved skill acquisition. furthermore, alertness can increase the capacity for mental flexibility and problem-solving (greenberger et al., 1971; ren et al., 2011), allowing individuals to adapt their strategies and approaches to the task at hand. however, we cannot rule out the possibility that simply engaging in a cognitively demanding process, such as procedural skill learning, might inherently increase attentiveness. conclusion collectively, these experiments offer mixed support for our hypotheses, emphasizing the need for further research employing diverse methods to induce affective tone. such studies can shed more light on the impact of emotionally-valenced interference at various stages of procedural skill acquisition and performance. additionally, these experiments underscore the importance of replication in psychology research and highlight the replication crisis, which pertains to the challenges of reproducing published research findings, especially in fields like psychology and other social sciences. replication promotes transparency, openness, and research reproducibility, facilitating systematic progress in our understanding of the subject, rather than leaving gaps in the literature, as is currently the case with our limited understanding of alertness in procedural memory. references adam, k. c. s., mance, i., fukuda, k., & vogel, e. k. 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(2014). how does this make you feel? a comparison of four affect induction procedures. frontiers in psychology, 5, 689. https://doi.org/10.3389/fpsyg.2014.00689 63 assessing interference effects table 1 descriptive statistics for experiment 1 note. this table displays the descriptive statistics of the final data used in experiment 1, after initial data removals, and separated by condition. * significant differences between mean completion times measured before and after respective condition tasks as indicated by the simple effects analysis (p < .001). 64 birkholz et al. table 2 descriptive statistics for experiment 2 note. this table displays the descriptive statistics of the final data used in experiment 2, after initial data removals, and separated by condition. * significant differences between median completion times measured before and after respective condition tasks as indicated by the mann-whitney u test (p < .05). 65 assessing interference effects table 3 descriptive statistics for experiment 3 note. this table displays the descriptive statistics of the final data used in each experiment 3 analysis, after initial data removals, and separated by condition. panas = positive and negative affect schedule; ct = completion time (s); nm = total number of moves. a attentiveness, as measured by the panas, was higher in the delayed panas conditions compared to the immediate panas conditions (p < .05). b ct of practice trials two and three were different within the positive groups (p < .005). c the rate of change was significantly different across practice trials two, three, and four (p < .001). d second test cts significantly differed between the immediate and delayed panas groups (p <.05). 66 birkholz et al. figure 1 tower of hanoi puzzle note. the tower of hanoi is a wooden puzzle that involves moving a stack of discs, one at a time, from a starting peg (the left peg in this image) to a target peg (the right peg in this image). there are specific rules to follow: only one disc can be moved at a time, and a larger disc cannot be placed on top of a smaller one. to complete the tower with four discs, it takes a minimum of 15 moves. the first step is to place the smallest disc on the middle peg (see karwath, 2005). the rules determine this choice. the next move is to put the smallest disc on the right peg, which creates space for moving the second largest disc to the middle peg. after building a three-disc tower on the middle peg, it becomes possible to move the largest disc to the target peg on the right. then, participants can rebuild the tower on the target peg. 67 assessing interference effects figure 2 ring puzzles note. a ring puzzle is typically a metal piece bent into a ring-like shape and linked with another piece. they are solved by twisting, sliding, or pulling the pieces apart. 6868 figure 3 peg puzzles note. the left panel shows a peg puzzle requiring all pegs to switch sides. the center panel illustrates an elimination peg puzzle involving the removal of pegs from play by jumping one over another to an open spot. the right panel exhibits a peg puzzle requiring all holes but one to be filled by starting in any position and then tracing preset lines between holes. birkholz et al. 69 figure 4 animated procedure for solving the tower of hanoi note. three slides from the digital .gif designed by karwath (2005) illustrate an animated procedure for copleting the tower of hanoi puzzle with 4 discs. assessing interference effects 70 birkholz et al. note. experiment 1 tower of hanoi completion time (s) before and after interference in the control, ring puzzle, and peg puzzle groups. error bars denote one standard error around each mean. figure 5 tower of hanoi completion times before and after interference 71 assessing interference effects figure 6 procedural sequences in experiment 3 note. experiment 3 procedures for each group respectively highlight differences in placement and affective tone. c = control; e = experimental; panas = positive and negative affect schedule expanded form. 72 birkholz et al. figure 7 attentiveness before and after learning the tower of hanoi note. experiment 3 self-reported attentiveness measured before and after learning the tower of hanoi. error bars denote one standard error around each mean. 73 assessing interference effects figure 8 tower of hanoi completion times before and after affect induction note. experiment 3 practice trial completion time measured at practice two and practice three, separated by affective condition. error bars denote one standard error around each mean. 37 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university changes in undergraduate students’ self-efficacy and outcome expectancy in an introductory statistics course milushka elbulok-charcape1, evan grandoit2, anjali krishnan1,3, rose bergdoll3, joshua fogel4, & laura rabin3 1psychology department, city university of new york graduate center, 2psychology department, northwestern university, 3psychology department, city university of new york brooklyn college, & 4management, marketing, and entrepreneurship department, city university of new york brooklyn college the exploration of psychological variables that potentially impact college student performance in challenging academic courses can be useful for understanding success in introductory statistics. although previous research has examined specific beliefs that students hold about their abilities and future outcomes, the current study is novel in its examination of changes in both self-efficacy (se) and outcome expectancy (oe) in relation to performance over the course of an undergraduate introductory psychology statistics course. these psychological variables—relating to one’s belief about one’s ability to accomplish a task and the anticipated outcomes—may impact student motivation and performance. students’ se, oe, and other variables related to statistics performance were measured through a survey administered at the beginning and end of the course. multivariate logistic regression and mcnemar tests were conducted to examine factors that affected changes in se and oe as the semester progressed. students with lower scores on the final exam demonstrated a decrease in both high se and positive oe. however, higher scores on exams earlier in the course were associated with increased odds for high se but not for positive oe, suggesting that se is less resilient to course performance. based on these findings, the authors recommend that statistics instructors identify students at risk for decreasing se. instructors can help foster high se in students struggling academically by connecting the course content to their everyday lives and suggesting strategies to enhance their confidence in their content knowledge and increase their comfort in navigating such a challenging course. keywords: statistics education, research, self-efficacy, outcome expectancy, statistics statistics is a mathematics-based course required by many undergraduate degree programs (norcross et al., 2016). a statistics course is fundamental for students because it fosters critical thinking and reasoning skills (cheng et al., 2018; vanhoof et al., 2011; wilson, 2013). students of statistics courses become informed consumers of knowledge (barber, 2002), and are equipped with the ability to evaluate and conduct analyses of research. as society’s reliance on complex data increases, the ability to analyze large sets of data and apply statistical skills and techniques is required for those entering the workforce (brown & kass, 2009). as a result, enrollment in statistics courses from 2010-2015 increased by 19% (blair et al., 2018) and employment opportunities for statisticians are projected to grow by 30% from 2018 to 2028, outpacing the rate of many other professions (the bureau of labor statistics, 2020). given that statistics courses carry such weight for students’ academic trajectory and their eventual entry into the workforce, research devoted to variables affecting academic performance in undergraduate introductory statistics courses has received much attention. diverse student characteristics and behaviors have been researched in relation to statistics course performance. studies focusing on the relationship between sex and statistics courses report that females hold more negative perceptions about statistics (cendales et al., 2013; zimprich, 2012) and that statistics anxiety may manifest differently in females compared to males. for example, procrastination—the tendency to delay initiation of academic tasks—and poorer learning strategies, such as memorization, were found more likely to lead to statistics anxiety in men (rodarte-luna & sherry, 2008). students with more experience and past achievements in statistics or related fields (e.g., mathematics) have higher achievement in statistics courses (johnson & kuennen, 2006; ramirez et al., 2012). academic procrastination (schraw et al., 2007), is negatively correlated with statistics engagement (onwuegbuzie, 2004) and academic performance (goroshit, 2018; paechter et al., 2017; rodarte-luna & sherry, 2008; wang & englander, 2010). research on help-seeking behavior, the tendency to seek academic assistance (newman, 2002), shows that the absence of help-seeking behavior may be related to predictors leading to lower statistics performance (rodarte-luna & sherry, 2008). psychological factors such as motivation, student beliefs, attitudes, and emotions are particularly important as they can impact academic performance in 38 elbulok-charcape et al. statistics courses. undergraduate students who were motivated had better exam grades and valued statistics more than those not motivated (budé et al., 2007). students’ beliefs and attitudes about their knowledge of statistics do not solely impact their course performance (chiesi & primi, 2009; dempster & mccorry, 2009; ramirez et al., 2012), but can also disrupt learning and application of statistical concepts outside of the classroom (gal & ginsberg, 1994). even in classes utilizing diverse teaching styles (e.g., lecture-based versus active learning), ambivalent attitudes toward statistics remain fairly stable throughout the semester (bateiha et al., 2020). finally, some emotional states such as fear (slootmaeckers et al., 2014) and anxiety (cui et al., 2019; davis & mirick, 2015; esnard et al., 2021; trassi et al., 2022) towards statistics negatively affect student academic performance in statistics. these emotional states impact cognitive factors, which ultimately alter students’ expectations of statistics courses, effort exerted, and academic performance. specific cognitive variables and their positive relationship to academic performance in statistics including self-regulation (acee & weinstein, 2010; dunn, 2014), the use of cognitive and meta-cognitive strategies (rodarte-luna & sherry, 2008; trogden & royal, 2019), and analytical skills (miller, 2019) have been investigated. among these cognitive variables, one of particular importance is students’ self-efficacy in statistics. self-efficacy is defined as an individual’s perceived ability to accomplish a designated task (bandura, 1977) and is believed to be domain-specific (bandura, 1997; pajares, 2009). self-efficacy as a predictor of academic success in statistics has yielded conflicting findings. while most studies (finney & schraw, 2003; mantooth et al., 2020; mcgrath et al., 2015) report high self-efficacy change to be a strong predictor of academic success in statistics, other studies failed to find a significant association between increased self-efficacy and success in statistics (mihai-bogdan et al., 2015; olani et al., 2011; walker & brakke, 2017). in one study, student self-efficacy for statistics increased as the semester progressed (walker & brakke, 2017). however, self-efficacy alone does not contribute to achievement in a statistics course (franceschini et al., 2014). outcome expectancy refers to beliefs about anticipated outcomes of action (bandura, 1986; 1997); these expectancies are mechanisms thought to influence performance and behavior (bandura, 1986). self-efficacy is also positively associated with outcome expectancy (williams, 2010). many studies exploring outcome expectancy focus on risky behavior such as smoking (glock et al., 2012; pokhrel et al., 2014; urbán, 2010), drinking (lopez-vergara et al., 2012; read, 2012), safe sex (newby et al., 2013), and gambling (st-pierre et al., 2013). one study focusing on academic aspects of outcome expectancy found that increasing high self-efficacy and outcome expectancy in low-performing students improved undergraduate students’ english course performance (elborolosy & al thenyan, 2020). another study on high school students enrolled in science and engineering-technology courses reported that students’ self-efficacy and outcome expectancy directly impacted their course performance (han et al., 2021). notably, student course performance was also impacted by the teachers’ self-efficacy and outcome expectancy regarding their own teaching ability—suggesting that student performance in other science, technology, engineering, and mathematics (stem) courses, such as statistics, could also be enhanced by improving their confidence in their own ability and outcome expectation related to those courses. another study found that chinese elementary school students’ increased stem stereotype beliefs negatively predicted their stem self-efficacy and positive outcome expectancy. additionally, their stem self-efficacy and positive outcome expectancy predicted their stem career interest (luo et al., 2021). three studies have focused on outcome expectancy concerning statistics courses, although they did not study change in outcome expectancy. in one study, outcome expectancy was influenced by perceived controllability and perhaps unsurprisingly, negative outcome expectancy had a negative association with effect on first-year students enrolled in a health sciences statistics course (budé et al., 2007). in another study, significant predictors of achievement in a psychology statistics course were past academic performance in statistics and positive expectancy (hood et al., 2012). finally, self-efficacy has been found to directly affect expectations for performance in statistics (esnard et al., 2021). further understanding the association of change in outcome expectancy with other variables and statistics course performance is warranted. while numerous studies focus on self-efficacy in relation to undergraduate introductory statistics courses, few focus on outcome expectancy about this 39 changes in se and oe in a statistics course course, and the authors are not aware of any study that focuses on both psychological constructs. therefore, the current study tracks changes in undergraduate students’ academic self-efficacy and outcome expectancy while enrolled in an undergraduate introductory psychology statistics course. we study how these constructs change according to students’ academic performance over the course of an academic semester. we include other relevant variables shown to impact academic performance in a statistics course of sex, college year, help-seeking behavior, and academic procrastination as covariates. we predict that students’ outcome expectancy will be more resilient to change than their self-efficacy based on their performance in a statistics course and associated covariates. we predict that self-efficacy will change more than outcome expectancy, due to self-efficacy previously being associated with course performance (hii et al., 2013; mcgrath et al., 2015; waples, 2016). if our prediction is accurate, these results will support the conclusion that self-efficacy and outcome expectancy are not uniformly affected throughout a statistics course, in which students can begin the course with many preconceived fears and anxiety about the topic (cui et al., 2019; davis & mirick, 2015; esnard et al., 2021; slootmaeckers et al., 2014). as such, the use of different interventions to address these constructs in students enrolled in statistics courses would be warranted. methods participants participants were undergraduate students enrolled in introductory psychology statistics courses at an urban public college that is part of a large public university system in the northeast united states. all students who attended class during the first week of the semester were invited to participate. the study was conducted in three introductory psychology statistics course sections, each from a different academic semester. participation entailed completion of study pre and post-questionnaires at week 1 (beginning) and week 15 (end) of the semesters. participants were not compensated nor were they penalized for non-participation. there were 341 students initially enrolled, and 286 students participated for an 83.9% response rate. the study was ethically conducted and received irb approval. all participants provided informed consent. procedure the course instructor and two research assistants created the self-report questionnaire used in the current study, which inquired about student demographics, academic self-efficacy, academic outcome expectancy, academic help-seeking behavior, and academic procrastination. psychological measurements academic self-efficacy was assessed by self-report response to the statement, “i am [was] quite capable of mastering the material in this class.” academic outcome expectancy was assessed by self-report response to the statement, “i will [would] never [be able to] do well in this class” where disagreeing indicates positive outcome expectancy. the past tense of the verb [words included in brackets] was used for the follow-up questionnaire. both statements utilized a 4-point likert-type scale with response options of 1 = strongly agree, 2 = somewhat agree, 3= somewhat disagree, and 4 = strongly disagree. the self-efficacy item used in this study was influenced by the statistics self-efficacy assessment developed by hall and vance (2010), for which they reported a reliability coefficient of 0.92. the statistics self-efficacy item used in this study was inspired by the question in their assessment “how confident are you with solving statistical problems?”. to reduce the time and effort for students to respond to the entire survey used in this study, the full statistics self-efficacy assessment by hall and vance (2010) was not adapted. additionally, the number of scale responses for the adapted self-efficacy item was changed from five to four so the response valence would not be obscured by a neutral answer option. the outcome expectancy item used in this study was adapted from the statistics outcome expectancy assessment created by hood et al. (2012). their assessment question, “i expect to do well in this research methods and statistics course”, inspired the outcome expectancy item included in this study. to reduce the time and effort for students to respond to the entire survey used in this study, the full statistics outcome expectancy assessment by hood et al. (2012) was not adapted. the response scale for the adapted outcome expectancy item was reduced from a 7-point to a 4-point response scale to match the self-efficacy item. hood et al. (2012) reported a cronbach’s alpha of 0.69 for their outcome expectancy assessment. variability in participants’ responses to the ac40 elbulok-charcape et al. ademic self-efficacy and outcome expectancy scales was low. for the self-efficacy scale given at the beginning of the course, 28.3% of participants selected “strongly agree,” 64.7% of participants selected “somewhat agree,” 6.6% of participants selected “somewhat disagree,” and 0.3% of participants selected “strongly disagree.” for the self-efficacy scale given at the end of the course, 23.1% of participants selected “strongly agree,” 53.8% of participants selected “somewhat agree,” 19.6% of participants selected “somewhat disagree,” and 3.5% of participants “strongly disagree.” for the outcome expectancy scale given at the beginning of the course, 1% of participants selected “strongly agree,” 3.5% of participants selected “somewhat agree,” 33.9% of participants selected “somewhat disagree,” and 61.5% of participants “strongly disagree.” for the outcome expectancy scale given at the end of the course, 2.1% of participants selected “strongly agree,” 15.4% of participants selected “somewhat agree,” 35.7% of participants selected “somewhat disagree,” and 46.9% of participants “strongly disagree.” due to this limited variability, responses for both scales were categorized into agree or disagree. help-seeking behavior was assessed by self-report responses to the following two questions on the pre-and post-questionnaire: “if you did not understand something in class or got stuck when working on problems outside of class, how likely were you to: (1) attend a peer tutor session; and (2) go to the learning center.” both statements utilized a 4-point likert-type scale with response options of 1 = very likely, 2 = somewhat likely, 3 = somewhat unlikely, and 4 = never would. due to the limited variability, responses for those who responded positively to either question (i.e., very likely or somewhat likely) were categorized as self-reported help-seekers while those who endorsed negative responses (i.e., somewhat unlikely or never would) were categorized as non-help-seekers. kuder-richardson 20 for the baseline questionnaire was 0.78 and for the follow-up questionnaire was 0.73. academic procrastination was assessed by self-report responses to the following four questions on the pre-and post-questionnaire: with regard to academic tasks (e.g., reading for class, completing homework assignments, preparing for exams): (1) to what degree did you tend to delay or procrastinate?; (2) to what degree did you typically have to rush to complete a class-related task on time?; (3) how often did you begin assignments shortly after they are assigned? (reverse coded); and (4) to what degree was procrastination on academic tasks a problem for you? all statements utilized a 5-point likert-type scale with response options of: item 1: 1 = never procrastinate, 2 = almost never, 3 = sometimes, 4 = nearly always, and 5= always procrastinate; item 2: 1 = never rush, 2 = almost never, 3 = sometimes, 4 = nearly always, 5 = always rush; item 3: 1 = never begin shortly after they are assigned, 2 = almost never, 3 = sometimes, 4 = nearly always, 5 = always begin shortly after they are assigned; and item 4: 1 = not at all a problem, 2 = a small problem, 3 = a moderate problem, 4 = a large problem, and 5 = a very large problem. scores on the four items were summed to create a total academic procrastination score, with higher scores indicating a greater tendency to procrastinate. cronbach alpha for the baseline questionnaire was 0.79 and for the follow-up questionnaire was 0.82. course performance measurements students attended bi-weekly lectures taught by an instructor for 75 minutes per lecture and weekly laboratory sessions led by graduate student instructors for 110 minutes per session. during lecture, the instructor taught students how to use and compute various types of analyses. each of the three exams, administered during the lecture portion of the class, was semi-cumulative, covered approximately onethird of the course material, and was graded out of 100 possible points. the first examination consisted of multiple-choice questions that tested descriptive statistics, z-scores, correlation, regression, fundamentals of the normal curve, and basic probability theory. the second examination consisted of multiple-choice questions and one hypothesis testing procedure (i.e., complete a t-test by hand) on the principles and steps of hypothesis testing using single sample t-tests, dependent mean t-tests, z-tests, decision errors, effect size, power, and computation of confidence intervals. the third examination consisted of multiple-choice questions and one hypothesis testing procedure covering independent mean t-tests, analysis of variance, chi-square tests, rank-order tests, and specific advanced statistical procedures (e.g., hierarchical multiple regression, factor analysis, structural equation modeling). examinations were graded objectively by the lecturing professor and a graduate student instructor. partial credit for hypothesis testing responses was possible and awarded according to an objective scoring rubric. in the laboratory sessions, graduate student instructors reviewed lecture material, demonstrat41 changes in se and oe in a statistics course ed the use of statistical analysis using ibm spss statistics (ibm corporation, 2021), and administered weekly quizzes. additionally, two undergraduate peer tutors, who had previously taken the course and earned high marks, were available for voluntary tutoring for approximately 4-6 hours per week to reinforce course concepts and prepare students for exams. the laboratory grade was computed based on average scores of weekly homework assignments (60%), multiple-choice quizzes (15%), and attendance/participation (25%). homework assignments and laboratory quizzes were graded objectively by a graduate student instructor according to a detailed scoring rubric. students’ final course grades were calculated based on scores on the three in-class exams (each worth 23%), overall lab grade (26%), attendance during lectures (2%), and a brief in-class presentation (3%). statistical analyses descriptive statistics were calculated for the variables with means and standard deviations for the continuous variables and frequency and percentage for the categorical variables. the mcnemar test was performed to compare the self-efficacy and outcome expectancy variables from baseline to follow-up on the third exam because it was the performance measure closest in time to follow-up. multivariate logistic regression was performed to examine the factors that affected the self-efficacy and outcome expectancy variables. ibm spss statistics version 28 (ibm corporation, 2021) was used for all the analyses. all p-values were two-tailed. of the 286 participants, nine total students were not included in regression analyses. one student was not included because of missing laboratory quiz grades. six other students were excluded because they did not respond to all the procrastination questions in the post-questionnaire and two other students were excluded because they did not indicate their current year in college. results table 1 shows sample descriptive statistics. more than three-quarters (76.6%) of participants identified as female, which could indicate overall increased negative outcome expectancy for course outcomes (van es & weaver, 2018). college year was almost equally distributed with approximately one-third for each category, with third-year students representing the largest category. the fourth and other category included fourth-year students (n=64), students in a year greater than their fourth year (n=11), those obtaining their second bachelor’s degree/non-graduate post-baccalaureate status (n=2), graduate students (n=2), non-degree-seeking students (n=3), and unknown (n=1). toward the end of the semester (i.e., week 15), approximately two-thirds of students reported that they were likely to engage in help-seeking behavior when they got stuck or did not understand course content. mean exam scores were slightly above 80 for exam 1, approximately 75 for exam 2, and slightly above 70 for exam 3. mean lab quiz scores were slightly above 80. mean procrastination scores were approximately 10.4 (lowest score was 4 and highest score was 20), which was slightly above the midpoint of possible scores, slightly tilting in the direction of higher procrastination. self-efficacy lowered from slightly above 90% of participants at baseline endorsing a statement of feeling capable of mastering course material to approximately three-quarters feeling the same way towards the end of the course. additionally, outcome expectancy shifted negatively with about 95% of participants expecting to do well at the beginning of the course to slightly above 80% by the end of the course. table 2 shows mcnemar test comparisons from baseline to follow-up for agreeing with the statistics self-efficacy item, “i am [was] quite capable of mastering the material in this class.” for the entire sample, for those who scored below 70, and those who scored below 80 on exam 3, there was a statistically significant percentage decrease in statistics self-efficacy from baseline to follow-up. there were no statistically significant percentage decreases in reported statistics self-efficacy from baseline to follow-up for those who scored 80-89.9 or 90-100 on exam 3. table 3 shows mcnemar test comparisons from baseline to follow-up for disagreeing with the outcome expectancy item “i will [would] never [be able to] do well in this course.” in both the entire sample and those who scored below 70 on exam 3, there was a statistically significant percentage decrease in positive outcome expectancy from baseline to follow-up. there were no statistically significant percentage decreases from baseline to follow-up for those who scored from 70-79.9, 80-89.9, or 90-100 on exam 3. table 4 shows multivariate logistic regression analyses for follow-up of agreeing with the self-efficacy item “i was quite capable of mastering the course material in this class.” higher scores on the first two exams were each 42 elbulok-charcape et al. statistically significantly associated with increased odds for high self-efficacy. the other variables were not statistically significantly associated with high self-efficacy. table 5 shows multivariate logistic regression analyses for follow-up of positive outcome expectancy. no variables were significantly associated with positive outcome expectancy. discussion in the current study, both high self-efficacy and positive outcome expectancy significantly decreased from baseline to follow-up in univariate analyses for lower-performing students on the third (and final) exam of the semester. in our multivariate analyses, we found that test performance on exams 1 and 2 was significantly associated with increased odds of high self-efficacy. positive outcome expectancy, however, was not associated with any of the aforementioned variables; thus, as predicted, outcome expectancy was less susceptible to change throughout the course. as reported, higher scores on the first two exams were associated with high self-efficacy. this is consistent with previous findings of a moderate correlation between self-efficacy and course performance in statistics (hii et al., 2013; mcgrath et al., 2015; waples, 2016). importantly, we found that as performance decreased so did self-efficacy for the course. this was expected, as student performance is positively connected to student confidence (sucuoğlu, 2018). we did not find a significant association between exam 3 performance and increased odds for high self-efficacy. we speculate that students adjusted their self-efficacy based on performance on the earlier exams and by the final exam (exam 3), their self-efficacy was less susceptible to change. in light of this finding, instructors could track critical points where students’ self-efficacy decreases, discuss self-efficacy directly at the outset of the course, and provide explicit strategies to enhance self-efficacy in those who are ambivalent or struggling in an introductory statistics course. after all, students with higher self-efficacy are more likely to continue engaging with statistics potentially leading to improved statistics performance (gopal et al., 2018). in our univariate analyses, we found a similar pattern for high self-efficacy and positive outcome expectancy. students who obtained lower exam 3 scores from 0-69.9 showed decreases in both high self-efficacy and positive outcome expectancy from baseline to follow-up. conversely, for those who obtained higher scores of 80 or higher on exam 3, no statistically significant changes were found for high self-efficacy and positive outcome expectancy from baseline to follow-up. essentially, self-efficacy and outcome expectancy changed in the same direction as performance on the final exam. these directional changes are expected as students’ perceived competence is based on mastery experiences (bandura, 1986; 1997), including past successes as well as failures (fong & krause, 2014). in our multivariate analysis, no variables were significantly associated with positive outcome expectancy. this adds to the mixed findings of previous literature reporting achievement (exam grades) as associated with (hood et al., 2012) and not associated with outcome expectancy (budé et al., 2007). however, our finding is similar to the finding of effort (self-reported help-seeking) and outcome expectancy having no significant relationship (budé et al., 2007; esnard et al., 2021; hood et al., 2012). limitations this study has certain limitations. we combined first year with second year students and fourth year with more senior students because our samples of those students were much smaller compared to the number of third year students. responses to the self-efficacy and outcome expectancy questions were also dichotomized because of limited variability in the responses. second, self-efficacy and outcome expectancy were each self-assessed by only one item to reduce participant burden (as the current study was part of a larger study of performance in statistics courses). lengthier and validated measures of statistics self-efficacy, such as current statistics self-efficacy (csse) or self-efficacy to learn statistics (sels; finney & schraw, 2003) should be used in future research to determine if there are similar patterns as in our study. third, contextual factors such as sequence of courses, office hour meetings, and prerequisites were not included. recommendations considering our findings, we recommend that statistics instructors identify students who are at risk for decreasing self-efficacy. furthermore, instructors should help foster high self-efficacy in students by directly connecting course content to students’ everyday lives, incorporating formative low-stakes assessments that may help increase students’ mastery experiences (zientek et al., 2019), training students to employ study strategies (liao & wang, 2018), and teaching about 43 changes in se and oe in a statistics course growth mindset (samuel & warner, 2021). given the anxiety felt by students enrolling in statistics courses, a brief training based on this targeted instruction could be offered to statistics instructors to help them comprehend common pitfalls and psychological variables that could help students navigate such a challenging course. researchers found an improvement in statistics performance that correlated with post self-efficacy scores only for undergraduate students who first solved statistics problems in a group setting, in which each member provided explanations for their own answers, gave feedback on the answers and explanations of the other group members, and then solved the same problems again individually with no feedback, compared to students who only solved the problems once, individually, with no feedback (hall & vance, 2010). additionally, they suggested students be provided an explanation of the course material prior to measuring their statistics self-efficacy so that students can give an accurate assessment of their ability. based on their findings, we recommend that students be given opportunities to compare their statistics problem-solving and answer-choice rationale to their peers’ statistics problem-solving and answer-choice rationale in low-stakes assessments. it is also vital that these opportunities be provided numerous times throughout a statistics course so that changes in their self-efficacy and performance remain congruent and improve. conclusion in conclusion, through our multivariate analyses, we found that greater performance on class exams early in the semester was associated with high self-efficacy. change in positive outcome expectancy was not associated with exam performance. however, lower-performing students demonstrated decreases in both higher self-efficacy and positive outcome expectancy. self-efficacy was more vulnerable to course performance and strategies to address this should be considered as self-efficacy is a predictor of academic success and achievement in statistics (johnson & kuennen, 2006; mihai-bogdan et al., 2015; olani et al., 2011; ramirez et al., 2012; walker & brakke, 2017). references acee, t. w., & weinstein, c. e. 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(2012). attitudes toward statistics among swiss psychology students. swiss journal of psychology, 71(3), 149-155. https://doi. org/10.1024/1421-0185/a000082 48 changes in se and oe in a statistics course table 1 descriptive statistics of sample 49 elbulok-charcape et al. table 2 comparisons of high self-efficacy from baseline to follow-up note. n/a= not applicable since baseline had 100% agreement. 50 changes in se and oe in a statistics course table 3 comparisons of positive outcome expectancy from baseline to follow-up note. n/a= not applicable since baseline had 100% agreement. 51 elbulok-charcape et al. table 4 logistic regression analyses for follow-up of high self-efficacy 52 changes in se and oe in a statistics course table 5 logistic regression analyses for follow-up of positive outcome expectancy 5 graduate student journal of psychology 2023 vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university neuroplasticity knowledge and perceived self-efficacy in western adults: a qualitative examination self-efficacy is described as people's beliefs regarding their capabilities to produce designated levels of performance that affect their lives and is considered important for self-regulation of mental health disorders. biofeedback has demonstrated that knowledge of one’s physiology can help regulate mental health disorders, such as anxiety (mcke, 2008). neuroplasticity is defined as the capacity for the brain to rewire its structure and create new neural pathways to make up for lost functions due to brain injury. there is limited research in how neuroplasticity can be used as an agent for behavioral change. this qualitative study examined if knowledge of the brain’s malleability may affect adults’ perception of self-efficacy in recovery from evolutionary-based mental health disorders, with an aim to lay a foundation of general themes for further quantitative studies. following 12 interviews, themes were recorded regarding perceived self-efficacy at time points during mental health recovery from an adult group who was knowledgeable about neuroplasticity versus a group which wasn’t knowledgeable. in addition to other differences, the superordinate theme of will was mentioned 64 times across the knowledgeable group, versus only 11 times in the non-knowledgeable group. as variations between the groups were perceived, future quantitative research may determine if educational programs can assist adults who are turning to self-regulation as a means for recovery from said afflictions. keywords: neuroplasticity, neural plasticity, self-efficacy, biofeedback, cbt in the modern day, evolutionary traits can either positively or negatively intersect with cognition, which may lead to ailments such as addiction, anxiety, or depression. these evolutionary attributes (which once served us when human survival meant encountering a greater number of potential physical dangers), can contribute to displacement of thoughts, or attention, generating obstructive ideas or sensations when no physical threat exists (rossman, 2010). in contemporary times, without the same level of external threats for these responses to usefully react to, humans are faced with the task of regulating their thoughts. while addiction, anxiety, and depression may arise due to several factors (ducci, 2012), this study focuses on the perception of one’s ability to self-regulate addiction, anxiety, or depression (while operating under the assumption these afflictions have arisen as result of mismanagement of evolutionary traits). the study explores how awareness of the brain’s biological plasticity may assist in the perception of one’s ability to manage their cognition to improve their day-to-day experience. the supposition asks if adults with knowledge of neuroplasticity may generate a higher perception of self-efficacy through understanding that the brain is a malleable organ, and how their perception of self-efficacy may vary from those without knowledge on this topic. background for the past century, scientific evidence has supported the ability for individuals to change patterns in their cognition, and their behavior despite the traits we may have inherited through evolution. some successful models of management include: • metacognition: a term used for “hyper awareness” over one's thoughts which can be used as a learning tool when it comes to completing a task (flavell, 1979). • cognitive behavioral therapy (cbt): originally developed by aaron beck to utilize thoughts, feelings, and behaviors in conjunction with one another for self-regulation (beck et al., 1979). • biofeedback: a method that has been designed to monitor mental health issues, such as anxiety through observation of physiological metrics (mckee, 2008). neuroplasticity refers to the brain’s ability to rewire its neural pathways when injury occurs, or its ability to generate a novel syntax following the completion of an action. studies in neuroplasticity have demonstrated that structural changes in the brain is biologically possible, even in adulthood. brain malleability has been utilized in recovery from loss of functions due to brain injury or damage (doidge, 2007). however, neuroplasticity has yet to be explored as a tool to assist in behavioral change as related to mental health concerns. bandura, who coined the term “self-efficacy” (a term used in psychology today), described the term as “people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives.” (bandura, 1994, p. 71). due to the perceived success of recovery and/ or management of addiction, anxiety, or depression catherine agonis school of psychology, bpp university 6 agonis through cbt, biofeedback, and metacognition, this study examines if adults with knowledge of their biological makeup may have a stronger perception in their ability to self-regulate their recovery from the above-mentioned (possibly evolutionarily induced) mental health afflictions. this study will review how the above mentioned methods (cbt, biofeedback, metacognition) have aided behavioral re-programming to support this supposition. this study also asks if it may be worthwhile to further research if those who are aware of the brain’s biological ability to change in adulthood, may utilize this knowledge to cognitively enhance their sense of self-efficacy when it comes to recovery from said afflictions. the mind & evolution in a lecture at university of california, psychologist martin rossman (2010, 3:55) was quoted saying that humans have been born with faculties in our brains, that as far as we know, don’t belong to any other creature on earth, allowing us to evolve from a vulnerable prey animal to the dominant creature on earth. as human evolution, spanning millions of years, has carried changes to our environment, it has brought subsequent biological progression with it. dr. beth kurland (2018) explores how evolution of our species has included certain advantages that were once incredibly useful, but do not serve much purpose in a modern setting. these attributes still affect the way our thoughts, and even behavior functions today (kurland, 2018). in a contemporary setting, each of these evolutionary traits can contribute to the afflictions of addiction, anxiety, or depression. studies have demonstrated that certain substances can cause people to over-evaluate their rewards by disrupting our working memory while creating temporal myopia (schultz, 2011). this tendency stems from what kurland (2018) calls “the finger trap dilemma,” referring to a desire for humans to avoid unpleasantries (such as a snake). this desire which used to assist us while living in the wild, may enable us to proactively search for escape from discomfort through indulgence in things such as addictive substances (kurland, 2018). rolls and cowey (1970) captured data from both captive and semi-free-ranging rhesus monkeys, and they found that monkeys displaying impulsive and aggressive behavior (traits which are seen to have been beneficial for our evolution), were also pre-disposed to addiction. it has also been argued that because substance abuse is linked to human’s evolutionary traits (such as the reward system), it should be treated as a human tendency which requires management, as opposed to a disease which needs medical treatment (saah, 2005). when it comes to anxiety, brosschot et al. (2016) detailed how an inherited stress response in humans that is always running in the background, is ignited when a threat occurs. this stress response allowed us to stay alert when we had fewer protections and greater threats (rossman, 2010). to assist individuals with management of anxiety by providing metrics on what healthy levels of anxiety may look like, a signal detection framework was published in by bateson et al. (2011). a correlation (though not a causation), between symptoms of loneliness and symptoms of low mood has also been perceived, while detailing the evolutionary theory of loneliness (cacioppo et al., 2006). research across several studies has been gathered to demonstrate how depression can help with problem solving as an adaptive feature (andrews & thomson, 2009) as depressed moods help us to target and avoid exclusion from social groups, which is a danger when it comes to survival, particularly in the wild (badcock et al., 2017). given the remnants of these traits, it may be natural for adults to experience the sensations of addiction, anxiety, or depression in our ever-changing environment, requiring on-going management through models which are accessible to them. evolutionarily-based mental health disorders and access to healthcare today in recent decades, addiction, anxiety, and depression have been on the rise in the west (north america and europe). according to a study conducted by hidaka (2012), a quantitative measure of modernization and lifetime risk of a mood disorder trended toward significance (p = .060) which may be attributed to a country’s gdp per capita, the growing number of long-term illnesses as a result of changing environments, and increased levels of loneliness. it has been reported that up to 33.7% of the population in the modern day is affected by an anxiety disorder during their lifetime (bandelow & michaelis, 2015). it has also been recorded that there has been a surge in overdose deaths in the west related to addiction to opioids (garg et al., 2019). other studies have discussed the increase in difficulty to afford access to mental health care in the west due to inflation, a rise in demand for therapy leading to burnout from ther7 neuroplasticity knowledge and perceived self-efficacy . apists, and a lack of therapists in rural areas (chan, 2022). with these trends, it’s important for science to examine additional ways that adults can self-regulate experienced mental health symptoms, as access to clinical assistance isn’t consistently available for all. digitizing mental health care in the modern day became more prevalent and accepted following the covid-19 epidemic, which caused people worldwide to stay at home. a study examining digitalized mental health care cited talkspace, an online therapy application which reported a 65% increase in clients following the epidemic (gratzer et al., 2020). furthermore, researchers have examined the increase in the use of social media as a tool to self-regulate mental health (ozimek & förster, 2021). an example is the instagram channel @headspace, with over one million followers worldwide, which creates posts regarding the benefits of meditation, self-care, and more to help people at home with navigating their mental health experiences (headspace, 2023). continuing to digitize education surrounding psychology as a self-regulation tool may assist those who are suffering from the above-mentioned afflictions, with insufficient access to assistance in a clinical environment. neuroplasticity and the brain’s ability to change in the brain that changes itself, dr. doidge (2007) details how our neural pathways can be altered. if a neural pathway becomes damaged or blocked from an injury, the brain automatically searches for new connections for certain tasks or utilizes other paths to send signals. he also provides an example of people who become blind and are then able to enhance other sensations to complete a task. this is known as re-organization (doidge, 2007). doidge’s (2007) book details how the brain is the only organ that is capable of giving the owner a qualitative, subjective sensation and inner awareness. the sensation one has while eating gelato from grom in the latin quarter of paris will likely be different from the sensation one feels while living isolated with the flu in a london flat. each conscious state has “a certain feel to it.” the awareness of our sensations will be important later in this study. dr. paul bach-y-rita has done extensive work in the use of tongue sensors to treat balance disorders due to deteriorated vestibular functions. his findings show that re-calibrating the central nervous system through these sensors can improve patients’ balance (bach-yrita et al., 2005; tyler et al., 2003). dr. pascual-leone once said, “the system is not plastic, but elastic,” meaning the brain could be molded and formed, but was unable to completely “snap back,” to a previous iteration (doidge, 2007, p. 209). pascual-leone’s quote was demonstrated in a study where teachers of blind students were submerged in complete darkness for a week. at the end of the week, the teachers could decipher what kind of motorcycle was near to them by listening to the engines. when their blindfolds were lifted, they were completely disoriented. pascual-leone mapped their brains using transcranial magnetic stimulation. he then used the brain scans to perceive that the visual cortex had been used to process auditory signals (pascual-leone & hamilton, 2001). based on roll’s experiment, dr. jeffrey m. schwartz designed a study for his own patients with obsessive compulsive disorder (ocd). he introduced mindfulness into an ocd clinic and developed a four-step method, instructing patients to create real-time mental notes to obstruct the experience they were having with mindful commentary when they get caught up in compulsive thoughts. his findings were the following: our pet scans had shown that the orbital frontal cortex, the caudate nucleus, and the thalamus operate in lockstep in undoubtedly the source of a persistent error-detection signal that makes the patient feel that something is dreadfully wrong. by actively changing behaviors, refusing changes which brain circuits become activated, and thus also changes the gating through the striatum. the striatum has two output pathways, as noted earlier, direct and indirect. the direct pathway tends to activate the inhibited cortical activity. refocusing, i hoped, would change the balance of gating through the striatum so that the indirect, inhibitory pathway would become more traveled, and the direct, excitatory pathway would lose traffic. the result would be to damp the down activity of this ocd circuit (schwartz & begley, 2003, p. 85). following the completion of these studies, we better understand how the malleability of the brain may lead to recovery or improvement from certain neurological ailments and specific mental health afflictions, such as obsessive-compulsive disorder (ocd). it is 8 agonis worth exploring if it may potentially do the same for evolutionarily induced mental health disorders which are currently regulated with use of biofeedback, metacognition, or cbt. we will explore the current understanding of these methods more in the following sections. biofeedback & self-regulation biofeedback is a process which measures physiological information that is displayed to patients so they can better attempt to control their symptoms. in the case of psychology, biofeedback is utilized for management of stress and anxiety, and requires patients who have a strong psychological awareness of their own symptoms. patients have recorded physiological changes they’ve experienced during times of stress (such as sweating), demonstrating it is possible for notions of mind-body interactions to resonate with an individual (mckee, 2008). accurate feedback of performance facilitates the learning of any skill, not just when it comes to controlling physiological behaviors. it assists with everything from hitting a golf ball into the hole on the green to solving an algebra problem (we will observe this more in the section on metacognition). a person bowling with a blindfold on isn’t as likely to make a strike – not only because they cannot see what they're doing – but because the visual feedback of their performance following an action informs their next attempt. for instance, if they visually recorded that the way they tossed the bowling ball forced it to go too much to the left, and therefore into the gutter, they know to straighten up their grip in the next round. for biofeedback to work successfully with patients, the patient must have the capacity to respond, be motivated, receive positive reinforcement from learning, and be provided with accurate information regarding the results of their learning. from biofeedback, we see the potential of observation when it comes to recovery from mental health issues, namely anxiety (mckee, 2008). in a study related to obesity reduction, teufel et al. (2013) recorded an increase in self-efficacy following treatments of biofeedback in 31 women, however, additional studies would need to be conducted to statistically support this theory. as science has recorded the benefits of observing our biology as self-regulation tool for mental health disorders, the author asked whether a similar methodology could be applied when it comes to neuroplasticity, training adults on the malleability of the brain, and testing their perception of self-efficacy before and after. before designing a research proposal on this hypothesis, it was supposed that conducting a preliminary study on any key differences in themes between adults who are knowledgeable about neuroplasticity and those who aren’t would be prudent. through this initial, qualitative study, science can first assess if variation in perceived self-efficacy exists between those with knowledge of brain malleability and those without knowledge. metacognition & cbt metacognition is a term used for “hyper awareness” over one's thoughts. this concept has been developed in various ways since aristotle, however, it is often associated with john flavell who suggested that an awareness of control regarding cognitive processing of thoughts regarding learning was drawn from both metacognitive knowledge, followed by regulation (flavell, 1979). to properly evaluate and monitor one’s own learning, metacognition not only involves a patient thinking about what they’ve learned, but how they learned, in addition to examining their own learning process (flavell, 1979). flavell’s 1979 work detailed metacognition into the various forms: • content knowledge (declarative knowledge): an understanding of capabilities, such as a singer knowing the strength of their vocal cords, or a salesperson knowing their memorization skills. • task knowledge (procedural knowledge): a perception of a tasks’ difficulty based on the type of assignment, the length and what it entails. • strategic knowledge (conditional knowledge): the ability to strategize based on the available tools to learn. metacognition has recorded that using our cognitive thoughts in learning can improve performance in an array of ways. it has been found that self-questioning as a strategy to monitor and regulate perceived performance was effective (child et al., 1998). studies have also recorded a significant positive relationship between the use of metacognitive reading strategies and mastery-approach goal orientation (baker & brown, 1984). the practices behind metacognition has led into cbt which is described by the national health service (nhs, 2023) as the following: • cbt is based on the concept that your 9 neuroplasticity knowledge and perceived self-efficacy thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a negative cycle. • cbt aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts. you're shown how to change these negative patterns to improve the way you feel. unlike some other talking treatments, cbt deals with your current problems, rather than focusing on issues from your past. evidence-based practice of cbt details that there are numerous empirical studies published regarding the success of this treatment for ailments such as addiction, anxiety, and depression, with literature on this topic from less than 2,000 studies, articles or books published in 1995-1999, to 14,000 in between 2010-2014. the three principles are defined by dobson and dobson (2017) as the following: 1. access hypothesis: this means that thoughts are accessible to us and aren’t unconscious. 2. the mediation hypothesis: this means that our thoughts are responsible for how we experience or feel about situations which surround us. 3. the change hypothesis: this means that by changing our thoughts we can change our behavioral or emotional response to certain stimuli or events. given the current research and understanding of cbt as a tool to regulate thoughts which then effect behaviors or emotions, this study questions if knowledge of the makeup of the brain itself may be used as a self-regulation tool within these methods. visualization, a psychological perspective “worry gets a lot of bad press because we don’t use it very well.” (rossman, 2010, 3:44) in his lecture, how your brain can turn anxiety into calmness, dr. rossman (2010) makes the case that imagination is the key mental faculty that separates humans from animals. imagination allows humans to remember things from the past and project inventions or creative ideas into the future. it allows us to picture how reality may vary if we try things in different ways. rossman argues that few of us have been taught the correct way to use our imagination. empirical analysis designed by philosophers such as aristotle have also contributed to the progression of society. for us to test a hypothesis and survey the results, we first must make observations, invent a scenario, then bring that scenario to fruition. in other words, without science, ideas are just ideas. but still, the scientific discoveries, prior to being tested, were ideas first to examine how the imagination may manifest itself into action, dr. pascual-leone (1995) conducted an experiment with piano players which demonstrated that visualizing playing the piano lit up the visual cortex in the same format as if one were actually playing it. in other words, when people close their eyes and imagine a simple object, such as the letter a, the primary visual cortex lights up, just as it would if the subjects were looking at the letter a. imagining scenarios or outcomes also overlaps with the neural circuits required to complete the execution of an action (agnati et al., 2013). with this knowledge, it is implied that visualization as a function of the imagination can improve performance–with a drawback being humans oftentimes visualize or imagine negative events or scenarios, partially due to our evolutionary faculties. while this study is preliminary research regarding cognitive awareness as it pertains to neuroplasticity, it is worth asking if holding knowledge of the brain’s malleability may assist in the ability for one to imagine their brain changing physically, which will be further explored in the discussion section. criticisms and gaps in knowledge regarding neuroplasticity, biofeedback, and metacognition as tools for change while neuroplasticity has been examined through several studies, its usage has mainly been applied regarding recovery from loss of brain function, or to assist with ocd. research has supported that plasticity of the brain may be a key function into improving sensations of depression (wilkinson et al., 2019), meanwhile, other studies perceived how various gray matter in the brain is responsible for the ability to learn as we age (fischer et al., 2022). however, when it comes to the ability to form new pathways or connections, there are also no current experiments or papers which examine how knowledge of this capability may affect the perceived self-efficacy of recovery from the mental health issues of addiction, anxiety, and depression. while biofeedback has been a successful tool when it comes to the monitoring of anxiety, it is costly and requires the patient to be in a certain place at a certain time, with specific facilities available. biofeedback’s in10 agonis ability to scale is a hindrance to its overall success as a tool for recovery from mental health disorders, particularly given the earlier research cited regarding the growing trend to self-regulate mental health disorders in the west due to a lack of access to such facilities. metacognition is a helpful practice when it comes to learning, but there aren’t current searchable studies which function on its ability to change behavior. finally, certain research has perceived brain activity during visualization in its participants as well as some physiological effects, though it did not allow us to explore how associating cognitive thought with the power of imagination may relate to perceived self-efficacy in recovery from mental health afflictions (chen et al., 2017). purpose of the study as a recap, science is aware of the following: • certain mental health afflictions are induced by evolutionary traits, and are rising in prevalence today, with an increasingly difficult access to healthcare in the west, leading to a growing tendency for adults to self-regulate mental health disorders. • cognitive awareness is an effective tool in the regulation from these evolutionarily based disorders through methods such as cbt. • observation of biology is also an effective tool in the regulation of evolutionarily based disorders, mainly anxiety through the method of biofeedback. • it is biologically possible for the brain to form new neural pathways. science has yet to record if knowledge regarding the biological malleability of the brain may equip people with a higher sense of perceived self-efficacy when it comes to recovery, and/or management from these evolutionarily based-mental health disorders. the purpose of this study is to lay a foundation for the uses of neuroplasticity in conjunction with cognition and biological awareness and examine how these faculties may work with each other. this is an initial investigation into any potential associations between adults’ knowledge in neuroplasticity and their belief in the potential for recovery from mental health afflictions. the three afflictions of addiction, anxiety, and depression were chosen as a focus as these disorders may be evolutionarily induced and therefore treatable through self-regulation. if these disorders are present in the modern day as a response to humans attempting to navigate a rapidly changing environment which our evolutionary fear responses cannot adequately adapt to, it is possible that utilizing cognitive awareness around the topic of neuroplasticity may be an agent of assistance. by examining the potential difference in themes between those who are knowledgeable regarding brain malleability and those who aren’t when it comes to perceived self-efficacy for recovery from addiction, anxiety, and depression, the psychological community can determine if promoting knowledge regarding neuroplasticity to the general population can help with management of said disorders. should the findings of the interviews demonstrate themes that knowledge of neuroplasticity may correlate to one's perceived self-efficacy when it comes to recovery from these mental health disorders, there may be opportunity to explore how training people on the functions of the brain may help with their own self-regulation as a form of therapy. scaling such training and education could potentially be more accessible and affordable than individual patients utilizing clinical assistance, such as cbt, or biofeedback sessions. the potential for knowledge sharing as a means of assisting with recovery from these disorders should be further explored after quantitative investigations, which would be dependent on the findings of this study. method a foundational, qualitative study based on combining knowledge of neuroplasticity and cognitive awareness was created, aiming to perceive how these two components may correlate in adults with the mental health disorders of addiction, anxiety, and depression. in this preliminary investigation, the researcher examined potential associations between knowledge of neuroplasticity and a positive outlook on recovery from mental health issues with an objective to document initial research. the study utilized ground theory (strauss & corbin, 1994), reasoning that allowing themes to arise from the data may detail potential findings that justified resources for more extensive quantitative studies. this was decided following a non-conclusive search for published studies regarding this supposition. research design the research was carried out in 12 interviews total, across an adult population ages 25-71. six participants who held general knowledge of the subject 11 neuroplasticity knowledge and perceived self-efficacy of neuroplasticity were placed in the knowledgeable group, while six who attested they had no general knowledge of the subject of neuroplasticity were placed in the non-knowledgeable group. the aim of dividing the results into two groups was to examine the variation of themes (whether superordinate or subordinate) which arose between those with knowledge versus those without knowledge and to record any differences. prior to the interviews, each of the participants filled in a survey which asked two questions detailed below to place them in the correct group. the exact questions sent in the survey are detailed below with the full survey detailed in appendix b. survey questions: 1. have you heard of the term neuroplasticity? (yes/no) 2. please rate your knowledge of neuroplasticity from 1-5, with 1 being little-to-no knowledge and 5 being an expert in the subject. (1,2,3,4,5) participants who answered question one with “yes,” and question two with any rating of “two” or above, were placed in the knowledgeable group. once six participants for each group had been gathered, the interviews commenced. research questions participants in both groups were asked the questions detailed below in a one-to-one interview with the researcher which was recorded and then transcribed. the questions chosen were the same across both groups as the aim was to see any general differences in the perception of one’s ability to change and possibly recover from addiction, depression, or anxiety and then assess the different themes. the researcher did not ask about knowledge of brain malleability during the interview, as the goal was not to provoke an association between knowledge and the themes of recovery that the participants may not have had. by asking both groups the same set of questions and analyzing the themes afterwards, differences in the groups which existed regarding the overall sentiment towards recovery and the possibility for change in adults were able to be recorded. the full interview schedule with instructions can be seen in appendix c. • do you think that human beings can change habits once they become an adult? • how much do you believe in the phrase, “you can’t teach an old dog new tricks?” • do you believe people with mental health disorders such as addiction, depression or anxiety have a high potential to recover if they’re provided with the right resources? • on a scale of 1-5 with 1 being the lowest ability and 5 being the highest ability, how do you rate your own ability to change habits or behaviors you find are no longer serving you? • what techniques do you use to change what you view as unhelpful behaviors? • is there anything else you’d like to add? research setting all participants were interviewed remotely using microsoft teams via an invitation sent out using the researcher’s bpp university sponsored email account c.agonis@my.bpp.com. participants the inclusion criteria for participants required that they were over the age of 18 (therefore in the adult category) and weren’t part of a known vulnerable group within that category (such as those with a learning disability). the questions asked were focused around the participant’s views on the ability to recover from addiction, anxiety, and depression, and didn’t examine active recovery from these afflictions. therefore, there was no mental health criteria utilized in recruitment. those who expressed verbally or in writing that they may be part of a vulnerable category were excluded, as this study was a preliminary investigation on the general adult population to lay a foundation for further studies and wasn’t set to examine those of a particular vulnerable group. participants were chosen from countries within north america and europe, as the research conducted for the study pertained to western trends and practices. of the 12 participants sampled, the demographics included two male-identifying adults and 10 female-identifying adults, ages 31-71 residing in the uk, usa, and switzerland. the full table of participant characteristics can be viewed in appendix a. procedure & data collection each participant was recruited using the researcher’s personal instagram account (@chixonthehud) and facebook page (dallas_athent). the full advertisement text was pre-approved by bpp’s ethics community prior to posting, and is detailed below: slide 1: as many of you know, i’m currently obtaining my msc in psychology at bpp university. for my dissertation, i’m running a study on self-efficacy for recovery from mental health issues in adults. 12 slide 2: i will be interviewing participants regarding their perception on the potential to recover from mental health issues, and examine if that has any correlation with knowledge of neuroplasticity. slide 3: if you’d like to help me by partaking in the study, please submit your email here and i will email you additional information. you do not need to have knowledge about neuroplasticity. we need participants for both the study group and control group. thank you all. participants were accepted for the study regardless of if they knew the researcher personally. the only utilized criteria is that listed above in the participants section. once interest was expressed via the instagram and facebook posts, participants were emailed a consent form via the researcher’s bpp university email address (c.agonis@my.bpp.com) which asked them if they consented to participate in the study and informed them they could withdraw any time without consequence. the consent form provided the basic outline of the study and a breakdown of the kinds of questions that were to be asked. it detailed that the study was run as part of the researcher’s msc in psychology and that the researcher was a student at bpp university. the full consent form and information sheet sent to the participants can be viewed in appendix d. upon receiving the participants’ signed consent forms, participants were then sent the survey detailed above in this document’s research design section using the microsoft forms account connected to the researcher’s bpp university email address. the survey notification informed the participants it was capturing their email addresses for the purposes of adding them to the non-knowledgeable group or knowledgeable group. once the groups were formed, the participants were emailed virtual appointment options held on microsoft teams which were recorded and saved (audio only) in the researcher’s password protected bpp university sharepoint account, with no personal information included. participants were advised prior to recording to turn off their cameras for additional privacy. no identifiable information was shared in any interview recording including names. the recorded interviews were then transcribed using sonix, and permanently deleted once transcription had concluded. the participants were notified via email upon deletion of the recordings. interview process to ensure consistency across the interviews, each participant was interviewed by the author of this paper. each participant was asked a set of pre-defined questions during the interviews, which can be seen in appendix c. these questions were not altered across all 12 interviews, nor were they re-ordered. if the participant only gave a short answer, (such as only a few words), the interviewer would ask them what they thought of when they heard the word “resources” following question three, in order to generate additional insight. all participants were able to speak at their own desired length to each question. ethical considerations ethical considerations for this study were low, as all participants were adults over the age of 18 and weren’t part of a known vulnerable group. in the information sheet provided prior to the interviews, candidates with any mental health issues they felt could be affected by partaking from the study were encouraged to withdraw, which was also shared with the participants verbally prior to the interviews being recorded. during the recording process of the interviews, the researcher ensured not to use any of the participants’ names so that they would not appear in any transcripts. the study conducted was not experimental, meaning there was no intervention throughout the interviews. during the study and in line with the bpp university ethics committee, participants were notified that they could opt out at any time throughout the study, including during the interview. data analysis following the transcription of all interviews, the transcripts were analyzed using thematic analysis (ta) using the steps outlined by braun and clarke (2006). ta was the chosen process for reviewing the results of this study, as the process of the researcher familiarizing themselves with the material via several read-throughs ensured thorough examination of potential underlying themes. additionally, using ta would also allow for replication of this study, or further analysis of the interviews already conducted by additional parties, who can continue to iterate on the transcribed interviews if necessary. in a qualitative analysis, ta involves a process of pre-determining themes and searching for codes in the research which may support or negate those themes, or reading each transcript several times, and marking each expression of a thought, feeling, idea or association made by a participant as a “code” (byrne, 2021). this study took agonis 13 the second approach. once the codes were marked, common themes emerged from the data. themes were not proactively searched for in the process and were only determined following the coding process. in an example from participant’s 8 interview, two codes were marked in the sentence “i think there is capacity (code 12) to change both depending on just where you are on the spectrum of your brain's ability (code 13) and what's left of it,” as they both expressed a thought, feeling, idea or association. the first expression that was coded was that there is capacity to change, and the second was that there was a neurological component related to this capacity. a full example of the coding process and following ta can be seen in appendix f. a quantitative measure was added to the thematic analysis, with the frequency of each mentioned code being recorded to heighten each code's prevalence within their respective themes. to promote consistency, all codes listed in the results were transcribed in their original form and were not used as placeholders for other terms. ambiguous sentences were interpreted within context following several read-throughs by the author of this paper and researcher, catherine agonis, who remained the sole reader of the results throughout the study. how the researcher’s own experience may have affected these interpretations are detailed in the reflexivity statement below. as the researcher is aware that having one reader may result in a potential bias in the analysis of the results, they have included a sample analysis in the appendix, which is color coded, for review. the researcher can also be contacted to release the transcripts of all 12 interviews should peers wish to examine their contents for further analysis. once the interview transcripts were printed, read, and the codes were marked, they were organized in a google sheet utilizing various tabs for each theme. to begin the thematic analysis, the interviews were first broken into two groups, the non-knowledgeable and knowledgeable groups. the researcher then familiarized themself by reading each transcribed interview three times. codes that were mentioned more than once have been marked with the count number in their respective tables denoting the number of times mentioned. the amount of mentions also affected the importance of the code for the overall theme, as it was supposed that if a code was mentioned more than once in an interview, or across multiple interviews, it was held in higher regard to the speaker. the top themes with the most code “counts” were then selected as the superordinate themes, and the rate of frequency from which the theme was mentioned was denoted. any codes or themes not related to the key themes were considered outliers and removed from the analysis. to ensure consistency in the analysis of the codes, the researcher conducted all the reviews using braun & clarke’s (2006) ta structure. the researcher reviewed the four most frequently mentioned superordinate themes per each group, in addition to the key overall themes mentioned, as recommended by eval academy in this kind of thematic analysis (jones, 2022). reflexivity statement as an individual who grew up in the usa in the 1990s, i understand i am personally used to “finding a solution” to my own issues and tend to be “solutions oriented” when an uncomfortable experience arises. during my upbringing, the usa maintained a “pull yourself up by your bootstraps” culture, in conjunction with the notion of the “american dream.” both sentiments induced not only a belief, but a pressure on citizens to “make it” at all costs and persevere no matter the background or experience. this is demonstrated in pop culture of the era, including hollywood films such as forest gump and superhero comics such as spiderman which tell stories regarding individuals who found triumph despite all unlikely adversaries, largely due to the accepted, innate goodness and strength of their persona. these narratives (some realistic and others clearly fantasy), shared a different message than that of media from other periods, such as the victorian age. an example of a popularized narrative whose aesthetics varied from that of contemporary times would be edith wharton’s summer, (1917) which ends tragically for the heroine despite all her efforts to live “truthfully” as a single woman during a time where marriage was considered of utmost importance. with the influx of positive messaging in the usa during the 1980s-early 2000s, it felt accepted by society that if you “really pushed and tried,” and “had a magical touch,” you could make anything happen. in addition to the cultural surroundings, the household of my upbringing lacked a comparatively large presence of an authoritative figure compared to that of my peers. learning to self-govern potentially gave me a personally higher sense of perceived self-efficacy as i never believed designated authorities were to credit for my success (nor my failures). with this said, there’s the neuroplasticity knowledge and perceived self-efficacy 14 possibility that my position in this study, which examines perceived self-efficacy, was influenced by my general position that i personally hold will and influence over my own behavior and the subsequent outcomes. additionally, as it pertains to the review of the codes, it should be noted that i was raised speaking american-english, which may hold a different analysis than an individual of a different english-speaking country, as americans have the tendency to be more expressive, thereby potentially reducing the perception of the implied intensity when it came to the interpretation of particular thoughts. results identified codes & themes to begin the thematic analysis, the participants were put into one of two groups, those being the knowledgeable group and the non-knowledgeable group. the findings for both groups are listed below, with breakouts for superordinate themes and subordinate themes particular to each group. several of the codes were related to themes which did not have enough total mentions to substantiate inclusion in the results. for instance, within the non-knowledgeable group, the theme of the perception of biology playing a major role in one’s ability to change was mentioned only 10 times across all six of the interviews. codes related to this theme, and this theme itself were removed. common themes across both groups in order to assess the themes respective to the non-knowledgeable group versus the knowledgeable group, the themes were coded separately and then combined into common superordinate themes where there were major alignments. the three superordinate themes which overlapped are discussed in this section, and are listed and detailed as the following in table 1: • the day-to-day environment is a key factor in one’s ability to change. • the possible techniques one can utilize range from medical to holistic. • overall, one’s ability to change their behaviors or recover from addiction, anxiety or depression is not only possible, but promising. on average, the length of the interviews for the knowledgeable group were 18% longer than the non-knowledgeable group with an average of 1278 words spoken in the former group versus an average of 1052 in the latter. the knowledgeable group’s extended length of average interview times meant that certain themes were mentioned with greater frequency, as the topics were discussed at longer intervals. what these metrics may indicate will be examined more in the discussion section. the day-to-day environment is a key factor in one’s ability to change both groups of participants recorded one’s environmental surroundings as a key contributing factor to their ability to change. environmental factors mentioned were access to basic needs, access to varied experiences, and access to mental health resources. this theme had a total of 83 code mentions across all 12 interviews. sub-theme: community, family, friends and having a person is a key component to recovery. “having a person,” whether that person was a partner, family, chosen family or friends, was reported as a needed element to an individual’s direct surroundings to support change from both groups of participants, as seen below. interviewer: when you think of the resources, what does it look like to you? participant 1: okay. so, in the very beginning, the support of your immediate circle, whether that's family or chosen family. (participant 1, non-knowledgeable group) when discussing available resources that assist with recovery accessible within one’s environment, participant 1 named support from family first. partner-related comments were made 26 times within the knowledgeable group, versus 13 times in the non-knowledgeable group. in some cases, such as in participant 10’s statement below, the perceived potential of assistance from loved one’s was also dependent on the ability of a person to keep a relationship, indicating there is an element of responsibility on the individual to ensure that resource is available. but, you know, family resources and friend resources and the ability to develop relationships and friendships is an important resource, which is very much based on the individual. (participant 10, knowledgeable group). it was unclear from the interviews what correlation knowledge of neuroplasticity (if any) may have to a stronger belief in perceived self-efficacy if human connections are also formed. agonis 15 possible techniques one can utilize range from medical to holistic perceived techniques mentioned to help people change habits or behaviors ranged from medical (namely attending therapy and use of prescribed medications), to holistic (such as taking part in meditation). this theme’s codes had 70 mentions across all 12 interviews. two sub-themes regarding techniques were mentioned frequently across both groups as discussed below. sub-theme: therapy. it was reported across both groups that therapy was a helpful component to recover from mental health afflictions with some participants also mentioning medication in conjunction with seeking professional help. this indicated that institutionally supported assistance was relevant to recovery, regardless of perceived personal capabilities. therapy was mentioned 17 times in the knowledgeable group, and six times in the non-knowledgeable group. quote 1: interviewer: and what do you think the kinds of resources that should be provided are? participant 2: firstly, as many forms of therapy as possible, like cognitive behavioral therapy, for example. (participant 2, non-knowledgeable group) quote 2: my first thought is therapy when i hear resources. (participant 9, knowledgeable group) similarly to participant 10 who viewed access to support from family and friends as a key resource within one’s surroundings, participants 2 and 9 associated therapy as a technique one can turn to which could be used to aid recovery. the prevalence of therapy in discussions across both groups demonstrated an overall belief that professional assistance was a key factor for change, regardless of knowledge of brain malleability. sub-theme: writing / journaling. in both groups, several participants described using writing and journaling to assist with improving behaviors and advancing past bad habits. participant 1 expressed that the process of writing helped assist them in knocking off small intentions throughout the day. i actually have to write it down. if i put it on my phone, i'm less likely to have completed it. i don't know why i have to write it. (participant 1, non-knowledgeable group). as participant 1 shared, a greater level of satisfaction occurred when writing-by-hand was involved. participant 9 expressed the satisfaction they received by crossing things off a to-do list or seeing their intentions written on the page, sharing a similar sentiment to participant 1 of writing and/or journaling as a useful technique inconsequential to levels of neuroplasticity knowledge. my biggest thing that i do is bullet journaling, and so i've done habit trackers in there where like for example, one thing that i really wanted to start doing a few years ago was to make sure to always read something before i looked at my phone in the morning and something that i tracked where i wrote out the days of the week and i put a little dot for every day that i did it, and it just felt very satisfying to look when there were a lot of dots. (participant 9, knowledgeable group) while this sub-theme had arisen between both of the groups, its presence wasn’t related to the thesis question at large. one’s ability to change their behaviors or recover from addiction, anxiety or depression is not only possible, but promising all 12 participants expressed they believed change was possible when it came to the mental health afflictions of addiction, anxiety, and depression, in addition to a disbelief that one is unable to change habits once reaching adult age. in referring to the colloquial phrase “you can’t teach an old dog new tricks” as “nonsense,” participant 3 expressed a disbelief that adulthood hindered one’s ability to update their programming. similarly, negative reactions to this phrase were present across all participants. additionally, when asked at the beginning of the interview “do you think that human beings can change their habits once they’ve become an adult?”, all participants responded affirmatively regardless of which group they were in, alas, no difference in this sentiment was recorded between the groups. however, sentiments of positivity were expressed with greater prevalence in the knowledgeable group. in total, this theme received 64 mentions across 10 interviews, with 41 mentions in the knowledgeable group versus 23 in the non-knowledgeable group. non-knowledgeable group: particular themes following the initial analysis, the non-knowledgeable group generated 90 codes which were collated into eight superordinate themes. each of the superordinate themes were ranked according to the neuroplasticity knowledge and perceived self-efficacy 16 number of total codes mentioned with repeated codes counted towards the total. after additional re-reads of all interviews, the list of codes was reduced to 66 out of the original set of 90. codes which did not relate to an overall theme, and were therefore outliers, were removed. a recount of the codes within each theme was completed, allowing deduction to four major themes with linked subordinate themes. the breakdown of final codes can be seen in table 2. while three of these superordinate themes were included in the overall theme group and discussed above, this paper will highlight the superordinate themes and subordinate themes particular to the non-knowledgeable group in this section so their differences from the knowledgeable group may be discussed for additional analysis. changing one’s behavior is possible through activity despite having no knowledge in neuroplasticity as demonstrated by the participants’ surveys, the participants in the non-knowledgeable group each attested to a belief or understanding that the brain is a malleable object whose structure can be altered through a repetition of actions or activity. this theme had a total of 39 codes mentioned across six interviews. sub-theme: introduce randomness. participants in the non-knowledgeable group recorded the need for an individual to attempt to introduce varied experiences into their own surroundings independent of the immediate offerings of their environment to aid their ability to change behaviors. the call to action in participant 3’s statement below utilized an understanding of evolution as an exploration of how randomness helps us evolve on a macro-level. the more randomness you introduce, the higher your probability is that you will find an experience that teaches you something meaningful or that will lead to change. i think that’s how biology evolves, right? it doesn’t know what a good gene is, so it just keeps changing its genes and the good genes survive. and yeah, i think that that can be taken for human behavior as well… reading a book is randomness…traveling is randomness. (participant 3) the scientific outlook, despite claiming no knowledge of neuroplasticity, took an empirical approach towards personal advancement. it has the potential to be linked to the environmental sub-theme described later in this section. sub-theme: repetition as a driver for change. several participants within the non-knowledgeable group mentioned how the repetition of tasks as a practice could eventually induce a new pattern from a person who is looking to alter their behavior. for example, participant 5 described a belief that dedicating oneself to a conscious repetition led to an acceleration towards self-improvement despite claiming no knowledge regarding brain malleability and the ability to reorganize or create new pathways through activity via this study’s survey. and you continue to proceed forward as a different human. it takes constant practice and control. (participant 5) where this supposition stemmed from was unclear and will be examined further in the discussion section. (the day-to-day environment is a key factor in one’s ability to change) subordinate theme: varied surroundings participants in the non-knowledgeable group brought up diversity and exposure to varied experiences as a key factor in one's environment which will help them to change. these mentions were different from the codes related to the subordinate theme of “introducing randomness.” i think observations play a huge role, and if you've never had a chance to observe an improved version of a state, then you might just not know that that is something that could be improved or something that can even change if you've never seen a change. if you grow up in a broken household where i don't know, the parents are always arguing, the relationship is toxic and you're never exposed to a positive relationship, it is possible that you just don't have the observation to know that good relationships are possible. (participant 6) via this quote from participant 6, it is possible that the idea of benefiting from varied surroundings is linked to the idea of introducing randomness. both express a need for diversity to advance improvement, with the above comment leaning more towards the general environmental factors outside of a person’s control as a resource, and the introduction of randomness through activities such as reading and travel as a technique within an individual’s authority. sub-theme: privilege. participants in the non-knowledgeable group mentioned privilege when agonis 17 it came to access to basic human needs including healthcare, housing, and time as affecting one’s ability to change. i feel like i'm privileged enough to have the resources to make any change that i choose to make. (participant 3) as participant 3 implied, their own privilege was seen as a factor in their ability to alter their habits. it was indicated from participants without knowledge regarding the brain’s plasticity that environmental factors, which may be out of a person’s control, may affect their perception of self-efficacy when it comes to recovery from these disorders. knowledgeable group: particular themes following the initial analysis, the knowledgeable group generated 280 codes which were collated into seven superordinate themes. each of the superordinate themes were ranked according to the number of total codes mentioned with repeated codes counted towards the total. after additional re-reads of all interviews, the list of codes was reduced to 192 out of the original set of 280. a recount of the codes within each theme was completed, allowing deduction to four major themes with linked subordinate themes. the breakdown of final codes can be seen in table 3. while three of these superordinate themes were included in the overall theme group and discussed above, this paper will call out superordinate themes, and the subordinate themes particular to the knowledgeable group in this section. will is a key factor in changing behavior the participants in the knowledgeable group recorded the importance behind individual will when it comes to recovery from mental health afflictions or unhelpful behaviors. numerically, this was the most expressed theme between any group, with 62 total mentions across six interviews, and the highest frequency of mentions across all interviews with one mention per 0:50 minutes on average. while this theme was also raised in the non-knowledgeable group, the total mentions were 11, ranking it below other more commonly mentioned themes and excluding it from the overarching themes from that group. the difference in mentions highlights the relevance of this theme to the knowledgeable group. sub-theme: positive mindset. participants in this group recorded that maintaining hope, positivity and/or an intrinsic outlook towards “the glass being half-full” assisted in their perception of self-efficacy when it came to behavioral change. an example was expressed by participant 7, who shared a belief that a solution is always available. i think intrinsically it's the hope, like the everyday will bring something new. every day there is always a chance to modify whatever is being like in the past. there is always a solution. i'm 100% convinced. there is always a solution for everything. (participant 7) while none of the participants linked a positive mindset with knowledge of the brain’s malleability, the concept of “keeping positive” as an agent for change was demonstrated more frequently within this group. sub-theme: although possible, change isn’t easy and takes effort. mentions regarding the amount of effort required to induce change were sometimes linked to the desire of the individual. participants in this group called on the reality that change is a process, which requires personal dedication and intention. i would say that's completely based on your openness and receptiveness to changing behaviors. i think that that's a really difficult thing to change in somebody subconsciously if they're not open to it themselves. (participant 8) in addition to discussing the effort required from an individual to recover from addiction, depression, or anxiety and/or change their behavior, participant 8 indicated that improvement efforts were characteristic. sub-theme: openness. several participants in the knowledgeable group shared that an individual’s ability to changed was linked to a personal openness to do so. there wasn’t a recorded trend regarding what the participants believed led to openness. interviewer: and how much do you believe in the phrase you can't teach an old dog new tricks? participant 8: for dogs or for people? [laughter] interviewer: i guess it's a phrase for people. participant 8: i definitely don't believe that at all. i think if the dog is open to learning new tricks, then the dog handler can teach it new tricks, yeah. (participant 8) while records such as participant 8’s demonstrated a belief that the ability to change in adulthood stems from an individual’s openness, it is unclear how this may be linked to knowledge of brain malleability. (additionally, it is important to note that while responding, the participant was laughing, leading to an interpretation that they were playfully joking about the analogy referring to dogs. due to the non-verbal reactions during the interview, it neuroplasticity knowledge and perceived self-efficacy 18 was supposed that the participant was continuing to speak about the dog as an analogy for humans.) the possible techniques one can utilize range from medical to holistic-subordinate theme: self-awareness participants in the knowledgeable group detailed the need for cognitive self-awareness as a requirement for one to change. quote 1: i think it takes a lot of work and self-awareness, but yeah, i think it's absolutely possible. (participant 11) quote 2: i think there has to be an awareness of whatever it is that you want to change. (participant 12) although the knowledgeable group detailed a need for self-awareness of one’s issues in order to change, it was not indicated in how that self-awareness can be obtained, nor how this may be linked to knowledge of brain malleability. comparison of groups despite the non-knowledgeable group attesting to having no knowledge regarding neuroplasticity, a belief that change in one’s behaviors was possible, as well as their ability to recover from addiction, anxiety, and depression was recorded in all six interviews from this group. this belief was equally expressed in the knowledgeable group, demonstrating that perception regarding the ability to change and recover existed. originally, when assembling this study, it was supposed that the sentiment regarding the possibility of change would be more affirmative with the knowledgeable group versus the non-knowledgeable group, meaning the non-knowledgeable group would thematically indicate change wasn't always possible for adults. however, these findings recorded that regardless of knowledge as it relates to neuroplasticity, the participants believed that the potential to recover from mental health disorders in individuals is present, and no difference in this point of view was perceived across the two groups (for instance, no participants responded to the question of the ability to change negatively). in total, the theme, “overall, one’s ability to change their behaviors or recover from addiction, anxiety or depression is not only possible, but promising,” received 64 mentions across 10 interviews, with 41 mentions in the knowledgeable versus 23 in the non-knowledgeable group. while the overall sentiment remained consistent, the greater number of mentions in the knowledgeable group is worth examination as it pertains to this supposition and demonstrated a variance in prevalence from the non-knowledgeable group. of the original list of superordinate themes, “childhood development as a key-factor in one’s ability to change” was mentioned throughout both groups, but less frequently than the final superordinate themes selected, leading to its exclusion in the final superordinate themes list. it was originally presumed that those who believed childhood events and experiences grossly affected one’s ability to change may have a lower sense of perceived self-efficacy when it came to the possibility of recovery, as this theme may imply a deterministic outcome set by the first few years of our lives. the theme of development (which oftentimes cited childhood upbringing or trauma in this study) insinuated that recovery is more difficult once we reach adulthood as we are coded from a young age. an example of this would be from participant, 2, who stated, “your ability to do that is the direct result of trauma. so, people who have suffered trauma fall into some behaviors to either self soothe or survive, and so i think those things are hard to change.” of the knowledgeable group, the theme of development was mentioned 22 times across six interviews, and from the non-knowledgeable group it was mentioned 17 times across six interviews. it was first suspected during the original read through of the transcripts that the equality of this theme’s importance across both groups demonstrated a corresponding sense of perceived self-efficacy despite the presence of knowledge. this was due to the theme of change being possible arising as a superordinate theme in both groups, and development being a less mentioned theme in both groups. however, upon the second screening of the superordinate themes across groups, key differences emerged and were noted. firstly, the importance of will and self-determination in an individual was the major theme in the knowledgeable group, with more mentions and a higher frequency than any other theme across both groups. within the knowledgeable group, this theme was mentioned 62 times, as opposed to the non-knowledgeable group who mentioned it only 11 times, excluding it from an overall superordinate theme for the knowledgeable group agonis 19 while being excluded in the final list of superordinate themes for the non-knowledgeable group. self-efficacy is defined as an individual's belief in their ability to complete behaviors or tasks to attain a certain performance (bandura, 1977). from the study’s metrics and definitions described, it is worth further investigation if those with knowledge of neuroplasticity may also believe that a person has a higher ability to change if they have the will to do so. a link between will and perceived self-efficacy may possibly imply that ability to recover from the mental health disorders of addiction, anxiety, and depression via this capability lies more under their control than under other outlying factors, but this would need to be examined further. when it came to the superordinate theme of “environment playing a key role,” beliefs in how the environmental factors influenced one’s ability to recover from mental health disorders varied across the knowledgeable and non-knowledgeable group. for the non-knowledgeable group, the environment's sub-themes included an acknowledgement of privilege regarding having access to basic needs, such as housing and healthcare, possibly indicating that the ability to change is affected by external factors as opposed to internal ones. factors of basic needs were not recorded in the knowledgeable group, meaning the subordinate theme of privilege did not arise. the presence of this subordinate theme in the non-knowledgeable group, versus the presence of the subordinate theme of will in the knowledgeable group, signaled a variation in the perception of what is within one’s control versus out of one’s control. it was also found that despite not having formal knowledge regarding neuroplasticity, the non-knowledgeable group believed that the brain was “re-codable” or malleable through action. while contemporary science largely steers away from nativist claims, it may be implied from the records of the non-knowledgeable group that an innate understanding potentially exists regarding brain malleability. this is worth further consideration separate from this study. it is unclear where exactly this understanding stemmed from, and whether it was assumed or taught to these participants under some other name, or induced through subliminal, cultural messages (such as the popularization of sayings like “i think, therefore i am” by descartes). finally, the lengthened average of interviews from the knowledgeable group presented additional codes, and heightened support behind those codes by a higher frequency of mentions. returning to the research behind metacognition and biofeedback, science currently accepts that witnessing feedback regarding one's performance can assist in the advancement of an individual aiming to change a sensation or ability. while both groups expressed a belief in adults’ abilities to recover and change, the record of longer talk times combined with the supposition that will plays a major factor in ability indicates a difference between the groups. this supports the justification for quantitative research on how knowledge of neuroplasticity may influence perceived self-efficacy in recovery from addiction, anxiety, or depression. discussion as presented, a difference in themes was demonstrated regarding the perception of self-efficacy from mental health recovery between groups of adults who have knowledge of neuroplasticity and those who don’t. themes related to internal factors (such as will) were more present in the knowledgeable group and themes related to external factors (such as environment) were more present in the non-knowledgeable group. locus of control, which is the term describing an expectation of one’s influence on an outcome being more internal or external, was not examined as a factor in this study during the research process (nieben et al., 2022). however, based on the themes presented between the groups, it may be relevant to examine perceived locus control in participants in addition to perceived self-efficacy in future studies. following the conclusion of this study, overarching questions to ask for psychology at large may be: 1. should there be a focus on knowledge of neuroplasticity as an agent of change? 2. is it possible that knowledge regarding brain malleability is innate? 3. does knowledge of neuroplasticity affect one’s locus of control? regarding the question of focusing on neuroplasticity as an agent of change, there is room for quantitative examinations regarding education of neuroplasticity as a self-regulation tool, particularly given the themes recorded in this initial qualitative study and the previous successful demonstration of biofeedback, cbt, and metacognition as regulation tools. as discussed in the introduction, evolutionneuroplasticity knowledge and perceived self-efficacy 20 ary-based mental health disorders remain prevalent in the modern day, especially when set against a landscape of challenges in accessing clinical assistance. through these questions, science can potentially develop additional quantitative studies which examine the components behind utilization of knowledge of neuroplasticity as an agent for recovery from mental health disorders, and not just as an agent for recovery from cognitive function due to brain damage. limitations as this was a preliminary qualitative study, only 12 participants were interviewed total, with six in the knowledgeable and six in the non-knowledgeable group. as mentioned, during the thematic analysis, to accurately represent the importance of each code, the comments were quantitatively ranked by not only marking the codes mentioned, but also by counting the total number of mentions. however, the number of participants and the methodology doesn’t qualify for statistical relevance, and so for this hypothesis to be validated in a statistical format, additional quantitative studies would need to be conducted. considering the research as a qualitative study, whose purpose was to lay a groundwork for further research, no statistical analysis was completed due to a low-level of participants. additionally, as this research was conducted as part of a student thesis, there was only one reviewer analyzing the codes, which may have left an individual bias in how the system was coded. should another qualitative study be conducted to further examine this subject matter, it would be recommended to have additional researchers reviewing the codes and determining a final list of codes and themes in tandem. while no mention of neuroplasticity was made during the interviews themselves, since the survey sent out prior to the study as well as the information sheet included the term, it is possible that participants had done their own investigation and that had influenced their interviews. finally, the pool of participants ranged between three countries and a wide age range of adults, each of which may have their own cultural influences when it comes to their perception of recovery. it is possible that with a quantitative analysis we would see themes differ across demographics. practical implications the findings of this study suggest there may be a difference in how those with knowledge of brain malleability (knowledgeable group) regard perceived self-efficacy when it comes to the recovery of mental health disorders versus those without knowledge of neuroplasticity (non-knowledgeable group). as this study only utilized a small sample, it doesn’t hold a statistical relevance, and so there are no immediate suggestions regarding practical changes in the administration of mental health care. additional studies and analyses should measure the impact of these suggestions prior to practical applications being suggested for the adult population at large. suggestions for further research based on the study’s f indings from the non-knowledgeable group, it was perceived that those without knowledge of neuroplasticity still held a belief that the brain can be re-coded through activity. while concepts regarding innate knowledge aren’t popularized in modern-day psychology, it may be worthwhile to investigate where this seemingly “innate” understanding regarding malleability comes from whether it is subliminal societal cues or education regarding brain plasticity occurring in subliminal formats. from this, we may understand better if this belief is indeed generally understood or if it is induced through learning. it would also be worthwhile to conduct such interviews across various cultures, as it is possible the answer would differ depending on different groups. furthermore, as indicated in the background section of this study, visualization (which as far as we understand isa faculty particular to humans) is a useful tool when it comes to re-arrangement of cognitive thoughts. depending on the findings from any further studies on this topic, it may be beneficial to conduct an experiment of visualizing the re-routing of neural pathways as a mechanism for changing behavior. additionally, it is possible that individuals have received non-explicit affirmative feedback regarding brain malleability through experience. this may have been achieved through introspection following the changing of behavior over time or through the reward of society followingdemonstrated improvement (such as loved ones supporting an individual going through therapy). a further examination on how the topic of brain malleability may be subliminally shared in the west will help science understand the implications of this study. finally, studies may ask in what ways can we quantitatively test the impact knowledge of neuroplasticity has on self-efficacy regarding recovery from mental health disorders. agonis 21 conclusion due to the perceived success of recovery and/ or management of addiction, anxiety, or depression through cbt, biofeedback, and metacognition, this study’s aim was to examine if adults with knowledge of their biological makeup may have a stronger perception in their ability to self-regulate their recovery from the above-mentioned mental health afflictions which may be evolutionarily induced. as presented, the findings between the non-knowledgeable and knowledgeable groups have recorded a variation in themes regarding sense of self-efficacy when it comes to recovery from mental health disorders of addiction, anxiety, and depression. these differences included: • the knowledgeable group’s themes holding a focus on internal control, and the non-knowledgeable group’s themes holding a focus on external control. • a higher sense that individual will plays a key role in the ability to change from the knowledgeable group. • a higher sense that privilege and access to basic needs is a major contribution to the ability to change from the non-knowledgeable group. • more lengthy interviews and ability to discuss the possibility to change from 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(2003). closing an open-loop control system: vestibular substitution through the tongue. journal of integrative neuroscience, 02(02), 159–164. https:// doi.org/10.1142/s0219635203000263 neuroplasticity knowledge and perceived self-efficacy 24 table 1 overall superordinate and subordinate themes agonis 25 table 2 superordinate and subordinate themes for non-knowledgeable group neuroplasticity knowledge and perceived self-efficacy 26 agonis 27 table 3 superordinate and subordinate themes for knowledgeable group neuroplasticity knowledge and perceived self-efficacy 28 agonis 29 neuroplasticity knowledge and perceived self-efficacy graduate student journal of psychology copyright 2012 by the department of counseling and clinical psychology 2012, vol. 14 teachers college, columbia university 53 mediators and mechanisms of psychotherapy: evaluating criteria for causality joshua wilt northwestern university although the efficacy of psychotherapy for treating many disorders has been demonstrated in randomized clinical trials (ekers, richards, & gilbody, 2008; hofman & smits, 2008; hoglend, 1999), little is known about the mechanisms through which psychotherapy achieves its effects (kazdin, 2005). the purpose of this review is to examine the state of research on the mechanisms of psychotherapy. first, a definition of mechanism is presented and the importance of studying mechanisms in psychotherapy is discussed. then, methods of demonstrating mediation in empirical studies are reviewed along with selected areas of empirical research on mechanisms of cognitive therapy. finally, suggestions for future directions in studying mechanisms are offered. a mechanism is defined as a step or series of steps in a process through which change is produced (johannson & hoglend, 2007). each intermediate step in a process of change can also be thought of as a mediator―a mediator is an intervening variable that is causally related to the mechanism of change (doss & atkins, 2006). this definition of mediation is crucial to research on how psychotherapy works, as research in the aim of elucidating psychotherapy mechanisms is primarily concerned with identifying mediators of change. in psychotherapy research, a mediator is a construct that explains why therapy results in symptom improvement. mediation must therefore take place during the course of psychotherapy and before symptom change.  it is important to distinguish mediation from causality. logically, causality is a necessary condition for mediation; only when something has a causal effect can the intervening mediating pathway be established. a common misconception in psychotherapy research until recently was that establishing causal effects gives information about possible mediators of those effects (kazdin, 2007). for example, if cognitive therapy were shown to be effective, it may have been assumed to work through cognitive change. however, this line of reasoning is faulty. knowing that therapy works is not in any way informative of the way in which therapy works―based on efficacy research alone, it is likely to be difficult to draw any conclusions regarding the mechanism(s) of change without measurement of potential mediators. in the example of cognitive therapy, there is a chance that affective change (or any variable, no matter how implausible) may actually explain why cognitive therapy was shown to be effective. mediators must be evaluated on their own terms, rather than being inferred from the modality of therapy. joshua wilt, department of psychology, northwestern university, evanston, il. correspondence concerning this article should be addressed to joshua wilt, northwestern university, department psychology, swift hall 109, evanston, il 6020. email: joshuawilt2008@u.northwestern.edu. it is important to study the mechanisms of psychotherapy for at least four reasons. the first reason is based on the extremely high proliferation of different types of psychotherapy. it is highly unlikely that all of these types of therapy work in unique ways; therefore, identifying common mediators across psychotherapies may add parsimony to the varied theories of what happens when psychotherapy works (johansson & hoglend, 2007). second, identifying mediators may advance the understanding of differential responses to treatment. even in the most successful clinical trials, only 60% of depressed patients show clinically significant symptom improvement (derubeis, tang, & beck, 2001). third, identifying mediators may maximize treatment effectiveness (laurenceau, hayes, & feldman, 2007). psychotherapies contain multiple components, and yet each component may not be causally related to the mechanism by which therapy works. for example, although cognitive behavioral therapy (cbt) includes both cognitive and behavioral components, it is possible that only cognitive or only behavioral components are causally related to change depending on the disorder being treated. identifying mechanisms may allow therapists to focus on only those aspects that are actively contributing to the patient’s improvement, making therapy much more efficient and economical. knowledge about how therapy works also allows for generalization from clinical trials. a common criticism of randomized clinical trials (rcts), a clinical experiment in which participants are randomly allocated to receive different forms of treatment, is that the various constraints and artificialities imposed on participants prevent the results from transferring to “real world” psychotherapy (doss & atkins, 2006). if it was known why a specific psychotherapy worked, this knowledge would be potentially transferrable across a wide range of community settings. fourth, there is the potential for benefits outside the realm of psychotherapy. specifically, knowing about the process by which maladaptive functioning changes into adaptive functioning may reflect upon the processes underlying different forms of psychopathology and healthy functioning in general. wilt 54 criteria for mediation causality may be logically identified when an experiment utilizes random assignment of participants. therefore, rcts by definition are able to establish that psychotherapy causes symptom improvement. however, there is no comparable method to show that a possible mediator is responsible for the effects of psychotherapy. this is because the variables that may be responsible for change are left to vary freely rather than being randomly assigned. the lack of a definitive method for showing that mediators are part of a causal mechanism presents a difficult hurdle for achieving certainty regarding potential mediators. numerous criteria have been proposed that supposedly strengthen the inferences one can make about whether a putative mediator is actually a part of the mechanism of psychotherapy (doss & atkins, 2006; johansson & hoglend, 2007; kazdin, 2007; nock, 2007; weersing, 2006). however, the myriad criteria have not been reviewed in a systematic way. it is important to organize these criteria in order to establish a method for evaluating the degree of support for a given mediator as a link in the causal chain between psychotherapy and treatment outcome. there are two important clarifications to make before discussing the criteria for mediation. first, because rcts are the gold standard in psychotherapy research, much of the discussion of criteria below centers on research conducted in the context of an rct; however, with the exception of criterion 4 (that the mediator was discovered in the context of an rct), each of the criteria may be applied to non-rct designs. second, the distinction between full mediation (in which a mediator completely accounts for the association between treatment and outcome) and partial mediation (in which a mediator accounts for only part of the association between treatment and outcome) is an important issue but is outside the scope of this paper. the discussion focuses on mediation in the general sense―that is, whether a particular mediator is part of the causal chain linking treatment to outcome. the first criterion, temporal precedence, is a necessary condition for mediation (i.e., the mediator must occur temporally before symptom change). this criterion had not been explicitly recognized by psychotherapy research until recently, as it only just became common practice to measure mediator variables and symptom changes at multiple time points in psychotherapy studies (hayes, laurenceau, feldman, straus, & cardaciatto, 2007; laurenceau et al., 2007). it is a logical flaw to claim as a potential mediator any changes that occurred after symptoms have already changed. the most commonly cited evidence used to support mediation are statistical criteria (baron & kenny, 1986); see figure 1 for a depiction of this model as applied to psychotherapy). each path in the figure signifies a criterion that must be met in order for mediation to be achieved. path “a” indicates that the relationship between treatment and outcome must be statistically significant. path “b” indicates that the relationship between the treatment and mediator must be significant, and path “c” indicates the relationship between the mediator and outcome must be significant. path “d” is shown as a dotted line, symbolizing that the relationship between treatment and outcome should be significantly reduced when taking the mediator into account. more recent statistical mediation models (mackinnon, lockwood, hoffman, west, & sheets, 2002) have relaxed the baron and kenny model by excluding path “d” from the mediation model in order to maximize power to detect significant mediation effects. there are various other statistics that assess mediation (fritz & mackinnon, 2007); however, distinguishing between those statistics is beyond the scope of this paper. the point of establishing statistical mediation is that it lessens the possibility that a potential mediator went unidentified due to type ii error alone. for example, consider a case in which multiple mediators (a, b, and c) are examined in the same study. if mediator a meets statistical criteria and mediators b and c do not, then it is probable that mediators b and c failed to meet statistical significance because they are less causally implicated in the mechanism of psychotherapy (relative to mediator a), rather than for power reasons alone. establishing statistical mediation in the context of an rct strengthens the case for the potential mediator being examined. this is because, if random assignment was correctly implemented, pre-existing conditions cannot account for the effects of the mediator. however, it is still entirely possible that a different variable that changed as a result of therapy accounts for the effects of the mediator being examined. in addition to statistical criteria, there are a number of other criteria that can be used to evaluate the likelihood that a potential mediator is a causal component of therapy. these additional criteria are helpful in ruling out or at least reducing alternative possibilities, thereby strengthening inferences that can be made about potential mediators. for example, rcts can examine whether mediators meet a dose-response criterion; this means that, the more change in the mediator, the more change in the outcome. doseresponse increases confidence in the conclusion that mediators systematically relate to outcome across the range of possible outcomes; mediators that do not meet the doseresponse criterion may only be relevant or related to outcomes in a very narrow range. for example, if a moderate amount of cognitive change is associated with moderate symptom improvement, and a high amount of cognitive change is associated with high symptom improvement, the range over which cognitive change is relevant to the outcome would be greater than if all levels of cognitive change were associated with moderate symptom change only. the specificity of mediators may also be examined. specificity refers to the fidelity of a mediator to a particular form of psychotherapy. for example, if cognitive change met criteria for statistical mediation in cognitive therapy but not in behavioral therapy, then cognitive change would have higher specificity than if it were shown to mediate the effects of both mediators and mechanisms of psychotherapy 55 figure 1. the mediation model of baron and kenny (1986) as applied to psychotherapy. note. path “a” indicates that the relationship between treatment and outcome must be statistically significant. path “b” indicates that the relationship between the treatment and mediator must be significant, and path “c” indicates the relationship between the mediator and outcome must be significant. path “d” is shown as a dotted line, symbolizing that the path between treatment and outcome should be significantly reduced when taking the mediator into account. cognitive therapy and behavioral therapy. specificity says more about the psychotherapy in question than the mediator per se. it is possible that all psychotherapies work through the same or similar mechanisms―in this extreme case, there would be no specificity for mediators even though the mediator would be completely valid. however, if a particular brand of psychotherapy were not tied to a specific mediator, then the validity of the unique components of the psychotherapy could be called into question. if multiple rcts for the same psychotherapy found evidence supporting a particular mediator, then the mediator would have high consistency. high consistency reduces the possibility that the mediator in question met the statistical definition of mediation due to type i error. similarly, converging evidence―evidence obtained across a variety of methodologies in a variety of settings―increases confidence in the conclusion that the mediator is not simply an artifact of the context of a particular rct. converging evidence may be obtained through lab studies, field studies, and even studies examining different species. for example, suppose that exposure therapy for spider phobia was thought to reduce phobic symptoms by reducing autonomic arousal. then, evidence that both individuals without clinically significant phobic symptoms as well as rats exhibit diminished autonomic responses to various potentially fear-inducing stimuli after undergoing exposure therapy would constitute converging evidence supporting reduced autonomic arousal as a mediator. finally, plausibility (the degree to which a mediator makes intuitive sense) has been suggested as another criterion that may increase the confidence that can be placed in a mediator (kazdin, 2007). however, one difficulty in evaluating a mediator’s plausibility is that there may be disagreement in regard to whether a proposed mediator is a plausible explanation of change. in general, potential mediators that are recognized as valid constructs have more plausibility compared to potential mediators that are not firmly established as valid scientific constructs. for example, the empirical evidence for repressed memories (davis & loftus, 2009) is not as strong as the empirical evidence for cognitive biases (hallion & ruscio, 2011). thus, the idea that reductions in cognitive bias mediated symptom improvement in a trial would be inherently more plausible than the idea that therapy worked by activating repressed memories. examining mediators that have been well established within other empirical contexts reduces the likelihood that the potential mediator is not a valid scientific construct. it is important to note that the criteria intended to bolster the case for mediators only lessens the likelihood of alternative explanations (or rules out alternative explanations) instead of providing evidence in favor of mediation effects. however, evidence that some potential mediators meet the aforementioned criteria to a greater extent than other potential mediators does carry some very important implications. specifically, practical decisions can be informed by taking into account the cumulative evidence for or against any possible mediator. when deciding which psychotherapies should be widely disseminated or which components of psychotherapies should be emphasized, decisions that are normally best made by examining efficacy research may be well-served by also taking into account mechanism research. based on the rationale that potential mediators meeting criteria are less likely to be the result of extraneous explanations compared to potential mediators not meeting criteria, interventions based on mediators meeting criteria may have a greater likelihood of success. however, this idea d treatment outcome mediator b a c wilt 56 is currently only speculation. examination of interventions based on potential mediators meeting higher numbers of criteria versus interventions that are not based on this evidence could clarify whether using the additional criteria to evaluate mediation is indeed practically useful. in addition to the possibility that a potential mediator is actually part of the causal mechanism, evidence to support mediation may be due to a variety of alternative explanations (e.g., statistical artifacts or methodological artifacts). if a mediator meets many of the criteria above, the likelihood that the mediator can be explained by such alternative explanations is decreased. thus, more confidence can be placed in mediators that meet additional criteria than potential mediators that do not meet said criteria (see figure 2 for a schematic summary). evaluating mediation in rcts: common statistical and methodological pitfalls as discussed above, various methods may be used to obtain evidence for mediation. however the primary evidence for mediation should be garnered within the context of rcts because rcts can establish causality, a necessary condition for mediation. the most common way to evaluate mediation in rcts is to use the statistical criteria for mediation proposed by baron and kenny (1986). although these criteria are rather straightforward, there are some subtleties involved in applying them to rcts that have led to confusion in some research studies. first, when examining the relationship between treatment and outcome (path “a”), evidence that multiple treatments are equally effective does not prohibit testing for mediation. if any treatment is shown to be significantly related to the outcome, then path “a” is said to be established for that treatment. second, if a significant path exists between a treatment and mediator, then path “b” is said to be established. third, a non-significant relationship between mediator and outcome (path “c”) across all participants does not necessarily preclude the possibility that mediation occurred. this is because path “c” may only be significant within the treatment group that improved significantly on the outcome variable. tests for treatment-bymediator interactions should be used to detect this possibility. these considerations apply regardless of the particular statistical modeling technique being used to evaluate mediation (e.g., multiple regression, multilevel-modeling, or structural equation modeling) as they each deal with the same fundamental assumptions of mediation. even if all statistical criteria for mediation are met, many existing studies purporting to have found mediation effects suffer from methodological limitations related to the timing of mechanism and outcome assessments. as a result, these authors often conclude erroneously that mediation occurred without having determined that the mediator changed before outcome variable changed. examples of flawed designs are enumerated in table 1, along with an empirical example of each design variation. one example of flawed methodology includes studies that assess mediators and outcomes at two time points only, prior to the experimental manipulation and after the experimental manipulation. one study used this type of design to find evidence suggesting that cbt helped to criterion 1 (necessary condition): change in mediator precedes change in outcome criterion 2: mediator meets statistical criteria proposed by baron and kenny (1986) – rules out type ii error criterion 3: mediator is found consistently across studies – reduces chances that mediator was due to type i error criterion 4: mediator was discovered in the context of an rct – reduces the likelihood that pre-existing conditions account for mediation effects. criterion 5: mediator exhibits dose-responsive relationship to outcome – reduces the likelihood that the mediator works only in a narrow range criterion 6: mediator is specific to certain types of therapy – reduces the likelihood that mediator is due to general effects of psychotherapy criterion 7: evidence supporting mediation converges across methods – reduces the likelihood that the mediator is due to methodological artifact criterion 8: mediator is well-grounded in empirical research – reduces the likelihood that the mediator is not a valid scientific construct figure 2. this figure shows how achieving criteria for mediation reduces the likelihood that mediation effects are due to extraneous explanations. mediators and mechanisms of psychotherapy 57 table 1 examples of flawed designs commonly used for studying mediation effects study disorder studied mediator assessment outcome assessment limitation pre during post pre during post smits, powers, cho, and telch (2004) panic disorder y n y y n y cannot determine whether the mediator changed prior to the outcome due to lack of assessments during the study hofmann (2004) social phobia n y n y n y cannot determine whether mediator changed during the study due to only assessing mediator one time wilson, fairburn, agras, walsh, and kraemer, h. (2002) bulimia nervosa y y y y n y although it is possible to determine that change in the mediator preceded the final outcome assessment, it is not possible to establish that the mediator changed before the outcome because the outcome was not assessed during the study note. “y” indicates that the mediator or outcome is measured at the time specified by the column label: “pre” = prior to treatment, “during” = during treatment, and “post” = following treatment. decrease panic symptoms through the mechanism of reducing “fear of fear,” or feelings of anxiety related to physical symptoms (smits, powers, cho, & telch, 2004). this study consisted of 130 participants who were referred to the study by mental health professionals for treatment of panic disorder. ninety participants were randomized to the treatment condition and 40 to a waitlist condition. “fear of fear,” assessed by the anxiety sensitivity index (peterson & reiss, 1987) met all of baron and kenny’s (1986) criteria for mediation; however, as “fear of fear” was only measured concurrently with panic symptoms, there is no evidence to make the claim that “fear of fear” changed before panic symptoms. failing to include pre-treatment measures of mediators also limits the conclusions that can be drawn from a study. for example, one study presented evidence suggesting that cognitive behavioral group therapy reduced symptoms of social phobia through the putative mediator of patients’ appraisals of hypothetical events associated with social phobia (hofmann, 2004). this study consisted of 90 participants who were randomly selected from among individuals seeking outpatient treatment at a university anxiety clinic. participants were randomly assigned to receive either cognitive behavioral group therapy or exposure therapy, or were assigned to a waitlist control condition. although judgments of events, as assessed by the social cost questionnaire (foa, franklin, perry, & herbert, 1996) were reported during the study and thus before the post-treatment assessment of social phobia, the lack of a baseline assessment of the mediator prohibits conclusions about whether the mediator changed during treatment. designs that do not measure outcome variables during the study are also flawed. one study showed that the effects of cbt and interpersonal psychotherapy (ipt) on symptoms of bulimia nervosa were statistically mediated by changes in dietary restraint (wilson, fairburn, agras, walsh, & kraemer, 2002). this study consisted of 220 participants diagnosed with bulimia nervosa and was conducted on an outpatient basis at two university treatment centers. participants were randomly assigned to either the cbt or ipt conditions the study’s design was able to establish that the mediator of dietary restraint (as assessed by the eating disorder examination questionnaire; fairburn & beglin, 1994) changed in response to treatment, and that the mediator changed during the treatment and thus before the posttreatment outcome assessment. however, as no assessments of bulimia symptoms were made during the study, the possibility still exists that those symptoms changed prior to the mediator of dietary restraint. it is worth noting that a substantial body of research ostensibly supporting the wilt 58 meditational effects of therapeutic alliance (i.e., the degree to which a patient and therapist collaborate, agree on goals, and form a personal bond; henry, strupp, schacth, & gaston, 1994) has been largely discredited due to failure to measure symptom change during studies (derubeis et al., 2001). when symptom change has been included in assessments during the course of treatment, therapeutic alliance has not emerged as a significant predictor of post-treatment symptom change (derubeis & feeley, 1990; tang & derubeis, 1999). to avoid the pitfalls of these studies, the best possible design would include assessments of potential mediators and outcome variables before and after the treatment is implemented, and also at multiple time points while the treatment is being implemented. cognitive therapy for depression works through cognitive change the methodological limitations described above have the consequence of preventing the accumulation of knowledge about how psychotherapy works. however, one exception is the study of cognitive therapy for depression. this section describes how various studies are converging on the possibility that cognitive therapy works through producing cognitive change, and that cognitive change mediates not only response to treatment but also reduction of relapse rates. examples of studies providing evidence in support of the criterion for mediation are presented below (see figure 2 for a list of each criterion identified by number). the first direct evidence for mediation by cognitive change was provided by tang and derubeis (1999). in this study, cognitive therapy was found to be effective for treating depression in the context of an rct (thus establishing causality and meeting criterion 4, that the research was conducted in the context of an rct). importantly, symptoms of depression as well as cognitive change were monitored at multiple time points throughout the course of treatment. cognitive change was assessed with a well-validated measure of cognition in depression, the patient cognitive change scale (tang, derubeis, beberman, & pham, 2005), suggesting that the proposed mediator is a valid scientific construct (criterion 8). when considered together, two noteworthy findings of this study make a strong case that cognitive change mediated the effects of therapy. first, individuals who experienced “sudden gains,” or large reductions in depressive symptoms from one session to the next, were much more likely to improve than individuals who did not experience sudden gains (meeting the statistical criterion from criterion 2). second, the session in which sudden gains occurred was likely to have been preceded by cognitive change in the previous session (criterion 1), but not during a control session (i.e., two sessions prior to sudden gains). these findings were subsequently replicated in an independent sample (tang et al., 2005), providing some evidence that cognitive change meets the consistency criteria for mediation (criterion 3). additionally, there is some evidence that cognitive change meets specificity criteria (criterion 6), as cognitive change has not been found to mediate the effects of supportive-expressive therapy (andrusyna, luborsky, pham, & tang, 2006) on depression. encouraging findings are also occurring in the domain of relapse prevention. it was recently found that lower rates of relapse in depressed patients receiving cognitive therapy were predicted by sudden gains (tang, derubeis, hollon, amsterdan, & shelton, 2007) as well as by competence in cognitive techniques emphasized during cognitive therapy (strunk, derubeis, chiu, & alvarez, 2007). these findings provide more evidence for consistency, and they also suggest that cognitive change is durable and robust rather than a transient effect of cognitive therapy. thus, cognitive change does reasonably well (meeting six of eight criteria) when evaluated on the criteria of mediation reviewed in this paper. future research should test for a dose-response relationship (criterion 5) and use additional measures of cognitive change (criterion 7). conclusions and future directions research on the mechanisms of psychotherapy is still in its earliest stages. although much has been written on the ways in which psychotherapy might work, little empirical research has investigated the process of psychotherapy, and a high percentage of this research was plagued by serious methodological flaws. therefore, there is an urgent need for mechanism research that is conducted with appropriate methodological rigor and that establishes treatment efficacy before evaluating mechanisms. while this area holds great promise for future researchers, moving forward with blind enthusiasm (by not establishing treatment efficacy first) would be just as detrimental to progress as the methodological pitfalls described in this paper. one way that mechanism research could have a significant impact is by finding some common ground across the vast number of psychotherapies in existence. new psychotherapies are developed frequently, each laying claim to a somewhat unique theoretical basis. thus, the theoretical landscape of psychotherapy is likely much more complex than it needs to be, which has the important practical implication of making treatment choices seem overwhelming and impossible to navigate for clients. mechanism research has the potential to reveal the processes that are shared between different therapies. this development would increase parsimony and would hopefully lead to the incorporation of techniques relevant to the ways in which psychotherapy works across its disparate forms. mechanism research incorporating multiple efficacious psychotherapies and multiple putative mediators in the same rct may be especially helpful for identifying mediators that are common across psychotherapies. the identification of mediators also has the potential to distill treatments down to their essential components, which might result in reductions to the time and cost to train therapists as well as to disseminate psychotherapy. mechanism research may thus increase the efficiency of psychotherapy. perhaps the most important mediators and mechanisms of psychotherapy 59 benefit of increased efficiency is that more economical therapies increase the availability of psychotherapy, especially to underserved populations (kazdin & blase, 2011). another suggestion for future research is made specifically for investigating cognitive change. cognitive change has a special status among potential mediators due to the increasing evidence which suggests that cognitive change mediates the effects of cognitive therapy on depressive symptom reduction. future efforts to further validate this mediator may focus on meeting the various criteria described earlier (e.g., dose-response and consistency). meeting these criteria may strengthen confidence in the conclusion that cognitive change truly is involved in the causal pathway from cognitive therapy to symptom reduction. perhaps most important would be research that examines the “convergence of evidence” criterion by investigating whether cognitive therapy works through cognitive change across various disorders. if this were the case, the validity of applying cognitive change techniques across disorders would be strengthened. the studies summarized in table 1 (hofmann, 2004; smits et al., 2004; wilson et al., 2002) each investigated potential mediators of the effects of cognitive therapy on different disorders (panic disorder, social phobia, and bulimia nervosa); however, these studies included methodological flaws. thus, new research taking multiple assessments of potential mediators and outcomes is needed across the realm of psychopathologies for which cognitive therapy has proven effective. any mediator may be evaluated based on the criteria proposed in this paper, and the degree to which a mediator meets those criteria could serve as a useful basis for making judgments about whether the mediator should be considered a causal mechanism. in summary, it is necessary for changes in mediators to precede changes in outcomes (criterion 1). establishing that a mediator meets the statistical criteria proposed by baron and kenny (1986) rules out the possibility of type ii error (criterion 2). finding evidence for a mediator across studies reduces the chances that the any individual study committed a type i error (criterion 3). if the mediator was discovered in the context of an rct, it is less likely that pre-existing conditions could have accounted for mediation effects (criterion 4). evidence for a doseresponse relationship between a mediator and outcome reduces the likelihood that the mediator works only in a narrow set of circumstances (criterion 5). showing that a mediator is specific to certain type of therapy reduces the likelihood that the mediator is due to general effects of psychotherapy (criterion 6). finding that mediation converges across methodologies reduces the likelihood that the mediator is due to methodological artifact (criterion 7). finally, examining potential mediators that have that have been well established within other empirical contexts reduces the likelihood that the mediator is not a valid scientific construct (criterion 8). these criteria for mediation have the potential to clarify the scientific status of potential mediators by serving as a framework in which research on mediation in psychotherapy may be systematically organized. references andrusyna, t. p., luborsky, l., pham, t., & tang, t. z. 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(2002). cognitive-behavioral therapy for bulimia nervosa: time course and mechanisms of change. journal of consulting and clinical psychology, 70, 267-274. doi:10.1037/0022-006x.70.2.267 gsjp volume 16 final 100 graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 100 rewriting history: attachment theory in the practice of adult psychotherapy jillian d. farrell, b.a. department of counseling and clinical psychology teachers college, columbia university jacqueline a. carleton, phd national institute for the psychotherapies attachment theory can enhance both the therapist’s and patient’s awareness of their roles in the psychotherapeutic process, their effect on the therapeutic alliance, and their understanding of themselves and one another. john bowlby (1980) proposed that the innate developmental task of infants is to seek and grow a relationship with their primary caregiver, offering the child protection and security (dolan et al., 1993; farber et al., 1995; levy, 2005; sable, 2007). as an adult, the acquired pattern of attachment behavior guides how an individual relates to others, functions in interpersonal situations and relationships, regulates emotions, and reáhfwv� rq� sdvw� ru� suhvhqw� dwwdfkphqwv� �$wnlqvrq� hw� do��� ������ 0lnxolqfhu� hw� do��� ������ 6deoh�� ������ =lofkd� hw� do��� ������� %\� uhylhzlqj� wkh� vhohfwhg� olwhudwxuh� lq� wkh� àhog�� wkh� suhvhqw� duwlfoh� vwulyhv� wr� khos� folqlfldqv� ghhshq� their understanding of the role of attachment theory with adult patients, in the psychotherapeutic process, as it has been elaborated in the recent literature. it is hoped that clinicians will be inspired to follow up with some of the multitudinous references we have provided to this fascinating literature. we would also hope that they realize that a great deal of evidence has accrued of the effectiveness of attachment based psychotherapy. introduction background john bowlby (1980), the father of attachment theory, established a conceptual framework that continues to inspire attention and research. the principles of the theory address the innate developmental task of infants to seek and grow a relationship with their primary caregiver, offering the child protection and security (sable, 2007; levy, 2005; dolan et al., 1993; farber et al., 1995). this is congruent with the ethological principle that all mammals require the suhvhqfh�ri �d�fduhjlylqj�àjxuh�dv�wkh�surwhfwru�ri �wkh� fragile infant striving for survival (bernier et al., 2002; bowlby, 1980; diener et al., 2011; muller, 2009). using bowlby’s theory as a foundation, mary ainsworth went on to systematically assess attachment needs and behaviors of toddlers in her well-known experiment, the strange situation (ainsworth, 1985; ainsworth et al., 1978). from there, mary main and colleagues developed the adult attachment interview (aai), enabling researchers and clinicians to explore attachment related phenomena in late adolescence and adulthood (wallin, 2007). an enormous amount of dwwdfkphqw�uhvhdufk�frqwlqxhv�wr�árxulvk�dqg�wkhuh�lv� now substantial empirical support for bowlby’s (1980) conviction that early family experience is related to later personality functioning (harris, 2004; sable, 2007). the present paper strives to help clinicians deepen their understanding of the role of attachment theory in the psychotherapeutic process with adult patients, as it has been elaborated in the plethora of recent olwhudwxuh��%\�uhylhzlqj�vhohfwhg�olwhudwxuh�lq�wkh�àhog�� knowledge and perspectives of attachment concepts are examined and integrated to form a comprehensive overview. the various elements of attachment theory are discussed in the context of psychotherapy, including suggestions for the application of theory to practice and possible directions for future research. 6ljqlàfdqfh�ri �$wwdfkphqw�7khru\�lq�&olqlfdo� practice the phrase “attachment state of mind” denotes the way an individual in adulthood processes attachment-related cognitions, feelings, and memories (atkinson et al., 2004). attachment systems impact people’s trust in close relationships, their fears of rejection, their weak or intense yearning for intimacy, and their tendency to favor dependency or autonomy (meyer et al., 2001). the acquired pattern of attachment behavior guides how he or she relates to others, functions in interpersonal situations and reodwlrqvklsv�� uhjxodwhv�hprwlrqv�� dqg� uháhfwv�rq�sdvw� or present attachments (atkinson et al., 2004; mi-keywords: attachment, psychotherapy, working alliance, aai 101 kulincer et al., 2007; sable, 2007; zilcha et al., 2011). indeed, attachment theory offers a foundation from which a clinician can better understand the limitations and capacities of an adult patient through the consideration of childhood and current relationships that have brought about the person’s representations of the self and others (sable, 2007; smith et al., 2009). utilizing attachment theory, an adult patient’s capacity to form positive relationships can be examined (smith et al., 2009). in adults, psychopathology may arise from or result in the inability to form and maintain close relationships (sable, 2007). additionally, attachment theory can be understood as a theory of trauma in which the lack of and/or disruption in secure connections to others generates traumatic stress dqg�prglàhg�vw\ohv�ri �dwwdfkphqw��/hy\���������$q� individual’s attachment system is associated with the capacity for intersubjectivity, affect-regulation, mentalization, and other developmental processes; thus, the disruption or weakness of these processes due to a maladaptive attachment system can weigh heavily on one’s functioning and be manifested in symptoms (bowlby, 1980; sable, 2007). lamagna (in press) states, “this ‘internal attachment system’, comprising states representing our subjective experience and vwdwhv� uháhfwlqj� rq� dqg� dssudlvlqj� wkdw� h[shulhqfh� coordinates its activity in ways that best regulate the individual’s affects, thoughts, perceptions, and behavior.” research shows a convincing connection bewzhhq�dwwdfkphqw�ghàflwv�dqg�$[lv�,�dqg�$[lv�,,�glagnoses (shorey et al., 2006). bowlby (1980) pointed out long ago that separations, losses, and other disturbances in attachment are the foundations from which emotional distress and personality disorders arise. how attachment theory is related to psychopathology in adulthood wallin (2007) proposes that the guiding rules of a person’s life are those evolved from the “rules of attachment” that were internalized and embedded in infancy through interactions with caregivers. these “rules”, in wlph��ghàqh�wkh�phdqv�e\�zklfk�rqh�dffhvvhv�dwwdfkment-related cognitions, emotions, and recollections. the attachment they had as infants has been found to be strongly linked to their psychological health as adults (atkinson et al., 2004; shorey et al., 2006). the individuals typically exhibiting psychopathology are unable to protect themselves against and/or cope with threats, stresses of human interaction, and the hassles of everyday life due to wkh� devhqfh� ri � wkh� áh[leoh� sv\fkrorjlfdo� surfhvves developed through early attachment experiences (bateman et al., 2003; bowlby, 1980; levy, 2005; sable, 2007; zilcha et al., 2011). losses and unresolved experiences in a person’s attachment system can be kept hidden in a dissociated state that only releases these overwhelming experiences when provoked with cues relating to them (wallin, 2007). 7kh�0rglàfdwlrq�ri �$wwdfkphqw�6\vwhpv�lq� psychotherapy fortunately, attachment systems can be modlàhg� e\� vxevhtxhqw� uhodwlrqvklsv�� rqh� ri � zklfk� lv� psychotherapy (mikulincer et al., 2007; wallin, 2007; zilcha et al., 2011). the experience of psychotherds\�� àuvw� ghvfulehg� e\� )uhxg� dv� ´wkh� wdonlqj� fxuhµ�� generally involves self-disclosure of concerns by the client and facilitation of change by the therapist (leger, 1998). vaughn and burgoon (1976) noted, “parsons (1951) maintains that therapy becomes necessary when the control mechanisms inherent in the reciprocities of ordinary human relationships break down” (p.256, quoted from leger, 1998). thus, psychotherapy, particularly attachment-focused psychotherapy, has the potential to transform the rigid processes of one’s attachment system to become more robust, as well as re-write the way a person views him or her self and others (harris, 2004). the growing research in attachment is beginning to facilitate greater application of the theory to the practice of psychotherapy (mikulincer et al., 2007; wallin, 2007). findings have supported the notion that clinicians’ knowledge of attachment theory enkdqfhv� wkh� hiàfdf\� ri � wkh� wkhudshxwlf� uhodwlrqvkls� (farber et el., 1995). psychotherapeutic treatment utilizing attachment theory provides an opportunity for a patient to delve into both early and current attachment experiences while in a safe setting and with a safe person: the therapist (bowlby, 1980; sable, 2007). attachment theory can “enrich (rather than dictate) the therapist’s understanding of his or her patient” (steele et al., 2008), allowing the therapeutic alliance farrell, carleton 102 and intervention techniques to be designed to match a sdwlhqw·v�vshflàf�qhhgv��0doolqfnurgw�hw�do����������� developmental processes starting in early attachment experiences internal working models of attachment internal working models are the foundations of adaptive or maladaptive thoughts and behaviors (zilcha et al., 2011). an individual’s unique internal repuhvhqwdwlrqv� vwurqjo\� lqáxhqfh�klv� ru�khu�ehkdylruv� and security later on in life (bowlby, 1980; cortina et al., 2003; harris, 2004; lamagna, in press; levy, 2005; smith et al., 2009; zilcha et al., 2011). these internal working models are organized behavioral systems and cognitive structures developed through the internalization of early interactions with caregivers and the environment (bowlby, 1980; cortina et al., 2003; diener et al., 2011; harris, 2004; levy, 2005; meyer et al., 2001; mikulincer et al., 2007; sable, 2007; zilcha et al., 2011). once these representations of self and others are formed, one’s expectations and style of thinking are virtually automatically implemented in subsequent relationships (diener et al., 2011; muller, 2009). the meaning of events is constructed to be congruent with the inner working models, whether accurate or inaccurate. negative internal working models lead to the misinterpretation of social cues, like attributing hostility to others’ benign intentions (muller, 2009). in other words, as a child matures through life his or her internal expectations, established from early experiences, govern the experience and navigation of the external world (harris, 2004; leger, 1998). the propositions of both bowlby (1980) and interpersonal theorists suggest that an essential goal of therapy is the restructuring of representations of early attachment interactions and the transformation of insecure internal working models and destructive relational behaviors (diener et al., 2011). these changes are thought to occur as a result of the new relationship experiences with the therapist (diener et al., 2011). although initially clients’ negative working models lqáxhqfh�klv�khu�dwwdfkphqw�dqg�shufhswlrqv�ri �wkh� therapist, they become more secure during the course of therapy as the client is subjected to the consistency and responsiveness of the therapist (bowlby, 1980; mallinckrodt et al., 2005; smith et al., 2009). for example, clients with a dismissing attachment style may be cold and unwelcoming towards the therapist at the rqvhw�ri �wkhuds\��pdnlqj�lw�gliàfxow�wr�kdyh�d�frqyhusation. after they experience the warmth and helpfulness of the therapist at a carefully titrated pace, these clients begin to feel more motivated and comfortable sharing with the therapist and interacting in sessions. through the internalization of the therapist dv� d� qxuwxulqj� dqg� uholdeoh� àjxuh�� d� folhqw� judgxdoo\� builds an internal working model of the therapist dqg�frphv�wr�vhh�wkh�wkhudslvw�dv�dq�dwwdfkphqw�àjure that he or she can resort to during distress, at àuvw� wkurxjk�gluhfw� frqwdfw� dqg�hyhqwxdoo\�e\� lqwhunalization (bowlby, 1980; farber et al., 1995). the evocation of the therapist by the client during emowlrqdo� dqg�ru� lqwhushuvrqdo� gliàfxow\� doorzv� iru� wkh� employment of affect regulation strategies and the revision of maladaptive expectations and behaviors (obegi, 2008). the changes in reaction to stressful circumstances and the experience of a positive attachment relationship contribute to an increased frqàghqfh�lq�wkh�vhoi �dqg�ru�rwkhuv��2ehjl�������� the internalization of the benevolent role of the therapist and the formation of a positive internal working model of the therapist is critical to therapeutic change (zilcha et al., 2011). clients can reveal their internal working models through attachment behaviors, transference, narratives, and self-reports (harris, 2004). in the case of transference, the patient actually projects his or her internal working models onto the therapist (smith et al, 2009). transference can include positive manifestations that progress treatment forward, or negative manifestations that may be seen as resistance (cortina et al., 2003). dozier and tyrell (1998) stressed the need for the therapist to gently challenge the client’s attachment patterns, assumptions about relationships, and coping strategies in order to encourage the steady exploration of emotional and interpersonal issues. the goal is to restructure the models to be more congruent with accurate and current knowledge and experiences (sable, 2007). dozier and tyrell (1998) termed this process a “correctional experience”. in adult patients, there is an unconscious, active adherence to the preexisting ´uxohv�ri �dwwdfkphqwµ��7khuhiruh��glvfrqàuplqj�wkh� attachment in psychotherapy 103 client’s internal working models propels the client to investigate, reevaluate, and understand past experiences that have shaped his/her problematic models and representations (eagle et al., 2006; shorey et al., 2006). some label this type of intervention involving a push for change as “purposeful misattunement” (shapiro et al., 1999). from this exploration, expectations and perceptions of the self and/or relationships can be revised and internal working models fdq�eh�uhfrqàjxuhg��=lofkd�hw�do����������$v�+rophv� (2000) describes, this restructuring of working models is like “story-making” and “story-breaking”. the internal world of the adult patient is reassembled in a way that allows a more coherent narrative of the self to be formed, as well as the events of one’s life to “fall into place” (sable, 2007). with regard to attachment, it is the discovery of meaning in our personal klvwru\� wkdw� lqáxhqfhv� wkh� vhfxulw\� ri � rxu� vwdwh� ri � mind, rather than the actual content of this history. attachment and interpersonal theorists agree that a therapist’s noncomplementary response to a client’s attachment tendencies promotes an opportunity for a client’s internal working models (also called “interpersonal complementary hypothesis”) to be challenged and revised (bernier et al., 2002; goodman, 2010). %\�áh[leo\�wdnlqj�rq�d�frqwudvwlqj�vwdqfh�wr�wkh�folent’s rigid assumptions, no reinforcement is given to wkh� folhqw·v� lqáh[leoh� lqwhushuvrqdo� rulhqwdwlrq� dqg� there is an opportunity for the client to explore alternative expectations of the self and/or relationships. for example, a therapist treating a dismissing patient qhhgv�wr�vorzo\�hqfrxudjh�uháhfwlrq�rq�wkh�sdwlhqw·v� emotional issues he/she is trying to ignore, rather than allowing these issues to be overlooked (bernier et al., 2002). on the other hand, a therapist working with a preoccupied patient, who is pouring out his/ her emotional issues and is clinging to the therapist, must gradually encourage autonomy (bernier et al., 2002). if the therapist gives in to every demand and need of the preoccupied patient, the individual’s internal working model of the self will only become more enmeshed with his/her relationships and the negative attachment behaviors will be reinforced. the security of the therapist’s own attachment system, which will be discussed below, contributes to his or her capacity to adapt to the needs of the client. in some cases, it is extremely challenging or impossible for a therapist to provide the patient with the sense of security needed to establish the restorative positive relationship with the therapist (mallinckrodt et al., 1995; zilcha et al., 2011). if this is the case, the patient may be able, guided by the therapist, to use a current intimate relationship. mentalization and attachment style mentalization is the ability to understand human action in the context of one’s underlying mental representations (bateman et al., 2003). the capacity for mentalization is the foundation of a stable structure of the self and is developed through early attachment and subsequent social experiences (gergely et al., 1996). disorganized and/or weak early attachments can become incorporated into the self-structure resulting in the experience of oneself and others in this maladaptive, disoriented mode. in adults, there is an unconscious, active adherence to the preexisting “rules of attachment” based on these assumptions. with an unstable sense of self, the individual inherently strives to defend their distorted and schematic perceptions of self, others, and relawlrqvklsv�djdlqvw�wkuhdwv�wkdw�pd\�frqálfw�zlwk�wkhvh� perceptions, perhaps through aggressive impulses or mental isolation (bateman et al., 2003). this regxfhg�fdsdflw\�wr�phqwdol]h�fdq�eh�uháhfwhg�lq�srru� interpersonal relations, maladaptive and insecure assumptions about oneself, and emotional volatility. in psychotherapy, the issues of mentalization can be addressed and improved (bonovitz, 2010). the therapist can help cultivate a patient’s capacity for phqwdol]dwlrq�e\�frqvlvwhqwo\�txhvwlrqlqj�dqg�uháhfwing on the internal states within the patient (and within the therapist) characterizing the current moment (bateman et al., 2003). the mutual exploration allows the therapist to discover links between external and internal experiences that seem incomprehensible for wkh�sdwlhqw��%dwhpdq�hw�do����������7klv�fodulàfdwlrq�dolows the patient to become aware and make sense of previously ambiguous feelings about oneself, others, and relationships (bateman et al., 2003). the argument is that feelings are re-experienced and released during the psychotherapeutic process as one reprocesses past experiences. this allows for the patient farrell, carleton 104 to organize a more accurate construction of experience and restructure the self (leger, 1998). consequently, this new understanding and sense of control over one’s internal states facilitates mentalization. internal working models of patients based on attachment style it is critical for the therapist to understand the nature of the internal working models each patient brings into treatment. individuals with a secure attachment style hold assumptions that are both practical dqg�ehqhàfldo�iru�wkhlu�lqwhuqdo�zhooehlqj�dqg�vrfldo� experiences. their internal working models sustain a trust in the goodness and competence of the self dqg�rwkhuv��dv�zhoo�dv�d�ghvluh�iru�dqg�d�frqàghqfh�lq� relationships (bordin, 1979; diener et al., 2011; levy, 2005). individuals with a secure attachment are less restricted by internal rule-based patterning, enabling wkhp�wr�eh�áh[leoh�lq�wkhlu�lqwhushuvrqdo�frppxqlfdtions (wallin, 2007). this internalized positive inner working model facilitates a higher tolerance for anxiety, especially in novel experiences, resulting in a greater freedom to explore the world and a more coherent integration of experiences (mallinckrodt et al., 2005). they have overall better functioning in areas such as impulse control, empathy, and marital relations (levy, 2005; main et al., 1986). a more secure attachment lv�ehqhàfldo� iru� wkh� w\sh�ri �phqwdol]dwlrq� wkdw�shuplwv� wkh� hiàfdf\� ri � lqwurvshfwlrq� wkdw� fdq� glvforvh� dqg�hydoxdwh�dwwdfkphqw�lqáxhqfhv�rq�rqh·v�uhodwlrqship functioning and affect regulation (obegi, 2008). in contrast, an insecure attachment style consists of internal working models that have a negative, ambiguous, and mistrusting view of the self and others (diener, et al., 2011). inadequate early caregiving experiences encode in the memory attachment interactions that are inconsistent (sable, 2007). the dissociated representations of attachment, hypothesized by main as “multiple models” of attachment, are similar to freud’s ideas regarding the dynamic unconscious. instead of the unlimited access to attachment-related information present within secure individuals, those with “multiple models” are governed by rigidity in what they are supposed to know and feel rather than being able to use the entirety of their experiences (particularly those that are threatening). therefore, an insecurely attached individual may feel discomfort with closeness in relationships and/or anxiety in times of separation (wallin, 2007). the negative internal working models of the self and/or other fuel distress gxh� wr� wkh� lqvxiàflhqw� ghyhorsphqw� ri � dssursuldwh� physiologic and affect regulation as a result of poor early caregiving experiences. in these cases, attachment repair must precede introspective exploration. categorization of attachment patterns in regards to childhood attachment, several different categorization schemes have been proposed consisting of different labels and numbers of categories. for the sake of simplicity, in this piece, i will focus on the categories proposed by ainsworth (1978) and main et al (1986). their work yielded four patterns of attachment: secure, insecure-ambivalent, insecure-avoidant, and disorganized (dolan et al., 1993; hietanen et al., 2006). children’s attachment styles are highly correlated with similar attachment patterns in adulthood. there are also children with attachment styles deemed “cannot classify” since a clear pattern of attachment does not present itself in the assessment. but, for most, placement into one of the four styles of attachments is possible. a caretaker may be nurturing and responsive, promoting the child’s development of a sense of security and secure attachment (levy, 2005; pally, 2001). on the contrary, inadequate early caregiving experiences could hinder processes like attaining the ability to self-regulate, as well as result in unstable attachment thoughts and insecure attachment (sable, 2007). for adults, the attachment styles are conceptualized as: secure-autonomous, preoccupied, dismissing, or unresolved/disorganized (hietanen et al., 2006). $vvhvvlqj�$wwdfkphqw�6w\oh� �7kh�$gxow� $wwdfkphqw�,qwhuylhz��$$,� as previously described, an infant’s early attachments to caregivers are internalized forming cognitive-affective structures (bowlby, 1980) that evolve into similar models in adulthood and are active in one’s current emotional and relational involvements. the concept of adult attachment styles refers to individuals’ comfort and position in close relationships, attachment in psychotherapy 105 their tendency to favor autonomy or dependency, as well as their anxiety regarding rejection and inaccessibility in relationships (ainsworth et al., 1978; meyer et al., 2001). for an attachment-informed psychotherapist, the initial assessment focuses on the quality of the potential client’s relationships (cortina et al., 2003). a central part of the assessment will be the history of primary caregivers’ responsiveness or inattentiveness, especially noting whether the client experienced a loss of or abandonment by a caregiver, and the subsequent attachment style the client developed (cortina et al., 2003). attachment style can usually be adequately assessed without the complete implementation of a validated instrument; however, a tool like the adult attachment interview (aai) is very useful (cortina et al., 2003). the adult attachment interview (aai) is the most accepted interview method of assessing adult attachment measures; however, self-report questionnaires can also be used to measure attachment patterns (eagle, 2006). the aai, formulated by mary main and her colleagues, involves an hour-long interview in which an adult self-reports behaviors in intimate relationships and narrates experiences in childhood concerning early relationships with his or her parents (bernier et al., 2002). this process unveils the person’s “states of mind regarding attachment” (harris, 2004) and “autobiographical competence” (holmes, 1995). of primary importance, is the coherency of the narrative one relates about childhood experiences and relations. the clinician’s task is to listen to the pawlhqw·v�vwru\��wu\�wr�àqg�phdqlqj�zlwklq�lw��dqg�xqfryer the clues in the story that underlie the attachment pattern (holmes, 1995). with treatment, the therapist and client can work jointly in re-writing the client’s narrative (holmes, 1995). as the psychotherapeutic process unfolds, change and improvement can be dvvhvvhg�e\�wkh�fxowlydwlrq�ri �d�pruh�árzlqj��frpprehensible, and expressive story (holmes, 1995). it is important to note the aai’s focus on childhood omits insight from some relevant relationships, such as those with siblings, marital partners, and coworkers (cortina et al., 2003). the optimal means of assessment may be for the clinician to use the aai with other measures or questions (cortina et al., 2003). a measure like the attachment style interview (asi) may be a valuable supplement given that it concentrates on the aspects and coherence of one’s narrative, but also addresses the entire range of adult relationships (cortina et al., 2003). there are also some measures that use a multi-item continuous scale (smith et al., 2009), such as the experiences in close relationship scale (ecrs; brennan et al., 1998) and the adult attachment inventory (aai; simpson et al., 1992). these measures evaluate anxiety and avoidance, with lower scores on both dimensions indicating a more secure attachment pattern (smith et al., 2009). the three insecure attachment styles discussed above are the result of poor and/or inadequate early attachment relationships. individuals possessing these attachment styles often suffer problems in emotional control and serious psychological distress that contribute to their anxiety, depression, hostility, and maladaptive patterns in interpersonal relations (bachelor et al., 2010). anderson and perris (2000) performed two studies to assess the relationship between adult attachment styles and dysfunctional working models using the aai, the attachment styles questionnaire (asq), and the dysfunctional working models 6fdoh� �':0�6��� 7kh\� irxqg� vwdwlvwlfdoo\� vljqlàfdqw� correlations supporting their hypotheses that secure attachment is negatively associated with dysfunctional assumption scores and insecure attachment is positively associated with dysfunctional assumptions. consequently, individuals with insecure attachments have a greater need to piece together experiences that have caused the dysfunctional working models increasing distress and symptomology (sable, 2007). cortina and marrone (2003) present a chart matching attachment style and type of prior caregiver with the related issues involving the creation of a supportive therapeutic alliance and potential solutions. for example, a client who is fearful of rejecwlrq�lv�sdluhg�zlwk�d�suhylrxv�fduhjlylqj�àjxuh�wkdw�lv� consistently rejecting and/or unresponsive to needs (cortina et al., 2003). an issue in therapy may be the client’s avoidance of talking about his or her actual concerns and needs since there is a fear that doing so will lead to rejection (cortina et al., 2003). to address this issue, the therapist must focus on conveying the non-judgmental context of therapy and the therapeutic relationship (cortina et al., 2003). farrell, carleton 106 the table provided by cortina & marrone (2003) lqfrusrudwhv�wkh�dxjphqwhg�fodvvlàfdwlrq�ri �dwwdfkment styles used by bifulco and colleagues (2002) as a guide to help the development of the alliance. however, a plausible concern for using attachment measures in a clinical setting is: if the patient is clasvlàhg�dv�kdylqj�d�fhuwdlq�dwwdfkphqw�vw\oh��lv�wkhuh�d� greater likelihood therapists will misinterpret experiences with a patient and establish their views based rq� wkh� sdwlhqw·v� lqlwldo� dwwdfkphqw� fodvvlàfdwlrq"� daly and mallinckrodt (2009) interviewed experienced therapists about approaches they found effective for clients with particular attachment styles. therapists reported the importance of gradually increasing the therapeutic distance with anxiously attached clients (daly et al., 2009). conversely, the therapists suggested a gradual decrease in therapeutic distance for avoidant patients (daly et al., 2009). in addition to guiding the therapist’s approach for the patient, awareness of the patient’s attachment history prepares the therapist for the types of transference experiences that may occur, as well as improves the therapist’s understanding of his or her own possible countertransference reactions (shilkret, 2005). there are different manifestations of transference that patients can display, which may vary throughout treatment (goodman, 2010). interestingly, freud (1912, 1913) discussed the dynamic of transference involved in psychotherapy: the unconscious negative component, the unconscious positive component, and the conscious “unobjectionable” component �*rrgpdq�� ������� 7kh� àuvw� wzr� vhuyh� dv� rssrvltions to treatment, while the latter represents feelings of value towards treatment and facilitates success in treatment (goodman, 2010). moreover, he lghqwlàhg� wkh� sdwlhqw·v� dwwdfkphqw� wr� wkh� wkhudslvw� as a requirement for the occurrence of unobjectionable transference, which facilitates the development of the working alliance (goodman, 2010). the “working alliance” in attachment-focused therapy with adults attachment theory and research shed enormous light on both the client’s and therapist’s internal zrunlqj�prghov�lqáxhqflqj�wkh�surjuhvvlrq�ri �wkhuapeutic process, especially with regard to the creation of the working alliance (or client-therapist alliance) (hietanen et al., 2006; smith et al., 2009). greenson �������zdv�wkh�àuvw�wr�xvh�wkh�whup�́ zrunlqj�dooldqfhµ� (diener et al., 2011; horvath et al., 1991), which he ghàqhg� dv� d� ´udwlrqdo� uhodwlrqvkls� ehwzhhq� sdwlhqw� dqg�dqdo\vwµ��s��������&rqvlghulqj�wkh�khdy\�lqáxhqfh� of the attachment styles of both the therapist and of the patient on the formation of the alliance, bordin (1979) views the alliance as “dyadic and mutual with the therapist and client as active co-constructors, constantly negotiating and renegotiating the alliance in order for successful work to take place” (bordin, 1979; smith et al., 2009). when it comes to the actual “alliance”, bordin (1979) hypothesized the alliance to consist of three facets: the goal, the task, and the bond (diener et al., 2011; hietanen et al., 2006; smith et al, 2009). the goal and the task involve the cogniwlyh� hohphqwv� ri � wkh� dooldqfh�� vshflàfdoo\� wkh� djuhhment on the general objectives of treatment and the particular actions that will be employed to achieve the set goals (bordin, 1979; hietanen et al., 2006). the bond, the emotional and relational component, involves all the affective experiences that enables client to develop an attachment to the therapist, such as the client’s feelings of trust and empathy (bordin, 1979; hietanen et al., 2006). it is the attachment to the therapist that allows the client to participate in the tasks and achieve the goals (smith et al., 2009). the opportunity for therapeutic change occurs with the therapist and client attending to and repairing obstacles resulting from a disagreement about one or more of the three components (smith et al., 2009). since times of danger or distress both activate attachment systems and often bring clients to therapy, researchers have come to link the concept of the therapeutic alliance with attachment theory (farber et al., 1995; harris, 2004; sable, 2007; smith et al., 2009). research has found that a stronger alliance is associated with less distress in psychotherapy as treatment progresses (sauer, 2010; smith et al., 2009). in contrast, the failure to develop an alliance can bring about a premature termination of therapy (harris, 2004). horvath and greenberg (1986) developed the working alliance inventory (wai) to measure this working alliance, which includes the three subscales (task, attachment in psychotherapy 107 goal, and bond) (goodman, 2010; smith et al., 2009). the therapist as a secure base the therapeutic relationship is more than a bond; it is also an attachment (obegi, 2008; zilcha et al., 2011). the relationship incorporates characteristics of child-caregiver relationships, such as the reassuring presence of the therapist and the possibility for emotion regulation ( goodman, 2010; meyer et al, 2001). first, the child must come to see the caregiver as a uholdeoh�dwwdfkphqw�àjxuh�wkdw�kh�ru�vkh�fdq�wxuq�wr� if threatened or distressed, making them a safe haven (eagle, 2006). through experiences of an encouraging dqg�dydlodeoh�dwwdfkphqw�àjxuh��wkh�fklog�wkhq�fdq�xvh� the caregiver as a secure base that provides the comiruw�dqg�frqàghqfh�d�fklog�qhhgv�wr�eh�prwlydwhg�wr� explore the world (ainsworth et al., 1978; ,1980; eagle, 2006; farber et al., 1995; lamagna, in press; levy, 2005; lipton & fosha, 2011; mikulincer et al., 2007). similar to the caregiver-infant relationship, bowlby (1980) proposes the therapist serve as a secure base from which the patient can safely explore difàfxow�sv\fkrorjlfdo�pdwwhuv�uhodwlqj�wr�erwk�lqwhuqdo� and external factors (dozier et al., 2004; eagle et al., 2009; farber et al., 1995; goodman, 2010; holmes, 1995; meyer et al., 2001; schauenburg et al., 2010; =lofkd�hw�do����������$v�d�uhfhswlyh�àjxuh��wkh�wkhudslvw� accepts the client’s feelings, offers emotional availability, and provides regulated affect, which allows for the development of attachment (malinckrodt et al., 1995; mikulincer et al., 2007; sable, 2007). the positive attachment relationship with the therapist idflolwdwhv� wkh� folhqw·v� frqàghqfh� lq� klv� ru� khu� rzq� delolwlhv�dqg�lq�wkh�fdsdflw\�wr�kdyh�ixoàoolqj�uhodwlrqal experiences (sable, 2007). therapists’ empathetic presence combined with the mastery they project embeds a base that a patient feels comfortable using wr� yhqwxuh� lqwr� gliàfxow� whuulwrulhv� �+rophv�� ������ � %\� uháhfwlqj� rq� sdvw� olih� h[shulhqfhv� dqg� hduo\� attachment relationships with the help and support of therapists, patients can give meaning to past exshulhqfhv�dqg�h[soruh�wkh�lqáxhqfh�wkh\�kdg�dqg�ru� have on their distress and functioning (sable, 2007). the availability of the therapist during exploration facilitates the change needed for the client to explore dqg�pdnh�prglàfdwlrqv�wr�klv�ru�khu�fxuuhqw�frjqltions, feelings, and behaviors (eagle et al., 2009; mahoney, 1990, paraphrased from leger, 1998; sable, 2007). this transformation towards a stable, coherent self-representation is not possible in psychotherapy without the therapist’s fundamental role as a “secure base” (bowlby, 1980; eagle et al., 2009; farber et al., 1995). the empathy of the therapist, the security of the client-therapist relationship, and the safe intimate space are needed for the patient to obtain the freedom to think and feel without the fear that his or her unstable or fragile self will be threatened or attacked. in addition to the therapist’s function as a secure base within the therapeutic setting, the patient can utilize the representations of the therapist developed through attachment, even after the termination of therapy, during times of stress in order to gain that sense of comfort and competence that allowed for problem solving during treatment, as well as to explore new opportunities and relationships (farber et al., 1995). the evocation of the therapist’s internal working model (discussed above during emotional and/or interpersonal strain can even help the individual regulate affect and change the way he or she approaches the stressful situation (eagle et al., 2009; obegi, 2008). the new strategies for dealing with vwuhvv� dqg� uhodwlrqvklsv� uháhfw� d� srvlwlyh� wudqvirumation in the client’s internal working models and attachment security (eagle et al., 2009). the client’s lqfuhdvhg� fdsdflw\� iru� uháhfwlyh� ixqfwlrqlqj� shumits the construction of a more coherent narrative, zklfk�lv�ohvv�dpeljxrxv�dqg�frqálfwlqj��(djoh�hw�do��� 2009). lipton and fosha (2011) propose, “through meta-therapeutic processing, or metaprocessing for short, the secure attachment relationship between patient and therapist becomes the vehicle through which a patient’s right-brain experiencing of psychotherapy is integrated with her left-brain, conscious, verbal knowing that a therapeutic experience has just occurred” (p. 271). the resulting clarity in one’s narudwlyh�dqg�wkh�lpsuryhphqw�ri �uháhfwlyh�ixqfwlrqlqj� foster a sense of security and stability in the view of not only oneself, but also in the view of others. the alliance as a predictor of therapeutic outcome research has indicated that the quality of the farrell, carleton 108 early working alliance and the nature of the therapist as a secure base is crucial to the therapeutic outcome (diener et al., 2011; harris, 2004; horvath et al., 1991; meyer et al., 2001; mikulincer et al, 2007; sauer et al., 2010; schauenburg et al., 2010; smith et al., 2009). byrd et al. (2010) studied the impact of the working alliance on the patient’s attachment style during treatment, as well as the impact of the attachment style on the psychotherapeutic process. results showed that two attachment dimensions (comfort with closeness and comfort depending on others) were positively related to the alliance and treatment rxwfrph�� $gglwlrqdoo\�� wkh� dooldqfh� lqáxhqfhg� wkh� dimension comfort with closeness, which, in turn, promoted more successful therapeutic outcome. it has also been proposed that therapists’ perceptions of the therapeutic alliance depend on the attachment style of the client, while the client’s perception of the therapeutic alliance was not related to attachment style (dolan et al., 1993; horvath et al., 1986). therapists reported a stronger therapeutic alliance with secure patients and a weaker alliance with patients that had a more avoidant attachment (dolan et al., 1993). a meta-analytic review investigated past research exploring the relationship between client attachment and the therapeutic alliance, which consist of two categories of client attachment, clients’ globdo� dwwdfkphqw� sdwwhuqv� dqg� folhqwv·� vshflàf� dwwdfkment pattern to their therapist (smith et al., 2009). the theoretical literature indicates that with regard to patients’ global attachment, clients’ secure attachment yields a stronger therapeutic alliance (diener et al., 2011; mikulincer et al., 2007; smith et al, 2009). similarly, those who perceive themselves as securely attached to their therapist develop stronger therapeutic alliances (smith et al., 2009). on the other hand, clients with an avoidant-fearful attachment pattern experience a less positive therapeutic alliance (smith et al., 2009) comparing the two categories, evidence supports that the client’s attachment to therapist has a greater impact on the therapeutic alliance than the client’s global attachment (smith hw� do��� ������� 3hukdsv�phdvxulqj� folhqwv·� vshflàf� dwtachment may be more valuable than measuring clients’ global attachment when interested in predicting the quality of the therapeutic alliance (smith et al., 2009). dolan et al. (1993) also propose that perhaps more research should be done on whether therapists’ modify their interpersonal stance and intervention strategies based on the client’s attachment style and how the therapist perceives the therapeutic alliance. studies investigating the working alliance relationship have primarily focused on clients’ individual pretreatment characteristics, such as motivation and sociability (horvath et al., 1986; smith et al., 2009). clients’ internal working models determine their perceptions of the therapist and the client-therapist relationship (bowlby, 1980; dozier et al., 2004; eames et al., 2000; smith et al., 2009; zilcha et al., 2011). especially when working with insecurely attached patients, knowledge of patients’ attachment histories can provide the therapist with insight that can help them predict potential ruptures in the alliance; therefore, they can be proactive in their methods for intervening (diener et al, 2011; shorey et al., 2006). 5hfrjql]lqj� wkh� vljqlàfdqfh� ri � dwwdfkphqw� h[shulences in the therapeutic relationship, mallinckrodt, gantt, and coble (1995) created the client attachment to therapist scale (cats) (sauer et al., 2010). the measure contains three subscales similar to atwdfkphqw�vw\oh�fodvvlàfdwlrqv��6hfxuh��$yrlgdqw�)hduful, and preoccupied-merger (sauer et al., 2010). a study investigating the relationship between attachment and the early therapeutic alliance reported that preoccupied attachment in patients predicted more frequency in ruptures, whereas dismissing attachment was associated with fewer ruptures (eames et al., 2000). attachment theory can facilitate the building and maintenance of the therapeutic alliance that endows a client with a perception of safety and a motivation for deep exploration, and, thus, the possibility for a positive therapeutic outcome and a reduction in symptomology (mallinckrodt et al., 2005). the patient’s attachment style the secure patient during the aai, adults with secure attachments convey coherent narratives that integrate past experiences in a relatively balanced manner (mallinckrodt et al., 2005). these individuals most likely do not have picture-perfect childhoods, yet they can understand attachment in psychotherapy 109 dqg� uháhfw� rq� sdvw� hduo\� dwwdfkphqw� uhodwlrqvklsv�� whether they were positive or negative (sable, 2007). lipton and fosha (2011) suggest, “several decades of research on the moment-to-moment (and even millisecond-to-millisecond) interactions between mothers and their babies tells us that reiterative, ongoing cycles of attunement, disruption and repair in the context of emotional experiencing are the essential building blocks of secure attachment”(p. 258; beebe et al., 2002). this type of security in attachment lv�qhfhvvdu\�iru�wkh�vhoi�uháhfwlyh�phqwdol]dwlrq�wkdw� supports introspection and metacognition (mallinckrodt et al., 2005). with the ability to examine current and past experiences in a constructive fashion, an adult can develop a more balanced approach and appraisal of relationships, as well as better strategies for resolving thoughts, memories, and feelings that are related to distress (sable, 2007). thus, attachment vhfxulw\� vwurqjo\� lqáxhqfhv� ixqfwlrqlqj� lq� lqwhushusonal relations, the capacity for affect regulation, and psychopathology in adulthood (atkinson et al., 2004 obegi, 2008). a person assessed as having a secure attachment will be more willing to self-disclose information about himor herself in psychotherapy (atkinson et al., 2004; mikulincer et al., 2007). therefore, the formation of an emotional bond between therapist and patient would most likely be an easier and quicker process than with those patients lacking a secure attachment (bordin, 1979; smith et al., 2009). the preoccupied patient among those assessed to have an attachment vw\oh�wkdw�lv�qrw�ghàqhg�e\�d�vhqvh�ri �vhfxulw\��wkhuh�lv� greater likelihood for psychopathology, dysfunction, and distress. for preoccupied individuals, intense anxiety, hyperactivation, and defense mechanisms are maintained in order to combat feelings of insecurity and psychological distress that has resulted from insecurity in early attachment experiences (bachelor et al., 2010; smith et al., 2009). most likely, as children their caregivers were unpredictable leading them to develop neuroceptions of potential danger, as well as create contradictory internal representations of the caregiver (badenoch, 2008). the disintegration characterizing their childhood experiences results in disruptions in the brain’s neural networks, bringing about emotional dysregulation and an overwhelming energy that blinds the individual from forming reasonable and objective perceptions (badenoch, 2008). badenoch (2008) terms the preoccupied individual’s internal world an “emotional jungle” (p. 70). with regards to relating with others, the mental models guiding them lead them to expect they will have jagged and unreliable relationships (badenoch, 2008). they exaggerate their personal distress and have an overwhelming need for the support and closeness of others (bernier et al., 2002; dozier et al., 1995; main et al., 1998). their state of mind typically consists of enmeshment in past and current relationships, as well as confused feelings, possibly anger or fear, toward relationships (atkinson et al., 2004; badenoch, 2008; bernier et al., 2002). an aai narrative would consist of continuous interchanges of past and present experiences that are tangled together in a confusing disintegrated web, representing a poor sense of self (badenoch, 2008). their narratives may be extremely lengthy, with the clients becoming so caught up in their memories that it seems as if they are reliving past experiences (atkinson et al., 2004). at the onset of therapy, preoccupied clients are more likely to have high anxiety and distress, and they often ruminate about what the therapist and others may have said (atkinson et al., 2004; mikulincer et al., 2007; shilkret, 2005; smith et al., 2009). they are often concerned with the availability of the therapist and want to be emotionally and physically close (mikulincer et al., 2007; smith et al., 2009). the chaotic swapping, lack of coherency, and anxiety the patient brings to therapy can even make the clinician a bit anxious (badenoch, 2008). in this case, it is important that the therapist be mindful and remain calm, as simply the presence of the therapist’s calmness can promote the patterning of emotion regulation (badenoch, 2008). the dismissing patient dismissing individuals, by contrast, tend to plqlpl]h� wkh� vljqlàfdqfh� ri � hduo\� dwwdfkphqwv� dqg� believe relationships are relatively unimportant (atkinson et al., 2004; badenoch, 2008; bernier et al., 2002; mikulincer et al., 2007; muller, 2009; zilcha et do����������7khvh�sdwlhqwv�kdyh�gliàfxow\�hqjdjlqj�lq� discussion regarding the inadequacy of their early atfarrell, carleton 110 tachment relationships, and, thus deny their feelings about these issues (atkinson et al., 2004; mikulincer et al., 2007; muller, 2009; zilcha et al., 2011). even traumatic events will be minimized into an occurrence that is more socially accepted (muller, 2009). applying the role of imagination proposed by bonovitz (2012), these individuals may overly use fantasy to avoid facing reality, resulting in rigidity in life and trouble in interpersonal relations (bonovitz, 2012). due to their insistence on self-reliance and vhsdudwhqhvv��wkh\�kdyh�gliàfxow\�iruplqj�erqgv�dqg� they reject or deny attachment needs (bernier et al., 2002; dozier, 2004; eagle, 2006; main et al., 1998; mikulincer et al., 2007; muller, 2009, 2007; shorey et al., 2006; smith et al., 2009; zilcha et al., 2011). the discourse of dismissing patients’ narratives pd\�eh�áxhqw�� \hw� vhhpv� wr�eh�yhu\� vxshuàfldo� dqg� lack details (badenoch, 2008; bernier et al., 2002; dozier et al., 2004). there is either dissociation or absence of many aspects of early attachment experiences and emotional numbness as well (bernier et al., 2002; muller, 2009). badenoch (2008) describes the mental model of a dismissing patient as an “emotional desert” (p. 68). the patient may describe their parents as “nice” or the relationship as “good” (badenoch, 2008). when listening to these narratives, clinicians may struggle to grasp the internal model and community directing the patient’s mind (badenoch, 2008). patients may convey cues that the therapist should not probe discussion on a certain topic or intrude in areas of their life that they insist are not troubling (dozier et al., 2004). when treating a dismissing patient, there may be a challenge in creating an interpersonal connection, especially since dismissing individuals often lack the ability to read others’ signals (badenoch, 2008). a particular obstacle to a therapist’s relationship with a dismissing client is “mutual avoidance” (muller, 2009). the patient’s ambiguous feelings toward a trauma or attachment relationship lead the therapist to question how to react; therefore, the therapist surrenders to the patient’s pull to avoid the topic (bernier et al., 2002; muller, 2009). muller (2009) suggests, “the challenge in treatment, then, is lq�khoslqj�vxfk�sdwlhqwv�àqg�d�zd\�wr�whoo�d�vwru\�wrr� painful to speak, but too compelling to ignore” (pp.79). the unresolved patient similarly, those with unresolved attachment styles often lack recollections of important experiences relating to attachment in childhood (dozier et al., 2004). they are so overwhelmed by the loss or trauma they experienced that they may have a lapse in reasoning (e.g., refusing to believe a person is dead), discourse, and behavior (dozier et al., 2004). these individuals are even more disorganized in their cognitions and behaviors due to the inability to resolve early traumas in attachment (bernier et al., 2002). their inner worlds are fragmented, consisting of both chaos and rigidity (badenoch, 2008). the disorganization that characterizes the unresolved pattern of attachment is demonstrated when these patients discuss early attachment experiences and current relationships (shilkret, 2005). not surprisingly, individuals with unresolved attachments are more likely than others to be found in a psychiatric setting (dozier et al., 2004). while relaying their narratives, unresolved-attached patients’ speech may appear disorganized in, for example, the use of incorrect tenses (e.g., using the present tense when speaking about the past), long sdxvhv��dqg�lqdelolw\�wr�àqg�rqh·v�zrugv��%dghqrfk�� 2008). during the course of therapy, they may present as one of the other attachment styles at different times, as they sporadically vary in the symptoms they are suffering from and their affective states (shilkret, 2005). lamagna (in press) describes this common manifestation as “come close/stay away” messages (p.8). the patient’s lack of coherency in discourse and behavior can cause a therapist to feel unstable and confused (badenoch, 2008). therapy with patients characterized by the unresolved attachment vw\oh�lv�àoohg�zlwk�frqixvlrq��wkhuhiruh��wkh�wkhudslvw� must strive to maintain calmness and clarity (shilkret, 2005). additionally, it is important to mention that these patients often come to therapy feeling ashamed about hurting those they loved with their unmanageable behaviors (badenoch, 2008). for this reason, the beginning of therapy must consist of the ther1 some theorists hold that those with unresolved attachments always can be diagnosed with an additional attachment pattern simultaneously (main & solomon, 1986; badenoch, 2008). for example, a patient may have a secure attachment to his father, while having an unresolved attachment with his mother (badenoch, 2008). attachment in psychotherapy 111 apist making a purposeful effort to provide patients with a sense of empathy, as well as emphasize the patients’ ability to change the dissociated mental models that led to regretful actions (badenoch, 2008). the therapist’s attachment style of tantamount importance to the therapeutic endeavor is the therapist’s attachment style (meyer et al., 2001). just like any other individual, the therapist possesses his or her own internal working models and attachment patterns (bennett, 2008). in order for treatphqw� wr�eh�hiàfdflrxv�� wkh� wkhudslvw�pxvw�eh�dzduh� of his or her attachment style due to its large impact on one’s interpersonal competencies and disposition, and, thus, the client’s experience of the therapist and vice versa (atkinson et al., 2004; bennett, 2008; wallin, 2007). the internal working models of therapists affect their patterns of self-protection, their ability to eh� vhoi�uháhfwlyh�� wkhlu� fdsdflw\� iru� fduhjlylqj� �hppathy), their proclivity for empathic understanding and their range of affect regulation (bennett, 2008). cortina and marrone (2003) suggest four importdqw� idfwruv� lqáxhqflqj� wkh�txdolw\�ri � wkh� wkhudslvw·v� empathetic understanding, which include: his/her own early attachment history, his/her own experiences as an analysand (client), his/her own experiences in clinical supervision, and his/her theoretical framework or biases. as a clinician, one needs to mentalize during sessions with patients in order to separate his or her feelings and experiences from those of the patient, while simultaneously recognizing the mental states of the patient (bateman et al., 2003). when inwhudfwlrqv�suryrnh�xqfrqvflrxv�frqálfwv�dqg�zlvkhv� in the therapist, it is possible for defense mechanisms to become mobilized and uncomfortable countertransference to occur (bateman et al., 2003). the phenomenon of countertransference involves the changes in the therapist’s state of mind and automatic verbal/nonverbal behaviors that the patient picks up, causing either the exacerbation or alleviation of anxiety and other symptoms (pally, 2001). countertransference may occur due to the therapist’s need to be guarded from the patient’s transference, resulting in a distancing in the relationship; or there can be an activation of automatic internal responses in the therapist, causing him or her to involuntarily react without thinking (pally, 2001). all of these occurrences can hinder the therapist’s capacity to be empathetic, the quality of his/her technical skills, and the capacity for affect attunement (mallinckrodt, 2010). these hohphqwv�kdyh�dq� lqáxhqfh�rq�wkh�wuhdwphqw�frqgltions and outcome, as well as the therapeutic relationship (meyer et al., 2001; pally, 2001; sable, 2007). securelyattached therapists therapists who are securely attached typically exhibit behaviors consistent with this attachment style, such as warmth and trustworthiness, which duh� ehqhàfldo� iru� ghyhorslqj� uhodwlrqvklsv� �2ehjl�� 2008). these secure attachment representations proylgh�wkh�wkhudslvw�zlwk�juhdwhu�áh[lelolw\��vwdelolw\��dqg� dxwrqrp\�zkhq� lq�gliàfxow� lqwhushuvrqdo� vlwxdwlrqv�� vxfk� dv� dq� xqfrpiruwdeoh� àjkw� zlwk� d� sdwlhqw� dqg� the inevitable ruptures in the therapeutic relationship (lopez & brennan, 2000; meyer, 2001). instead of acting on one’s own attachment related fears and needs, the therapist can adapt his or her behaviors to suit the needs of the patient involved in the intershuvrqdo�gliàfxow\�� diiruglqj�ehwwhu� fduh� iru� wkh�sdtient (cortina et al., 2003; schauenburg et al., 2010). the study by schauenburg et al (2010) focused on wkh� lqáxhqfh� ri � wkhudslvwv·� dwwdfkphqw� uhsuhvhqwdwlrqv� rq� wkh� dooldqfh� dqg� frqàuphg� wkh� ehqhàfldo� effect of therapists’ attachment security on the working alliance with interpersonally distressed patients. insecurelyattached therapists conversely, therapists with an insecure attachment style, such as dismissing or preoccupied, may kdyh�gliàfxow\�zkhq�lw�frphv�wr�zrunlqj�wkurxjk�dqg� dealing with ruptures given the anxiety and fear of rejection that constitute these attachment styles (meyer et al., 2001). their insecure attachment needs may also lead to substandard intervention strategies and dq�lqdelolw\�wr�eh�vhoi�uháhfwlyh��%hqqhww���������'xh� wr�wkh�odfn�ri �uháhfwlrq�lq� lqvhfxuho\�dwwdfkhg�wkhuapists, they may struggle with the regulation of their own affect; therefore, they lack the ability to facilitate affect regulation in the patient, a critical healing element in the therapeutic process (bennett, 2008). given that therapist attachment style predicts aspects farrell, carleton 112 of countertransference, therapists with dismissive atwdfkphqw�pd\�eh�pruh�glvwdqw�zlwk�gliàfxow�sdwlhqwv� and situations, as well as have more antagonistic countertransference reactions to patients (bennett, 2008). those with preoccupied attachment style might fear they are inadequate and struggle to separate their own anxieties and emotions from those of the patient �%dwhpdq�hw�do���������%hqqhww���������7khvh�àqglqjv� suggest that the therapist’s attachment style interacts with the client’s attachment style to determine transference and countertransferences, the interpersonal experience, and, most importantly, the building and strength of therapeutic relationship (bennett, 2008). interaction of therapist and client attachment styles taking into account the importance of the attachment style of both clinicians and patients, it is not surprising that the interaction between the two styles weighs heavily on the therapeutic process. some research has indicated the advantageous effect of similarities between the therapist and client regarding attitudes, personal beliefs and values, expectations toward counseling, and self-concept (bernier et al., 2002). this would lead one to think that similarity in attachment styles would be optimal for psychotherapy (bernier et al., 2002). however, interpersonal researchers and theorists suggest the presence of both complementary and non-complementary exchanges is superior to the employment of simply complementary or non-complementary stance (bernier et al., 2002). although interpersonal theorists believe in the need for complementary exchanges, they are in agreement with attachment theorists and studies proposing the importance of dissimilarities in the interpersonal facets of client and therapist, and the notion that noncomplementary attachment styles are optimal for treatment (bernier et al., 2002). if the therapist reinforces the client’s rigid expectations and/or replicates the aspects of the client’s poor early attachment experiences in therapy, it can possible re-traumatize the patient (cortina et al., 2003). � %rzoe\� ������� vxjjhvwv� wkdw� wkh� wkhudslvw� áh[ibly adopt a contrasting stance that will challenge the client’s beliefs and rigid expectations about relationships (bernier et al., 2002). dismissing patients are prone to using defensive deactivation (active inhibition of attachment-related material). therapists need to challenge the client’s defensive strategy because this coping mechanism will only save the patient from distress for a short time and will eventually fail (muller, 2009). according to cortina & marrone �������� glvfrqàuplqj� wkh� lqwhuqdo� zrunlqj� prghov� of dismissing (avoidant) patients’ is easier than doing the same for preoccupied patients. whereas avoiddqw� lqglylgxdov·� sulpdu\� dwwdfkphqw� àjxuhv� zhuh� unresponsive, preoccupied individuals experienced inconsistency in their primary attachments (cortina et al., 2003; smith et al., 2009). as discussed before, the capacity of the therapist to carry out this adaptation depends on his or her attachment style, with securely-attached therapists being the most adaptable (bernier et al., 2002). the therapist’s resistance to naturally respond to the patient’s attachment tendencies in a conforming manner can facilitate emotional change and growth within the patient (a corrective experience) (bernier et al., 2002; bowlby, 1980). for example, a dismissive client may avoid speflàf� wrslfv� frqwdlqlqj� ghhs� hprwlrqdo� frqwhqw�� ,qstead of courteously following the patient’s attempt to focus on nonthreatening issues, the therapist needs to carefully challenge the client’s strategies and promote the gradual exploration of the more intimate lvvxhv�wkh�folhqw�wulhv�wr�vkurxg�zlwk�vxshuàfldo�frqversation (bernier et al., 2002; dozier et al., 1998). on the other hand, excessively emotional or preoccupied patients may require interventions encouraging the control of emotions and autonomy (bernier et al., 2002; meyer et al., 2001). hence, corrective experiences are facilitated by matching therapist with patient based on dissimilar deactivating (avoidance) versus hyperactivating (clinging) dimensions of attachment (bernier et al., 2002; tyrell et al., 1999). one study reported by tyrell et al (1999) found that preoccupied therapists formed the strongest alliance with dismissing patients and vice versa (bernier et al., 2002). undoubtedly, the interaction of attachment styles in psychotherapy is impactful on the transformation of patient’s maladaptive thoughts and behaviors and the formation of the therapeutic alliance. in addition to the impact of the therapist’s attachment style, the style of interpretation a therapist attachment in psychotherapy 113 uses also has implications in psychotherapy (cortina et al., 2003). even in the context of a strong therapeutic relationship, certain types of interpretations fdq�kdyh�d�qhjdwlyh�lqáxhqfh��vxfk�dv�ghfrqwh[wxdoization and double binding (cortina et al., 2003). decontextualization refers to placing too much emphasis on the patients’ unconscious feelings and internal mechanisms (cortina et al., 2003). consequently, the therapist undervalues the patients’ subjective feelings and the effects of the external world (cortina et al., 2003). the other counterproductive interpretation, double binding, for example occurs when the therapist unintentionally instigates a feeling in the patient (e.g., makes the patient feel guilty) and then interprets that the patient possesses a guilt-ridden internal world (cortina et al., 2003). using attachment theory as a guide, the issues of decontextualization and double binding are less likely to occur in the psychotherapeutic process given the theory’s strong emphasis on the external world’s role in development (cortina et al., 2003). by taking into account the internal and external worlds of patients, the patient is less likely to feel he or she is being blamed, which would impair progress in psychotherapy. conclusion and summary attachment theory describes the instinctive style of individuals seeking proximity or protection when feeling threatened. further, it suggests ways in which attachment behavior is affected by environmental factors (bowlby, 1980; sable, 2007). research in attachment theory following john bowlby has given clinicians a compelling reason to explore the actual events and relationships in a patient’s early development, as well as the patient’s distinct interpretations and representations of experiences (eagle et al., 2009). early adverse experiences with attachment internalized by the receptive infant can impede the development of psychological structures that favor resilience; therefore, the infant’s vulnerability to the emergence of psychopathology is heightened (sable, 2007). it is suggested that, although an individual’s attachment style in infancy may be different from that of adulthood, a child’s internal working model strongo\� lqáxhqfhv� vxevhtxhqw� ehkdylru�� diihfwv� wkh� zd\� others treat them, and, thus, affects their likelihood to suffer from psychopathology (carlson, 1998 paraphrased from snyder & shorey, 2006; harris, 2004). undoubtedly, it is the internalization of these negative early experiences that generate negative internal working models (harris, 2004; levy, 2000; wallin, 2007). with their strong impact on how one carries out his or her life, internal working models may give the impression of being irreversible and resolute �:doolq����������$owkrxjk�wkh\�kdyh�d�vwurqj�lqáxhqfh� on personality and interpersonal interactions, internal working models and one’s attachment state of mind duh�rshq�wr�prglàfdwlrqv�e\�phdqv�ri �qhz�h[shulences and relationships, with psychotherapy being a useful modality for positive transformation (bernier et al., 2002; wallin, 2007). individuals with maladaptive attachment styles may have impairments in critical psychological processes; such as intersubjective relatedness, affect regulation, and mentalization (bateman et al., 2003). such dysfunctions can expose an individual to psychological, physical, and/or social distress. key goals of psychotherapeutic treatment using attachment theory involve aiding the patient in: identifying unresolved emotions and appropriately expressing affect, developing stable internal representations of self and others, constructing a secure and coherent sense of self, and acquiring interpersonal characteristics that promote the potential for positive relationships (bateman et al., 2003; holmes, 1995). internal working models can be revised as g\vixqfwlrqdo�uhsuhvhqwdwlrqv�duh�fkdoohqjhg��uháhfwed on, and transformed (mccluskey, 1999; zilcha et al., 2011). bowlby (1980) asserted that clients must comprehend how their working models cause their unhealthy thoughts and behaviors in order for these models to be revised (zilcha et al., 2011). the reorgaql]dwlrq�ri �wkhvh�lqáh[leoh�lqwhuqdo�zrunlqj�prghov� and the therapeutic relationship allows for psychological processes, like affect-regulation, to be established, as well as new realistic views of oneself and others to be formed (eagle et al., 2009; mccluskey et al., 1999). attachment-informed psychotherapy has its advantages since it not only focuses on the history of early attachment experiences that led to the maladaptive attachment behaviors of the patient in treatment, but also gives the therapist guidance in what approach farrell, carleton 114 to employ for a particular patient, illuminating an optimal trajectory of treatment (dolan et al., 1993; harris, 2004). with knowledge of a patient’s attachment style, the therapist can be sensitive and adaptive to the patient’s needs, increasing and accelerating the chance iru�h[sorudwlrq�dqg�ehqhàfldo�fkdqjh�wr�rffxu��(djoh� et al., 2009). the therapist’s consistent understanding from the start can enhance the experience of the therapist as a secure base and strengthen the bond between the therapist and client, allowing the client to increase his or her exploration, and resolve the issues involved (eagle et al., 2009). in addition to the therapist’s support in confronting negative feelings and forming new models, the patient’s experience of a trustworthy and reliable other (the therapist) is a healing element in itself (eagle et al., 2009; obegi, 2008). there is accumulating agreement that the quality of the therapeutic alliance is one of the strongest predictors of psychotherapeutic outcome (harris, 2004; horvath et al., 1991; cortina & marrone, 2003). some have argued that attachment theory isn’t applicable to the practice of psychotherapy (farber et al., 1995). hamilton (1987) believed attachment is a “background concept,” and “is all too palpable; we are surrounded by it; we can observe it; and yet, from a clinical point of view, we cannot use it directly.” (p. 69). the relationship between attachment theory and psychotherapy may not now boast enough empirical research for an explicit “attachment therapy” for adults, yet there continues to be growing evidence and innovative interventions supporting the beneàwv� ri � dsso\lqj� dwwdfkphqw� wkhru\� dqg� uhvhdufk� wr� the psychotherapeutic process (eagle et al., 2009). as more studies are undertaken, the importance of attachment theory and its applicability to practice becomes better understood. evidence suggests that attachment theory can enhance both the therapist’s and the adult patient’s awareness of their roles in the psychotherapeutic process and therapeutic alliance. additionally, attachment style it is a strong predictor of outcome for psychotherapy. taken together, the strengths of attachment theory suggest promising new directions for psychotherapy with adults. references ainsworth, m.d. 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(2011). pet in the therapy room: an attachment perspective on animal-assisted therapy. attachment & human development, 13(6), 541-561. 56 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university self-other agreement in the assessment of personality pathology: do we always know ourselves best? kimberly tom, b.s. teachers college, columbia university leonard j. simms, ph.d. the state university of new york, university at buffalo assessment of personality pathology can vary greatly depending on who is doing the assessment. agreement between selfand informant-reports can be influenced by deviating patterns of thoughts and behaviors which are characteristic of those with personality pathology. in the current study we investigated whether presence of personality pathology was associated with the level of agreement between selfand informant-reports using a sample of 83 current or recent psychiatric patients, each accompanied by a close other. target and informant participants reported presence of personality pathology using a measure for personality disorder criteria and a measure for maladaptive personality traits. personality disorder criteria scores and pid-5 trait scores were correlated with level of agreement on different measures to assess whether personality pathology was associated with self-other agreement. five-factor model traits were also included as criteria in the analysis. results were partially consistent with previous findings. higher informant-reported personality pathology was associated with lower agreement for a measure of five-factor model traits. however, higher target-reported personality pathology was actually associated with increased agreement for five-factor model traits. higher pathology as rated by the self and informant were both associated with increased agreement on pd criteria and maladaptive traits. higher target-rated personality pathology was also associated with higher agreement on acquaintanceship. in conclusion, insight about one’s own personality pathology is related to self-other agreement, and the strength and direction of this relationship can differ depending on the type of information that is being judged. is personality pathology associated with self-other agreement? personality disorders (pds) are characterized by enduring and inflexible patterns of thinking and behavior involving interpersonal functioning, cognition, affectivity, and impulse control, that can lead to distress or impairment (american psychiatric association, 2013). such dysfunction may lead others to view someone with a personality disorder differently than how this person would view themselves. these differences may call into question the utility of personality judgments made by the self or an informant. thus, practitioners who do not get multiple viewpoints may be missing important information about their clients; particularly those with limited insight. numerous studies have investigated personality assessment from the self and other perspectives (e.g., carlson, vazire, & oltmanns, 2013; human, biesanz, finseth, pierce, & le 2014; vazire, 2010; vazire & mehl, 2008) and have found many variables that influence accuracy (e.g., the visibility of different traits, how well the informant knows the person they are judging, the self ’s consistency of behavior). given the marked interpersonal problems and inconsistency of thoughts and behaviors typically associated with pds, a plausible yet relatively untested hypothesis is that when judging an individual with more personality pathology, agreement between the self and an informant on a particular override (hidden running head text): tom, simms self-other agreement in personality pathology assessment this study was supported by a research grant to l. j. simms from the national institute of mental health (no. r01mh080086). correspondence should be addressed to kimberly tom at kt2672@tc.columbia.edu. 57 self-other agreement in personality pathology assessment measure would be lower than those with less personality pathology. however, few studies have observed whether personality pathology is associated with differences in self-other agreement. if personality pathology does have a relationship to self-other agreement, then learning more about those relationships would be useful in a clinical setting. for example, larger discrepancies in between selfand informant-reports could be a diagnostic criterion for personality pathology. the current study will investigate whether the presence of personality pathology is associated with self-other agreement on measures of personality and personality pathology. selfand informant-reports differences between selfand informantreports. to understand how personality pathology may influence self-other agreement, it is important to first understand how selfand informant-reports inherently differ. self-report has been considered the standard for personality assessment measures. however, self-reports may be inaccurate for a variety of reasons, including distorted self-views (john & robins, 1994), self-serving bias (greenwald, 1980; holzbach, 1978; john & robins, 1993; paulhus & john, 1998; robins & beer, 2001), and the fish-and-water effect (i.e. the idea that overt patterns of behavior are highly observable to others, but not the self; kolar, funder, & colvin, 1996). self-reports demonstrate more accuracy than informant reports when reporting on inner emotional experience (spain, eaton, & funder 2000). early research has suggested informant-reports are more accurate than self-reports in predicting behavior (hofstee, 1994), and the better an informant knows the target, the more accurate their judgments become (connolly, kavanagh, & viswesvaran, 2007; connelly & ones 2010; kurtz & sherker, 2003; south, oltmanns, johnson, & turkheimer, 2011; tackett, 2011). newer research has reached consensus that selfand informant-reports offer similar accuracy for predicting behavior (ready, watson, & clark, 2002; vazire & mehl, 2008). although selfand informant-reports show similar levels of validity, each offers a unique perspective on a given target’s personality (carlson et al., 2013; clifton, turkheimer, & oltmanns, 2004; funder, 1995; oltmanns & turkheimer, 2009; vazire, 2010). self-other knowledge asymmetry model. according to the self-other knowledge asymmetry model (vazire, 2010), discrepancies between self and informants are mediated by the type of information available to the judge. for example, informants do not have access to inner emotional experiences of the self, and sometimes the self is not consciously aware of behaviors that are visible to informants. for an individual with personality pathology, factors such as identity disturbance or affectivity issues could mediate assessment of personality. convergence between selfreports and informant-reports might then be a function of these diverging assessments. realistic accuracy model. unlike the self-other knowledge asymmetry model, the realistic accuracy model (funder, 1995) considers more than just the type of information available to a judge. differences between selfand informant-reports were described in the “accuracy paradigm,” which denoted a shift of focus from error of personality judgments to accuracy of personality judgments (funder, 1995; funder & dobroth, 1987). the information available to each judge does not necessarily result in only error, in that each judge is interpreting the given information in a unique way. each judge is trying to make an accurate judgment, even though what is truly accurate cannot be definitively known.one could reasonably conclude that if a target and informant are agreeing more on some criterion, that those two judgments are likely both more accurate than if they diverged. such divergence may be more prevalent in those with personality pathology, and creates an interesting question in relation to the study of accuracy. accuracy of selfand informant-reports. studies concerned with the accuracy of selfand informant-reports have tried to determine whose judgments were more accurate for different criteria. the self tends to be more accurate in rating traits low in observability, and informants are more accurate on evaluative (e.g., intelligence) traits when predicting behavior (connelly & ones, 2010; vazire, 2010). carlson et al. (2013) found similar results when evaluating self and informant accuracy for pds. they concluded that the self was more accurate for less visible pds (e.g. avoidant, dependent, and obsessive-compulsive pd), informants were more accurate for more visible/antagonistic pds (e.g. antisocial and histrionic pd), and neither was more accurate for thought disorder and less visible/antagonistic pds (e.g. paranoid and borderline pd). carlson 58 tom, simms et al. used a non-clinical sample, so these findings may not generalize to those with pds. additionally, accuracy analyses were calculated using a composite of self, informant, and clinician judgments. when evaluating the accuracy of people’s judgments by drawing statistical connections between other judgments, conceptualization of accuracy in this context should be called into question. people with personality pathology tend to report personality traits of others in a different way than those without personality pathology, and are also described by others differently, compared to those with less personality pathology (tandler, mosch, wolf, & borkenau, 2015). these findings reinforce the idea that people with pds see the world differently (human & biesanz, 2011), because judgments are based on some internal awareness of normativity (biesanz, 2010), which can result in lower accuracy of assessment. ready, clark, watson, and westerhouse (2000) found that individuals whose own personalities were more associated with their own ratings of others had lower self-other agreement. this implies people sometimes use the self as a guide for judging others. if the target of judgment has a personality disorder, they may be judged more inaccurately because an informant may be filling in gaps in knowledge with assumptions based on themselves. judging undesirable traits. a number of studies implicate lower self-other agreement for undesirable traits. clifton et al. (2004) investigated selfand informant-reports on personality pathology traits and found low to moderate agreement. these findings are in line with research suggesting better agreement with more pro-social traits such as extraversion, agreeableness, conscientiousness, and being generally well-adjusted (colvin, 1993; connolly et al., 2007). however, south et al. (2011) did find self-spouse agreement on pathological personality traits to be better than what has been found with regular self-other agreement samples. the authors conclude that people tend towards positive presentation of the self with people they do not know very well, and so an informant must know someone far better in order to accurately judge socially undesirable traits as opposed normal range personality traits. individuals with personality pathology are less well-adjusted given the marked interpersonal problems and identity disturbance characteristics associated with personality pathology. therefore, the self and informants may vary more when reporting personality assessments. self-reports and informant-reports have unique variance (connolly et al., 2007), but well adjusted-individuals who are easier to judge show less variance (furr, dougherty, marsh, & mathias, 2007), perhaps because their actions are more consistent with their personality (human et al., 2014). leising, rehbein, and sporberg (2006) found that individuals actually downplay their most extreme behaviors, which may be particularly relevant with pds, which are seen as extreme presentations of normal traits (lynam & widiger, 2001; miller, lynam, widiger, & leukefeld, 2001). is personality pathology associated with self-other agreement? the literature has suggested that personality pathology moderates self-other agreement, but such studies are limited. furr et al. (2007) investigated the role of personality pathology in self-other agreement by looking at the difference between two groups: adolescents with conduct disorder and a normal control group. the study concluded that personality pathology moderated self-other agreement. the control group had higher overall self-other agreement on five-factor model personality traits than the conduct disorder group. lower agreement and unique variability in the conduct disorder group’s selfand informant-ratings suggests personality pathology leads to distinct differences in self-views and informant-views. however, furr et al. also found that presence of conduct disorder had higher agreement for traits more relevant to conduct disorder (e.g. extraversion and neuroticism). generalizing these results to pds, overall lower agreement in those with pds could indicate selfand informant-assessments of people with personality pathology is less valid, or flawed, simply because certain traits become harder to assess. one possible explanation would be that even if highly visible traits produce some agreement, less overt traits are obscured by inconsistent thoughts and behaviors of the target. in a study using a clinical sample with multiple informants, mosterman and hendriks (2011) concluded that higher self-other disagreement on the five-factor model inventory was correlated with higher self-rated shyness, introversion, hostility, and depression. they also claimed individuals meeting more dsm-iv axis ii (pd) criteria exhibited more self-other disagreement. this last 59 self-other agreement in personality pathology assessment finding was somewhat unreliable because their conclusion was drawn from a simple paired-sample t-test for participants with some personality problems and those without. only six of those 52 participants with personality problems met criteria for a personality disorder. in a round-robin style design, tandler et al. (2015) assessed interpersonal perception in groups of four acquaintances. assessment of interpersonal perception extends beyond the scope of the current context, but aspects pertaining to self-other agreement are closely related to the current study. individuals rated themselves and their group members on five-factor model traits. each participant also completed a self-report on personality pathology. tandler et al. explored multiple types of self-other agreement, but the type synonymous with the current study was expression-based distinctive self-other agreement. this analysis involved predicting agreement coefficients from pd scores. they concluded that personality pathology moderated agreement, where those endorsing more pd symptoms had lower self-other agreement for a five-factor model based assessment. the current study will replicate and extend these findings by correlating self-other agreement with both selfand informant-reported pd scores for fivefactor model traits, maladaptive traits, pd criteria, and personal acquaintanceship. additionally, participants of the study by tandler et al. were university students, and results may not generalize to psychiatric populations. self-other agreement on personality traits does not differ in magnitude or variability when comparing clinical to nonclinical samples (ready & clark, 2002), suggesting that other types of pathology do not moderate self-other agreement, at least to the degree that personality pathology might. however, ready and clark also found no difference in self-other ratings between clinical and nonclinical samples on interpersonal problems, which contradicts research presenting general lower self-other agreement on pd measures (klonsky, oltmanns, & turkheimer, 2002). summary and current study information that is uniquely available to the self or informants should influence the respective reports in distinctive ways (carlson et al., 2013; kenrick & stringfield, 1980; spain et al., 2000; vazire, 2010). the current study aims to find whether agreement on particular traits is associated with self-reported and informant-reported level of personality pathology on a measure of pd. the results of previous research suggest that higher personality pathology is associated with lower agreement on five-factor model traits. previous studies did not test higher personality pathology as rated by an informant, and also only investigated agreement on five-factor model traits. we hypothesized that, consistent with previous findings, more personality pathology as reported by the self, and as reported by the informant, would be associated with lower self-other agreement for a five-factor model measure. neuroticism, a salient trait in pds, was previously found to have increased agreement in a conduct disorder group compared to a non-conduct disorder group (furr et al., 2007). individuals with personality pathology may be more likely to display neurotic behaviors or discuss neurotic thoughts with close others. given this past finding, expectations for the maladaptive traits and pd criteria and their association with agreement were exploratory. it is possible that more personality pathology would predict some agreement for the maladaptive traits and pd criteria. method participants data for the current study were previously collected as part of the cat-pd project (computerized adaptive test of personality disorder; simms, goldberg, roberts, watson, weite, & rotterman, 2011), designed to develop and validate a comprehensive model of personality disorder traits. the current sample consists of 83 dyads from the original study. 89.2% of the dyads had known each other for at least one year. 44.6% of the dyads had known each other for at least 13–14 years. ages of the targets ranged from 17 to 65 years. ages of the informants ranged from 18 to 84 years. procedure current or recent clinical patients were recruited via postings in western new york mental health clinics. participants who responded to the posting were screened for eligibility. qualified individuals were then asked if they could also bring in a close friend or family member to participate in the study. only four of the measures from that larger dataset were used in the current study. for each assessment, the target participant 60 tom, simms (the self) answered questions about themselves on a variety of measures (e.g., i see myself as someone who is talkative.) for the informants, the same measures were administered, except phrasing was slightly modified to address the target participant (e.g., i see the person i came with today as someone who is talkative.), except for one measure, in which an informant form already existed. each participant received monetary compensation for their time. measures structured clinical interview for dsm-iii-r personality disorders (scid-ii). the scid-ii (first, spitzer, gibbon, & williams, 1995) is a semi-structure interview administered by a clinician to diagnose dsm-iv axis ii pds (american psychiatric association, 2000). the interview is done after an individual has answered a questionnaire based on pd criteria. the clinician follows up on these questionnaire items to determine which criteria for disorders are met. internal consistencies ranged by disorder (α = .58–.85 for targets, α = .65–.84 for informants). structured clinical interview for dsm-iv personality questionnaire (scid-ii pq). the scid-ii pq is comprised of 119 yes or no questions (“do you often worry about being criticized or rejected in social situations?”) based on dsm-iv axis ii (pd) (american psychiatric association, 2000) criteria. the scid-ii pq is the questionnaire portion of the scid-ii interview (first et al., 1995). internal consistency ranged by disorder (α = .64–.89 for targets, .60–.88 for informants). big five inventory (bfi). the bfi (john, donahue, & kentle, 1991) is a 44-item questionnaire that begins with the first half of a statement: “i see myself as someone who . . . ” items include ends of statements such as “is talkative” or “is depressed, blue” rated on a scale of 1 (disagree strongly) to 5 (agree strongly). items corresponded to five-factor model personality traits (extraversion, agreeableness, conscientiousness, neuroticism, and openness). the bfi traits had adequate internal consistency (α = .74–.75 for targets, α = .72–.89 for informants). personality inventory for dsm-5 (pid-5). the pid-5 (krueger, derringer, markon, & skodol, 2012) consists of 220 items corresponding to pathological personality traits. statements such as “i do a lot of things that others consider risky” are rated on a four-point scale of 0 (very false or often false) to 3 (very true or often true). internal consistencies for almost all 25 traits were high (α = .68–.95 for targets). personality inventory for dsm-5-informant form (pid-5irf). the pid-5-irf (markon, quilty, bagby, & krueger, 2013) consists of 218 items corresponding to maladaptive personality traits as rated by an informant, for a target. statements such as “he or she does a lot of things that others consider risky” are rated on a four-point scale of 0 (very false or often false) to 3 (very true or often true). internal consistencies for all traits were good (α = .74–.96) except for unusual beliefs and experiences (α = .52). results profile agreement for each measure was calculated as the pearson correlation between self and informant scale scores within those measures. for the bfi, if an individual had self-rated items of the bfi for openness, conscientiousness, extraversion, agreeableness, and neuroticism, summing the items for each trait provided a total score for each trait. this series of numbers was then correlated with the same trait total scores provided by an informant for a given dyad. profile agreement was calculated using pd criterion counts from the scid-ii pq, trait scores from the pid-5 and pid-5-irf, and trait scores from the bfi, so that each measure had an overall inter-dyad agreement correlation coefficient for every target-informant pair. the inter-dyad agreement correlations for each measure then were correlated with self-reported scores on various criteria (table 3). the scid-ii pd scores were counts of actual pd criteria met by the individual as determined by scid-ii pq responses, followed-up by a semi-structured interview performed by a clinician. scores on traits of the pid-5 and the bfi were simply the total of scale scores for those traits on their respective measures. the same calculations were repeated with informant-reported scores and the inter-dyad agreement correlations (table 4). though typically only administered to targets, scores on the scid-ii for informants were determined by semi-structured interviews of the informants about the targets. 61 self-other agreement in personality pathology assessment descriptive statistics results showed that levels of inter-dyad agreement and selfand informant-ratings had good variability and range. the mean level of inter-dyad agreement correlations for all measures were reasonably high, even with some dyads producing negative inter-dyad agreement correlations. the pid-5 had the highest mean level of agreement (m = .48) and the scid-ii pq had the lowest (m = .35). readers may email the authors for additional information on means, standard deviations, minimums, maximums of criteria rated by the self and their informants. intercorrelations table 2 presents intercorrelations of the four measures utilized for inter-dyad agreement correlations. only two intercorrelations were significantly associated. higher inter-dyad agreement on the bfi traits was associated with higher agreement on pid-5 trait scores. target-rated criteria and agreement table 3 displays the correlation matrix for criteria rated by targets, correlated with the four inter-dyad agreement variables described above. the general pattern indicated that higher target-rated personality pathology was associated with higher self-other agreement. surprisingly, no scid-ii rated pd criteria were significantly associated with scid-ii pq agreement. ratings for several pid-5 traits (anxiousness, distractibility, eccentricity, emotional liability, hostility, perseveration, and suspiciousness) were positively correlated with agreement on the scid-ii pq. one bfi trait (neuroticism) was positively associated with scid-ii pq agreement. for agreement on the pid-5, the self-reported rating of only one pd (obsessive-compulsive) resulted in a positive association. the pid-5 traits, anxiousness, emotional liability, hostility, and risking taking, were positively associated with pid-5 agreement. neuroticism was also positively correlated with agreement on the pid-5. increased inter-dyad agreement on the bfi was positively associated with target-rated dependent pd, eccentricity, and unusual beliefs and experiences. no other target-rated criteria were significantly associated with bfi agreement. informant-rated criteria and agreement results for informant-rated criteria (table 4) showed a different pattern compared to the results for target-ratings. informant-ratings for paranoid, narcissistic, and borderline pd criteria had moderate correlations with scid-ii pq agreement. almost half of the informant-ratings for pid-5 traits were positively associated with agreement on the scid-ii pq. for bfi rated traits, agreeableness and conscientiousness were negatively correlated with scid-ii pq agreement, and neuroticism was positively associated with scid-ii pq agreement. only one informant-rating was associated with pid-5 agreement; the pid-5 trait rigid perfectionism. consistent with previous studies, more personality pathology was associated with lower agreement for five-factor model traits. higher scores of informantrated histrionic pd criteria was associated with lower agreement on the bfi. six informant-rated pid-5 table 1 descriptive statistics m sd min max agreement correlations scid-ii pq 0.35 0.36 -0.89 0.97 pid-5 0.48 0.26 -0.24 0.89 bfi 0.41 0.47 -0.98 0.96 notes. n = 57–77. bfi = big five inventory; pid-5 = personality inventory for dsm-5; pd = personality disorder; scid-ii pq = structured clinical interview for dsm-iv, axis-ii, screening questionnaire. table 2 dyad agreement intercorrelations 1 2 3 1. scid-ii pq 2. pid-5 .12 3. bfi .12 .38** notes. *p < 0.05, **p < 0.01, ***p < 0.001. bfi = big five inventory; pam = personal acquaintance measure; pid-5 = personality inventory for dsm-5; scid-ii pq = structured clinical interview for dsm-iv, axis-ii, screening questionnaire. 62 tom, simms traits were negatively correlated with bfi agreement (callousness, deceitfulness, distractibility, grandiosity, hostility, and irresponsibility). bfi traits agreeableness, conscientiousness, and openness were positively associated with bfi agreement. discussion in previous research, individuals only selfreported personality pathology, and self-other agreement was only calculated for five-factor model traits. overall, the results of these studies found lower agreement for normal range personality traits (furr et al., 2007; mosterman and hendriks, 2011; tandler et al., 2015). in general, individuals self-reporting more personality pathology tended to agree more with a close other on maladaptive personality traits (pid-5), pd symptoms (scid-ii pq), , and normal range personality traits (bfi). in the current study, contrary to expectations, higher personality pathology correlated with higher agreement on normal range personality traits. one explanation for this unexpected result with selfratings of personality pathology is that participants of the current study had received some form of mental health treatment currently or in the past two years. mental health treatment often focuses on increasing self-reflection and insight. those individuals who were able to recognize their own higher levels of personality pathology, perhaps were then better at assessing their own normal range personality traits and personal relationships. in general, we had expected to find the same pattern of results with both selfand informantreports of personality pathology, but this was not the case. the negative relationship between informant-ratings of personality pathology and inter-dyad agreement correlations was similar to previous studies utilizing self-ratings. we speculate that these findings were more consistent with previous research for a couple of reasons. first, individuals whose informants rated them as higher in personality pathology may not necessarily rate themselves high in personality pathology for reasons such as self-serving biases or lack of insight. these informant ratings may actually be reflecting those individuals who are not aware of their personality table 3 relations between dyad agreement and target reports of pd criteria, traits, and acquaintanceship scid-ii pq agreement pid-5 agreement bfi agreement pd criteria avoidant .02 .03 .18 dependent -.16 .05 .27* obsessive-compulsive .03 .35** .24 paranoid .10 .14 .07 schizotypal -.07 .13 .12 schizoid -.08 -.07 -.03 histrionic .10 .04 .16 narcissistic .17 .18 .22 borderline .17 .22 .15 antisocial .10 .04 .10 pid-5 traits anhedonia .15 .07 .13 anxiousness .29* .30* .14 attention seeking .20 .16 .12 callousness .14 .10 .12 deceitfulness .04 .07 .05 depressivity .18 .19 .05 distractibility .24* .20 .20 eccentricity .29* .07 .31* emotional lability .33** .29* .22 grandiosity .16 -.15 .03 hostility .27* .35* .17 impulsivity .10 .17 .07 intimacy .13 -.18 -.10 irresponsibility .10 -.04 -.01 manipulativeness .22 .08 .04 perceptual dysregulation .21 .00 .20 perseveration .34** .14 .18 restricted affectivity .12 -.05 .12 rigid perfectionism .18 .17 .07 risk taking .21 .29* .08 separation insecurity .15 .23 .15 submissiveness .14 .06 .01 suspiciousness .27* .09 .06 unusual beliefs and experiences .14 -.17 .28* withdrawal .14 -.04 .04 bfi traits agreeableness -.14 -.12 -.03 conscientiousness -.07 .11 .09 extraversion .01 .13 .12 openness .10 .13 .24 neuroticism .25* .35* .20 notes. *p < 0.05, **p < 0.01, ***p < 0.001. bfi = big five inventory; pid-5 = personality inventory for dsm-5; pd = personality disorder; scid-ii pq = structured clinical interview for dsm-iv, axis-ii, screening questionnaire. 63 self-other agreement in personality pathology assessment pathology. in contrast, it seems reasonable that the target individuals who had recognized their own personality pathology would generally have more inter-dyad agreement with their partners. individuals whose informants reported higher personality pathology also agreed more with their targets about pd symptoms. this was similar to the results for self-rated personality pathology. this again went contrary to expectations, because we tend to predict that individuals with more personality pathology would be oblivious to their maladaptive traits. however, these results appear to indicate personality pathology is quite salient and visible to both targets and informants. even though maladaptive traits and symptoms are harder to judge and would normally have lower general agreement (clifton et al., 2004), in the current study, individuals with more personality pathology exhibited higher inter-dyad agreement on these undesirable criteria compared to individuals with less personality pathology. notably, only one informant rated criterion correlated with higher agreement on maladaptive traits. this was an odd result, given that many informant-reported criterion for personality pathology had significant associations. where higher self-reported personality pathology had resulted in higher agreement on both pd criteria and the maladaptive traits, the informant analysis had more significant associations for the pd criteria measure, but lacked significant correlations for maladaptive traits. we were unable to think of an explanation for this finding. bfi traits and self-other agreement although the primary focus of this study was to investigate level of personality pathology and its relationship to self-other agreement, we also included selfand informant-rated bfi traits in the analysis. similar to previous findings (furr et al. 2007), neuroticism had actually correlated positively with inter-dyad agreement correlations of the pd criteria measure for both the targetand informant-analysis. for the target-analysis, higher neuroticism was also associated with higher agreement on the maladaptive trait measure. table 4 relations between dyad agreement and informant reports of pd criteria, traits, and acquaintanceship scid-ii pq agreement pid-5 agreement bfi agreement pd criteria avoidant .13 .07 -.05 dependent .19 -.09 -.15 obsessive-compulsive .15 .02 -.06 paranoid .30** .05 -.24 schizotypal .17 .13 -.16 schizoid .15 .03 .00 histrionic .05 -.15 -.29* narcissistic .34** .01 -.20 borderline .41*** .07 -.20 antisocial .13 -.12 -.24 pid-5 traits anhedonia .25* -.04 -.21 anxiousness .28* .21 -.19 attention seeking .23 .05 -.13 callousness .29* -.10 -.29* deceitfulness .16 -.16 -.33* depressivity .36** .07 -.07 distractibility .32** .13 -.29* eccentricity .16 .07 -.20 emotional lability .36** -.15 -.20 grandiosity .18 -.06 -.30* hostility .29* -.12 -.32* impulsivity .30* -.10 -.25 intimacy .14 -.07 -.12 irresponsibility .19 -.23 -.28* manipulativeness .23 -.11 -.19 perceptual dysregulation .25* .03 -.24 perseveration .30** .03 -.14 restricted affectivity .12 -.10 -.17 rigid perfectionism .21 .30* .00 risk taking .19 .11 -.17 separation insecurity .38** .00 -.09 submissiveness .21 -.05 .08 suspiciousness .24* .00 -.23 unusual beliefs and experiences .17 -.04 -.15 withdrawal .22 -.00 -.20 bfi traits agreeableness -.29* -.03 .42** conscientiousness -.36** .10 .30* extraversion -.13 -.06 -.13 openness .03 .10 .46** neuroticism .43** .12 -.18 notes. *p < 0.05, **p < 0.01, ***p < 0.001. bfi = big five inventory; pid-5 = personality inventory for dsm-5; pd = personality disorder; scid-ii pq = structured clinical interview for dsm-iv, axis-ii, screening questionnaire. 64 tom, simms the other four of the five-factor model traits did not have any other significant correlations for the target-analysis. however, for the informant analysis, agreeableness, conscientiousness, and openness exhibited some reversed patterns compared to the maladaptive traits. higher agreeableness and openness meant lower inter-dyad agreement on pd criteria. maladaptive criteria are supposed to be more difficult to judge in those without personality pathology (clifton et al., 2004). individuals rated as higher in agreeableness and contentiousness may also be individuals who have less personality pathology, and therefore would have worse self-other agreement on pd criteria. those whose informants rated them as higher in agreeableness, conscientiousness, and openness, were positively associated with higher inter-dyad agreement on the normal range trait measure. these results were in line with previous findings that pro-social traits are easier to judge in well-adjusted individuals (colvin, 1993; connolly et al., 2007). strengths, limitations, and future directions the use of both selfand informant-ratings was a major strength to the study. self-reports only showed a fraction of the whole picture of the relationship between level of personality pathology and self-other agreement. informant-reports of personality pathology yielded more significant correlations and unique patterns of correlations in relation to inter-dyad agreement. the realistic accuracy model and the self-other asymmetries model alluded to differences in reception and interpretation of information by a judge on a given target. the differences in the pattern of results for the correlation matrices of the selfand informant-ratings reveals the importance of questioning accuracy, and that convergence for judgments of others may not be obtainable for someone higher in personality pathology. from the findings of the current study, this statement is of course only true for normal range traits. indeed, selfand informant-judgments of maladaptive criteria did reach better consensus. one limitation to the current study would be using pearson’s correlations to calculate self-other agreement. the literature has used various other methods for calculating self-other agreement. pearson’s correlation is considered a simpler, yet valid way of measuring selfother agreement (mccrae, 2008). however, a pearson’s correlation would not capture self-other agreement well if an informant consistently rated a target as many points above, or below, the target ratings. the same limitation has the potential to control for rating tendencies among pairs. for example, if one an informant consistently rated one point lower than the target for every item on a measure, the self-other agreement correlation would remain unchanged. the current study had a relatively small sample size that varied depending on different measures. this was a result of the large size of the initial dataset; additionally, the measures used in the current study were often missing data. during data collection, which lasted around four hours, sections were often skipped in the interest of saving time. the missing data was detrimental in the analysis due to lowered power. the sample size for bfi inter-dyad agreement was the lowest, at n = 57. several correlations had approached significance but did not cross that threshold. another major limitation to the current study was the use of selfand informant-ratings for calculating inter-dyad agreement correlations, and using the same ratings as criteria to correlate with the inter-dyad agreement correlations. this method was used for the pid-5and bfi. however, ratings of the self and informants for pd criteria used the scid-ii, which involved an interview with a clinician, and scores were strictly pd symptoms from the dsm-iv as determined by the clinician. the scid-ii’s inter-dyad agreement counterpart was the scid-ii pq, which utilized a questionnaire that did not involve an interview. the analysis was done this way presuming that the scid-ii pq would better reflect the judgments on the self and the informants. additionally, we inferred that the scid-ii at face value, provided a more valid judgment for the presence of pd symptoms. in the current study, we did not assess inter-dyad agreement of individual traits. we only calculated profile agreement on whole measures. this may have limited the significance of the results for bfi agreement, since this measure included prosocial traits and a maladaptive trait. in general, more significant relationships could be revealed in future studies by expanding the analysis to include agreement on individual traits. this was not done in the current study as to not exponentially multiply the volume of analysis. 65 self-other agreement in personality pathology assessment a study using a non-clinical sample will be the next step in this line of research. due to the unexpected finding that higher self-ratings of personality pathology resulted in higher agreement on a measure of normal range traits, using a non-clinical sample may produce results more consistent with previous results in the literature. it would be interesting to investigate whether a non-clinical sample would yield selfand informantresults in the same pattern as the current study. conclusion in this study, we found selfand informant-reports of personality pathology had a positive correlation with self-other agreement of maladaptive criteria. self-reports of higher personality pathology scores unexpectedly correlated with higher agreement for normal range traits. informant-reports of personality pathology, consistent with the literature, yielded a negative correlation with self-other agreement on normal range traits. selfand informant-reports are unique and are likely both picking up on valuable information, as 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(2008). knowing me, knowing you: the accuracy and unique predictive validity of self-ratings and other-ratings of daily behavior. journal of personality and social psychology, 95(5), 1202– 1216. doi:10.1037/a0013314 5 graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university exploring childhood trauma, race-related stress, racial socialization, and symptoms in black emerging adulthood childhood trauma (e.g., physical, sexual, emotional abuse, and physical and emotional neglect) can be detrimental, as it can exacerbate adverse well-being outcomes (gallagher et al., 2023). these adverse outcomes often persist into adulthood (gause et al., 2022). therefore, adults who experienced childhood trauma may continue to experience its psychological effects. intersectional factors contributing to systemic oppression— such as indirect racism (e.g., income inequality, mass incarceration) and direct racism (e.g., over-policing, community violence, and overt racial discrimination)— intensify trauma symptoms among black americans, who also face greater barriers to accessing mental health treatment (gallagher et al., 2023). research supports the notion that racial trauma or race-related stress amplifies the relationship between interpersonal trauma (e.g., childhood trauma) and the behavioral and psychological health outcomes of black americans (mekawi et al., 2021; metzger et al., 2021). race-related stress pertains to experiencing psychological distress from a racial encounter or experiences of racism (carter & pieterse, 2019; roberson & carter, 2022). race-related stress is significantly associated with internalizing symptoms, such as anxiety and depression (carter et al., 2019). emerging adulthood (ages 18 – 25) is a developmental time period for youth that bridges adolescence and adulthood. black emerging adults are more susceptible to racial discrimination than their counterparts from other racial/ethnic groups (arnett, 2000). for example, black emerging adults are more likely to experience racial discrimination when engaging in normative developmental tasks such as seeking jobs, training opportunities, advanced education, etc. (hurd et al., 2014; pearlin et al., 2005). the transition to adulthood and greater autonomy, coupled with race-related stress, can make black emerging adults feel vulnerable. for those with a history of childhood trauma, the additive stress of race-related events can further increase vulnerability and complicate psychological outcomes. therefore, it is critical to examine culturally relevant coping strategies that best fit the needs of this population. research indicates that racial socialization (rs) is a cultural coping strategy for black youth, which can produce positive emotional well-being outcomes (anderson et al., 2019). rs messages include themes of culture, attitudes, and values to prepare youth to navigate racial discrimination, oppression, and stressmaegan barber & gishawn mance department of psychology, howard university, washington, dc objective: systemic oppression contributes to disproportionate rates of childhood trauma and race-related stress among black emerging adults, heightening harmful psychological outcomes (hope et al., 2022; williams et al., 2010). this study explored how race-related stress influences the relationship between childhood trauma and internalizing symptoms in black emerging adults. it also investigated whether racial socialization messages moderated these effects in a three-way interaction. methods: black emerging adults (ages 18 – 25) were recruited through academic channels and social media platforms to complete a demographic questionnaire, the childhood trauma questionnaire – short form (ctq), the index of race-related stress – brief version (irrs-b), the racial socialization questionnaire-teen (rsq-t), and the brief symptom inventory–18 (bsi-18). hayes’ process model 3 was utilized to test moderated moderation analysis. results: analyses comprised 341 black emerging adults (75.4% women, 31% 18-year-olds). race-related stress did not moderate the relationship between childhood trauma and internalizing symptoms, b = -0.004, se = 0.0025, 95% ci [-0.0054, 0.0046]. the overall moderated moderation model was not significant, b = 0.00002, se = 0.0002, 95% ci [-0.0002, 0.0007]. however, higher endorsed childhood trauma and racial socialization messages, in the absence of race-related stress, were associated with increased internalized symptomology, b = 0.0105, se = .0045, 95% ci = [0.0017, 0.0194]. conclusions: these findings highlight the unique ways childhood trauma, race-related stress, and racial socialization messages impact black emerging adults’ psychological functioning. a higher frequency of endorsed racial socialization messages may amplify distress associated with childhood trauma. future research should investigate racial socialization competency and coping self-efficacy to better understand racial socialization’s role as a potential protective factor for black emerging adults facing psychological distress from trauma and stress. keywords: childhood trauma, race-related stress, black emerging adults, racial socialization, internalizing symptoms 6 trauma, race-related stress, and racial socialization ors related to racial and ethnic identity (hughes et al., 2006; lesane-brown et al., 2005; metzger et al., 2021). rs messages are often verbal and nonverbal communication from caregivers to youth (anderson et al., 2019; hughes et al., 2006). an example of a verbal rs message would be a caregiver communicating to a youth, “you should be proud to be black” (neblett et al., 2009). an example of an rs nonverbal or behavioral message would be a caregiver buying youth books focusing on black culture and history (neblett et al. 2009). five examples of notable rs messages are as follows: (1) instilling cultural pride by emphasizing heritage and ancestry (racial pride messages); (2) preparing for racial discrimination (barrier messages); (3) promoting racial equality or orienting youth to fit into mainstream culture (egalitarian messages); (4) reiterating positive traits (self-worth messages); and (5) participating in activities or demonstrating behaviors that promote black culture (behavioral messages) (bowman & howard, 1985; hughes et al., 2006; metzger et al., 2021; neblett et al., 2008; neblett et al., 2009). rs has been associated with decreased depressive and stress-related symptoms (metzger et al., 2021; neblett et al., 2008) while allowing black youth to gain a more robust and healthier sense of racial identity (metzger et al., 2021; neblett et al., 2008). it is also linked to positive psychological and behavioral outcomes for black youth who experience racial stress and discrimination (anderson et al., 2019) while promoting positive racial coping self-efficacy. however, while a wealth of research has examined rs as a protective factor for black youth who have experienced racial stress (e.g., neblett et al., 2013; jones and neblett, 2017; anderson et al., 2019), there are mixed findings when it comes to racial socialization messages. for example, the protective impact of rs messages, such as egalitarian messages (saleem et al., 2022, pp. 146–147) and racial barriers (rodriguez et al., 2008), may vary as their effectiveness depends on the frequency, content, and context in which they are delivered. however, the literature is clear that negative messages, which communicate negative stereotypes about black people (e.g., “told you that learning about black history is not that important.”), are linked to harmful mental health outcomes (anderson et al., 2024). this study will examine whether cumulative rs messages serve as a protective factor for black emerging adults who have experienced racial stress and childhood trauma, using the racial encounter coping appraisal and socialization theory (recast) model as a guiding framework. guiding theoretical frameworks: racial encounter coping appraisal and socialization theory stevenson (2014) adapted the transactional model of stress and coping (tmsc) to address race-related stressors. building on the foundational work of lazarus and folkman (1984), stevenson extended the tmsc by introducing recast. this theoretical framework offers a nuanced lens for understanding how race-related stress and rs impact psychological outcomes. tmsc emphasizes the role of primary appraisal in stress responses. folkman et al. (1986) describe primary appraisal as the initial assessment of whether an individual perceives an event as threatening or harmful. in the context of childhood trauma, traumatic experiences are associated with heightened psychological distress, which can persist into adulthood (gause et al., 2022). in this study, childhood traumatic experiences are examined as a predictor variable, representing an individual’s early exposure to stressors that likely shape how individuals appraise stress and threats. these experiences, in turn, influence psychological outcomes or internalizing symptomology in emerging adulthood, which serves as the outcome variable for this study. similarly, recast examines racial stress or race-related stress as an appraisal process, where individuals recognize a discriminatory racial encounter as racial (anderson & stevenson, 2019). in the recast framework, rs competency (the confidence and skills of families’ rs communication) is explored as a moderating variable, determining whether racial stress, coupled with the mediating variable of racial coping self-efficacy, influences outcomes for black youth. the recast framework suggests that higher rs competency will enhance coping self-efficacy, ultimately leading to more positive and adaptive well-being outcomes for black youth (anderson & stevenson, 2019). while recast focuses on rs competency as a potential protective factor, this study will explore the broader culmination of rs messages. specifically, we aim to determine whether the increased frequency of rs messages serves as a protective factor, moderating the effects of race-related stress. although both tmsc and recast examine secondary appraisal—where individuals assess their 7 barber & mance coping resources—this study focuses on the frameworks’ primary appraisal and outcome components. the current study will add to the literature through two broad goals. first, the study will examine internalizing symptoms of black emerging adults who have experienced race-related stress and childhood trauma. specifically, this study will examine the moderating effects of race-related stress on the relationship between childhood trauma and internalizing symptomology (i.e., anxiety, depression, and somatization). secondly, the study will investigate whether rs messages buffer against internalizing symptoms for black emerging adults who have experienced race-related stress and childhood trauma. thus, this study will examine the moderating effects of rs on the interaction of race-related stress and childhood trauma on internalizing symptoms. the study’s statistical framework is presented in figure 1. we hypothesize the following: hypothesis 1a (h1a): frequent exposure to race-related stress will increase internalizing symptoms. hypothesis 1b (h1b): frequent exposure to childhood trauma will increase internalizing symptoms. hypothesis 1c (h1c): higher endorsement of racial socialization messages will be associated with lower internalizing symptoms. hypothesis 2 (h2): the presence of race-related stress will exacerbate the relationship between childhood trauma and internalizing symptoms. hypothesis 3 (h3): racial socialization will moderate the relationship between childhood trauma and race-related stress such that greater experience of racial socialization will buffer against the negative effects of childhood trauma on internalizing symptoms. to our knowledge, this serves as the first research study to explore whether rs serves as a protective factor for black emerging adults who have experienced race-related stress and childhood trauma. specifically, limited studies have examined how traumatic events experienced in childhood, combined with race-related stress, impact black youth in emerging adulthood. additionally, there is a gap in research exploring rs messages as a potential protective factor for black emerging adults who have experienced both childhood trauma and race-related stress. methods a mid-atlantic university institutional review board approved all study procedures. data were collected between february 2022 and april 2022. participants participants were black emerging adults recruited from the mid-atlantic region and via online social media platforms. eligible participants were between the ages of 18 and 25, identified as black or of african descent (e.g., african american, african, black caribbean, afro-latinx, etc.), and considered english their primary language. exclusion criteria included respondents who did not identify as of african descent, were not between the ages of 18 and 25, and did not consider english their primary language. procedure recruitment for participation included informing potential participants about the study through academic channels and social media platforms. a recruitment flyer containing a quick response code or qr code that linked to the study’s qualtrics survey or questionnaire was distributed through social media platforms (e.g., facebook and instagram), shared with academic professors via email, and posted on a university online learning management system. the qualtrics questionnaire took approximately 25 minutes to complete. prior to beginning the survey, the initial page included the informed consent information for participants. participants were able to give their consent to the study by indicating yes or no electronically. after completing the survey, psychology students recruited from the subject pool had the option to receive extra credit for their course if approved by an undergraduate psychology professor. all other participants were eligible to receive one of three drawings for an electronic gift card valued at $25 . measures demographic information a demographic questionnaire was administered to participants to obtain brief background information. the questionnaire gathered information such as race/ethnicity, gender, family household income, the participant’s current income, description of the setting where the participant was raised (e.g., rural vs. urban setting), marital and occupational statuses, educational level, and mental health treatment history (i.e., “have you ever seen a therapist (for over a month) for trauma, anxiety, and/or depression?”). childhood trauma the childhood trauma questionnaire – short form (ctq; bernstein, 1998) is a 28-item self-report 8 trauma, race-related stress, and racial socialization questionnaire that screens childhood traumatic experiences using five subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. participants are asked to rate the severity in which a childhood trauma affected them using a 5-point likert scale of 1 (never true) to 5 (very often true). the item responses included four categories from non to low trauma exposure to extreme trauma exposure. thus, higher scores indicated higher trauma exposure. sample item statements are “i believe i was sexually abused,” and “i thought my parents wished i had never been born.” the ctq also contains a minimization/denial validity scale created to identify underreporting of maltreatment. for this study, the minimization/denial scale was not assessed. this study aimed to explore participants’ perceptions of childhood traumatic experiences, if experienced. therefore, the minimization/denial of experiences was not the focus of this study. in the current study, the five subscales (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) were summed for a global score. while this measure does not measure primary appraisal directly, it captures early stress exposure, which may influence how individuals appraise stressful situations. of note, as indicated by bernstein (1998), two subscales (i.e., emotional and physical neglect) on the childhood trauma questionnaire (ctq) were reverse-coded in spss. the ctq measure has test-retest reliability coefficients ranging from .79 to .86 and an internal consistency coefficient ranging from .66 to .92 (bernstein, 1998; bernstein et al., 2003; liebschutz et al., 2018). the ctq has also been shown to have good convergent validity when compared to clinician-administered interviews assessing child abuse (bernstein, 1998). cronbach's alpha for the current sample was excellent, α = 0.92. race-related stress the index of race-related stress – brief version (irrs-b) (utsey, 1999) is a 22-item questionnaire that measures african americans’ race-related stress on racism and discrimination across three factors: cultural, institutional, and individual racism. the irrs-b requires participants to assess racist events that either they or someone close to them has experienced and then rate the level of severity of how the experiences have impacted them. a 5-point likert scale of 0 (this never happened to me) to 4 (the event happened, and i was extremely upset) is used to rate the participants’ responses. sample item statements include “you notice that when individuals belonging to your ethnic group are killed by the police, the media informs the public of the victims criminal record,” and “while shopping at a store, or when attempting to make a purchase, you were ignored as if you were not a serious customer or didn’t have any money.” the cronbach alpha across scales include the cultural racism subscale being .78, the institutional racism subscale being .69, the individual racism subscale being .78, and global racism being .77. subsequently, the concurrent validity of the irrs-b was demonstrated through its positive and significant correlations with the perceived stress scale (cohen et al.,1983; utsey et al., 2002), particularly with the cultural and individual racism subscales. the global racism score was assessed as moderator 1 in this study. the summed scores for each subscale were transformed into z-scores and then summed to obtain a global racism score. cronbach's alpha for the global score of the current sample was good, α = 0.87. racial socialization racial socialization questionnaire-teen (rsq-t; lesane-brown et al., 2006) is a theoretically derived 26-item questionnaire that assesses participants’ perception of the frequency of racial socialization messages and activities they have received from parents over the past year. this measure seeks to capture how recent racial socialization messages may or may not buffer against the effects of past childhood trauma. there are six subscales measured within the rsq-t, which include racial pride messages (α = .63), racial barrier messages (α = .69), egalitarian messages (α = .64), self-worth messages (α = .74), negative messages (α = .66), and behavioral messages (α = .73). for this study, only five subscales were examined, excluding the negative messages subscale. the negative message subscale did not directly align with the study’s objective, which was to assess rs messages that have been found to be protective or associated with promoting psychological well-being. the five subscales were summed up to create a global score for racial socialization messages. participants use a 3-point scale of 0 (never) to 2 (more than twice) to respond to item statements such as “told you that you are somebody special, no matter what anybody says,” and “told you that some people may dislike you because of the color of your skin.” the rsq-t has shown good predictive validity of attitudes regarding racial identity and intergroup relationships (lesane-brown 9 barber & mance et al., 2006). additionally, the rsq has demonstrated good reliability and validity in predicting black american youths’ academic and psychological outcomes (neblett et al., 2008). although lesane-brown et al. (2006) originally developed the rsq-t mainly for adolescents, the cronbach’s alpha of the current sample, including black emerging adults, was good, α = 0.87. internalizing symptomology the brief symptom inventory – 18 (bsi-18; derogatis, 2011) is an 18-item self-report measure that screens for internalizing symptoms such as somatization, depression, and anxiety. the participants rate how much they have been bothered by internalizing symptoms in the past week using a 5-point likert scale of 0 (not at all) to 4 (extremely). sample item statements include “how much were you distressed by feeling lonely?” and “how much were you distressed by feeling hopeless about the future?” derogatis (2011) found that the internal consistency for somatization (α = .74), depression (α = .84), and anxiety (α = .79) was acceptable. the total range of scores is from 0 to 72, with higher scores indicating higher symptomology. the somatization, depression, and anxiety subscales were summed for a global score of internalizing symptomology. it has been shown to have well-established validity through its two-factor analysis structure (derogatis, 2011). likewise, it demonstrated good factorial validity in a study population comprised primarily of young or emerging adults (recklitis et al., 2006). cronbach's alpha for the current sample was excellent, α = 0.94. data analysis missingness data and preliminary assumptions three hundred-ninety-two study participants were initially recruited. before conducting the primary study analyses, preliminary assumptions were examined to assess normality, linearity, homoscedasticity, and outliers. cases were removed from the study if subscale measures of main study variables had more than 50% of their questions or items missing. this resulted in the removal of 47 cases. subsequently, two additional cases were removed because participants did not identify as being of african descent. mahalanobis distance scores were used to detect multivariate outliers. a threshold of p <.001 was utilized, which resulted in one case being identified as a potential outlier. therefore, this case was removed from the analysis. there were no other outliers detected. hayes process analysis (hayes, 2017) was utilized to examine the moderated-moderation analysis. the hayes process analysis conducted listwise deletion, removing one additional case. upon further investigation, the internalizing symptoms measure (i.e., bsi-18) was incomplete. this resulted in the regression analyses, including a final sample size of n = 341 participants. all assumptions of multiple regression were tested and met, including linearity, normality, and evidence of homoscedasticity. there was no major threat of multicollinearity because the correlation between childhood trauma and race-related stress is less than .90 (r (339) = .146, p > .05), childhood trauma and racial socialization (rs) messages is less than .90 (r (339) = -.253, p > .05), and race-related stress and rs messages is less than .90 (r (339) = -.270, p > .05). furthermore, the tolerance values .887, .878, and .840 exceed .20, and the vif factors of 1.127, 1.139, and 1.190 are lower than 4.00, meaning each independent variable has a strong uniqueness. descriptive statistics descriptive statistics were calculated in the statistical package for social sciences (spss) version 26 (ibm corp., 2019) for all available data, including the percentage for all categorical and demographic variables. the mean and standard deviation were also calculated for all main study variables and their subscales. descriptives of the main study variables are shown in table 1. primary statistical analyses were conducted in spss version 26, which included assessing multiple linear regression models and utilizing andrew hayes’ process model 3 (hayes, 2017; moderated moderation analysis). childhood trauma (independent variable; ctq score), internalizing symptoms (dependent variable; bsi-18 score), race-related stress (moderator 1; irrs-b score), and rs messages (moderator 2; rsq-t score) were examined in the moderated moderation model (hayes, 2017). all variables that define products were mean-centered. the conditioning values were set at -1sd, mean, and +1sd. confidence intervals were set to 95, with 5,000 bootstrap samples. results descriptive statistics our study sample was predominantly women (75.4%) and identified as black/african american (88.9%). nearly one-third of the sample was 18 years old (31%), and over half of the sample endorsed having “some college” (55.3%) as their highest level of educa10 trauma, race-related stress, and racial socialization tion. for further demographic information, see table 2. multiple linear regression models three hypotheses were analyzed utilizing the statistical package for social sciences (spss) version 26 (ibm corp., 2019) to test multiple linear regression models. the three hypotheses consisted of the following: frequent exposure to race-related stress will increase internalizing symptoms (h1a), frequent experiences of childhood trauma will increase internalizing symptoms (h1b), and higher endorsement of rs messages will be associated with lower internalizing symptoms (h1c). simple linear regression model results indicated that the predictors childhood trauma, race-related stress, and rs messages explained 27% of the variance (r2 = 0.271, f = 41.696, p < .001) in internalizing symptoms. it was found that race-related stress significantly predicted internalizing symptoms, b = .198, t (340) = 3.724, se = 0.53, se = 0.53, p < .001, 95% ci [0.093, 0.302]. therefore, the more black emerging adults experienced race-related stress, the higher their total internalizing symptoms, which supports hypothesis 1a. further, childhood trauma significantly predicted internalizing symptoms, b = .370, t (340) = 9.331, se = 0.040, p < .001, 95% ci [0.292, 0.448]. thus, the more childhood trauma black emerging adults experienced, the higher their total internalizing symptoms. this supports hypothesis 1b. interestingly, the relationship between rs messages and internalizing symptoms was not statistically significant, b = .072, t (340) = 0.766, p = .444, 95% ci [-0.113, 0.256]. therefore, hypothesis 1c is not supported. see table 3. moderated moderation the hypothesized moderated moderation effects were tested using process macro model number 3 (hayes, 2017). the model tested the moderating effects of race-related stress on the relationship between childhood trauma and internalizing symptomology (h2). further, the model examined the moderating effects of rs messages on the moderating variable of race-related stress on the path of childhood trauma and internalizing symptomology (h3). hypothesis 2 proposed that the presence of race-related stress would exacerbate the relationship between childhood trauma and internalizing symptoms. race-related stress did not moderate the relationship between childhood trauma and internalizing symptoms, b = -0.004, se = 0.0025, t (340) = -0.16, p = 0.87, 95% ci [-0.0054, 0.0046], which opposes the study’s hypothesis 2. hypothesis 3 proposed that rs messages would moderate the relationship between childhood trauma and race-related stress, such that greater endorsement of rs messages would buffer against the negative effects of childhood trauma on internalizing symptoms. the results indicated that there was a conditional interaction between childhood trauma and rs messages, b = 0.0105, se = .0045, t (340) = 2.35, p < .05, 95% ci = [0.0017, 0.0194]. thus, higher endorsed childhood trauma and rs messages, in the absence of race-related stress, were associated with increased internalized symptomology. this contradicts the proposed hypothesis that rs messages will buffer against deleterious symptoms of childhood trauma. while childhood trauma and race-related stress (respectively) were significantly related to internalizing symptoms, rs failed to act as a buffer against trauma and symptoms. rather, it appears to exacerbate internalizing symptoms in the presence of childhood trauma. the overall moderated moderation model was not supported, b = 0.0002, se = 0.0002, t (340) = 0.99, p = .32, 95% ci [-0.0002, 0.0007]. see table 4. exploratory analysis: simple moderation analysis the moderated-moderation model found that higher endorsed childhood trauma and rs messages, in the absence of race-related stress, were associated with increased internalized symptomology. based on the partially moderated moderation findings, a simple moderation (i.e., hayes model 1) was conducted to explore the direct relationships of rs messages on childhood trauma and internalizing symptoms. rs messages were found to moderate the relationship between childhood trauma and internalizing symptoms, b = 0.0095, se = 0.0043, t (340) = 2.2438, p < .05, 95%, ci [0.0012, 0.0179]. the interaction between trauma and rs messages accounts for 1.1% of the variance in internalizing symptoms for black emerging adults (r² = .011, f (1, 337) = 5.035, p < .05). additionally, it was found that when rs messages were one standard deviation above the mean, and the more black emerging adults were exposed to childhood trauma, this indicated higher internalizing symptomology, b = 0.4976, se = 0.0567, t (340) = 8.77, p < .001, 95% ci [0.3860, 0.6091]. see figure 2. 11 barber & mance discussion the present study sought to explore the relationship between childhood trauma, race-related stress, racial socialization (rs) messages, and internalizing symptoms among black emerging adults. specifically, this study investigated the influence of race-related stress on the relationship between childhood trauma and internalizing symptoms. further, rs messages were examined to see if they buffered against the effects of race-related stress on the relationship between childhood trauma and internalizing symptoms. as expected, the results of this study confirmed that black emerging adults who endorsed race-related stress experienced increased internalizing symptomology. additionally, the results found that black emerging adults who experienced childhood trauma experienced increased internalizing symptomology. the recast frameworks were used to explore the transactional pattern of childhood trauma, race-related stress, rs messages, and mental health outcomes in black emerging adults. specifically, the current study explored the internalizing symptomology (i.e., depression, anxiety, and somatization) of black emerging adults who have experienced childhood trauma and race-related stress. further, the recast framework was utilized to investigate if rs messages functioned as a protective factor for black emerging adults who experienced childhood trauma and race-related stress. it was initially predicted that for black emerging adults who had experienced childhood trauma, the presence of race-related stress would exacerbate their internalizing symptoms. additionally, it was predicted that for black emerging adults who experienced childhood trauma and race-related stress, the more rs messages endorsed would be associated with decreased internalizing symptomology. thus, higher endorsement of rs messages would be associated with lower internalizing symptoms. altogether, this study investigated the internalizing symptomology of black emerging adults who have experienced complex trauma (i.e., childhood trauma and race-related stress) and explored if rs messages served as a protective factor. race-related stress as a moderator the study results did not support the hypothesized moderated model that the presence of race-related stress would exacerbate the relationship between childhood trauma and internalizing symptoms. however, when solely examining the relationship between race-related stress and symptoms, our hypothesis aligned with previous literature, such that black emerging adults who experienced race-related stress experienced increased internalizing symptoms. previous literature confirms that black americans experience increased internalizing symptoms and disproportionately experience chronic stress due to racism and racial discrimination (franklin et al., 2006). although we found that race-related stress did not exacerbate the internalizing symptomology of black emerging adults who have experienced childhood trauma, the literature suggests that racial stress or trauma can worsen the mental health outcomes of black americans with trauma histories (mekawi et al., 2021; metzger et al., 2021). according to the recast framework, racial coping self-efficacy mediates the relationship between racial stress and coping, leading to psychological and overall well-being outcomes for black youth. the current study integrated a childhood trauma component absent from the recast model. this component was added in the current study to examine how interpersonal trauma, in addition to racial stress, influences black emerging adults’ mental health outcomes. thus, the lack of association between racial stress, childhood trauma, and symptoms may be due to the strong linear relationships between childhood trauma and symptoms, as well as race-related stress and symptoms. as a result, race-related stress may not have acted as a moderating variable or exacerbated the symptoms of childhood trauma, given that the internalizing symptoms of childhood trauma were already highly significant. further, another possible explanation for race-related stress not emerging as a significant moderator may pertain to racial socialization inherently involving elements of race-related stress. discussions that prepare individuals for discrimination or teach individuals how to navigate racism can be stress-inducing. as such, racial socialization messages may partially account for the effects of race-related stress, potentially overlapping with or absorbing its influence in the model. this explanation may help clarify why a higher frequency of racial socialization messages was associated with greater internalizing symptoms among black emerging adults with childhood trauma histories. additionally, as mentioned previously, the recast model incorporated racial coping self-efficacy as a mediator between racial stress and cop12 ing, leading to predicted outcomes. the current study did not examine coping self-efficacy. this may further explain the lack of association between variables, as the current study did not investigate black emerging adults’ perception of their ability to manage racial stressors and childhood trauma. racial socialization messages as moderator 2 in this study, we tested a moderated-moderation model to examine whether rs messages moderated the effect of race-related stress on the relationship between childhood trauma and internalizing symptomatology of black emerging adults. to our knowledge, this is the first study to test this moderated moderation model with black emerging adults. no significant relationship was found between childhood trauma, race-related stress, rs messages, and internalizing symptoms. therefore, our hypothesis was not supported; in fact, the research findings contradicted our hypothesis due to there being a significant conditional interaction between childhood trauma, rs messages, and symptoms. specifically, black emerging adults who experienced more childhood traumatic experiences and received rs messages (i.e., racial pride, racial barrier, egalitarian, self-worth, and behavioral) were associated with increased internalizing symptoms. this contradicts previous findings that have suggested that receiving a combination of rs messages is advantageous to black american youths’ mental health outcomes (davis et al., 2017; granberg et al., 2012; neblett et al., 2008). subsequently, our findings contradict the study results of fischer and shaw (1999), who noted that the more african american college students received rs messages, this moderated the relationship between racist experiences and poorer mental health outcomes. notably, these previous studies have found that the mental health outcomes of black adolescents receiving rs messages improve when experiencing racial stressors, not interpersonal or childhood trauma. in the present study, the lack of a significant association between childhood trauma, race-related stress, rs messages, and internalizing symptoms may pertain to the effects of rs deteriorating as a protective factor for black emerging adults who have experienced cumulative childhood trauma and race-related stress. accordingly, previous studies have found mixed findings when examining the effects of rs messages on black americans’ psychological well-being. for instance, while some studies have found racial or cultural pride messages to be associated with positive psychological outcomes (bynum et al., 2007; davis et al., 2017), some studies have found racial barrier messages to be associated with increased depressive symptoms (liu & lau, 2013; stevenson et al., 1996). for black emerging adults who have experienced childhood trauma, being more conscious of racial discrimination and navigating psychological challenges from childhood trauma may lead to adverse mental health outcomes. the present study’s findings contribute to the growing body of literature that rs messages may make black emerging adults more aware of racial discrimination. our findings further suggest that for black americans with extensive childhood trauma histories, the more endorsed rs messages have the potential to complicate mental health outcomes. limitations while study findings were notable, the study contained limitations. this study was cross-sectional. thus, the study findings cannot indicate any causal relationships between variables. additionally, as mentioned previously, the present study did not examine all the recast framework components. the recast framework examined black youths’ rs competency moderating racial stress and racial coping self-efficacy, and self-efficacy mediated the relationship between stress and coping, leading to black youths’ mental health and overall well-being outcomes. while the present study utilized the recast framework to examine the relationship between trauma and stress, rs as a coping strategy or moderator, and mental health outcomes, this study did not examine rs competency or racial coping self-efficacy. thus, we are not aware of black emerging adults’ perception of how they believe they manage racial stress and trauma, nor are we aware of this population’s confidence and skill level in engaging in rs communication (i.e., rs competency). examining these recast components would likely provide more context in understanding black emerging adults’ mental health outcomes that have experienced race-related stress and complex trauma. specifically, the recast model emphasized the importance of parent and youth competence in transmitting and engaging in rs communication (anderson & stevenson, 2019). future studies should examine rs competency and coping self-efficacy for trauma and race-related stress to effectively explore how rs can serve as a protective factor. trauma, race-related stress, and racial socialization 13 barber & mance in alignment with the recast model, the primary appraisal of discriminatory racial encounters determines one’s level of racial stress. the primary appraisal is best understood by determining the secondary appraisal of one’s racial coping self-efficacy, which will aid in determining how one engages and navigates discriminatory racial encounters. it is critical to note that data collection for this study occurred during a time when black americans were experiencing both the covid-19 pandemic and a racial pandemic. the covid-19 pandemic highlighted long-standing racial disparities in health outcomes, while black americans were also experiencing heightened racial injustices that were highly publicized across all media platforms. the heightened sociopolitical period and persistent racial injustice may have impacted how the study population attended to and their understanding of rs messages. thus, race-related stress was exacerbated during this time, which may explain why rs messages did not serve as a protective factor. therefore, a limitation of this study was not examining the population’s racial coping self-efficacy and rs competency, especially during a time of heightened discriminatory racial encounters. another limitation of this study was that our study population had similar demographics. the study population mainly consisted of college students. further, most of the study sample had a middle to high household family income during childhood. research has found that context is essential regarding rs. for example, previous studies have found that rs messages are communicated more frequently in families with higher education and ses (hughes et al., 2006). a more diverse sample consisting of a community sample could help provide more understanding of how rs can be generalized to black americans to serve as a protective factor for adverse outcomes of childhood trauma and race-related stress. subsequently, nearly half the study population indicated that they had seen a therapist for depression, anxiety, or trauma for over a month. whether the participant saw a therapist or not was not controlled. therefore, the lack of association between childhood trauma, race-related stress, rs messages, and internalizing symptoms may be due to coping contributing to other contextual factors, including mental health treatment. future studies may consider controlling for mental health treatment to assess rs as a protective factor. another possible reason for the lack of relationship between childhood trauma, race-related stress, rs messages, and internalizing symptoms may be due to the selected measures in the study. notably, the data collected was based on retrospective experiences, including black emerging adults recounting past childhood experiences and recalling rs messages they received or did not receive from their parents or caregivers. while we firmly believe our study participants’ understanding of their past experiences is insightful and informative, this study may be limited in participants' recounting all their experiences. further, our outcome measure was limited in exploring the full range of psychological distress this population may be experiencing. the bsi-18 explored only anxiety, depression, and somatization symptoms within seven days. additionally, the present study only used quantitative measures to examine the symptomology of black emerging adults who have experienced childhood trauma and race-related stress. this is limiting, as quantitative measures do not explore the in-depth life experiences of this population and how their experiences contribute to their mental health outcomes. qualitative and mixed-methods studies would help to better understand black emerging adults’ childhood trauma, racial stress, rs, and psychological outcomes. all of which could help provide more insight into how rs may serve as a protective factor for this population. lastly, the rsq-t measure, which assessed the frequency of racial socialization messages black emerging adults received from parents or caregivers, was limited in capturing messages across child development. this is a notable limitation, as emerging adults may engage in fewer race-related discussions with caregivers over time. future directions our study findings indicate that black emerging adults with childhood trauma histories and race-related stress are linked to increased internalizing symptoms. future research should consider exploring coping strategies that serve as protective factors for this population. specifically, future research should investigate different subtypes or different types of childhood trauma (e.g., physical abuse, sexual abuse, physical neglect), racial stressors (e.g., cultural, institutional, and individual racism), and rs messages (e.g., racial pride and self14 worth messages) as each experience could influence one’s mental health differently. specifically, future research should examine the associations between different types of childhood trauma, race-related stressors, and rs messages to determine whether certain types of trauma are linked to race-related stress and whether specific rs messages serve a protective role in these relationships. examining this relationship is particularly important because one possible explanation for why race-related stress did not emerge as a moderator or exacerbate the internalizing symptoms associated with childhood trauma may be that race-related stress is already closely tied to the traumatic experiences encountered during childhood for this population. although we found that rs did not serve as a protective factor for our study population’s symptoms, we hesitate to conclude that rs does not serve as a protective factor for black emerging adults who have experienced childhood trauma and race-related stress. this is due to previous studies suggesting that rs promotes positive mental health outcomes for black americans. in order to determine rs’s role as a coping mechanism for black emerging adults with a history of trauma and race-related stress, future research should examine the recast component variables, rs competency, and coping self-efficacy, and the present study variables, childhood trauma, race-related stress, rs, and internalizing symptoms. examining all study variables will provide more insight into this population’s perception of their traumatic and stressful experiences and how rs could buffer against symptoms. focusing on the quality of rs communication—specifically by examining rs competency (i.e., confidence and skills in rs communication)—rather than the frequency of rs messages, is likely to provide greater insight into its role as a protective factor. regarding methodology, future studies should include outcome measures that explore more symptomology (e.g., externalizing symptoms, self-esteem, hypervigilance, etc.) with a more diverse sample population. further, future research should consider using a qualitative or mixed-methods research design. this design would help scholars gain a more in-depth and nuanced understanding of black americans’ psychological outcomes who have experienced childhood trauma, race-related stress, and received rs messages. implications the current study’s findings indicate that childhood traumatic experiences and race-related stress influence mental health outcomes for black emerging adults. rs messages did not moderate symptoms for black emerging adults who experienced increased childhood trauma and race-related stress. however, results found that black emerging adults who experienced childhood traumatic experiences and received rs messages were associated with having increased internalizing symptoms. although we found that a higher frequency of cumulative rs messages has the ability to produce adverse mental health outcomes for black emerging adults who have experienced trauma, the literature supports that rs messages can serve as a protective factor for black americans who have experienced race-related stress (davis et al., 2017; granberg et al., 2012; neblett et al., 2008). our study adds to the growing body of literature that context is important when communicating rs messages. thus, it is essential to consider black americans’ trauma histories when utilizing rs, as certain messages may have the ability to improve or worsen mental health outcomes for this population. for rs to be effective in serving as a protective factor for black emerging adults who have experienced childhood trauma and race-related stress, assessing for and fostering rs competency may be beneficial for black emerging adults and social figures. social figures, including parents, caregivers, family members, teachers, mentors, mental health professionals, etc., may benefit from participating in accessible community workshops and work training that provide education on rs and practical rs communication tools. it is also suggested that rs resources and education are provided for black emerging adults, which will help strengthen rs communication and help build confidence in utilizing rs when navigating trauma and stress. social figures practicing cultural humility (being open, self-aware, and self-reflective when interacting with diverse individuals) is also essential (mosher et al., 2017). cultural humility is necessary as it embodies person-centered, respectable, and nonjudgmental communication. for black emerging adults who have experienced significant trauma and stress, cultural humility may help this population feel safe when feeling vulnerable discussing significant life stressors. researchers and clinicians should incorporate cultural humility into practice with ethnically, racially, and culturally diverse clients or patients and recognize within-group differences (metzger et al., trauma, race-related stress, and racial socialization 15 barber & mance 2021). this is critical when assessing and treating clients, as the trauma this population has experienced and the rs messages they receive will vary from person to person and impact individuals differently. therefore, mental health clinicians working with black emerging adults should consider implementing culturally tailored interventions in assessment and therapy settings to help meet this population’s unique needs. in terms of assessment, clinicians should use culturally appropriate assessment tools to assess the client’s childhood trauma and race-related stress history. additionally, clinicians should assess the rs messages that clients already receive and how those messages impact them. assessing the rs messages the client already receives and utilizes will help the clinician understand which messages have been beneficial and harmful for the client. this will further help the clinician know which messages to incorporate into treatment. following assessment, the clinician should collaborate with the client to provide culturally responsive treatment that best meets the client’s needs. this may include a cultural adaptation to trauma treatment. for example, metzger and colleagues (2021) created a culturally responsive adaptation to trauma focused cognitive behavioral therapy (tf-cbt) that focuses on implementing rs into tf-cbt for black youth with interpersonal and racial trauma histories. the findings of this study highlight that more exploration of culturally responsive and accessible coping strategies and treatment is needed for black emerging adults experiencing childhood trauma and race-related stress. notably, it is imperative to acknowledge that, regardless of rs serving as a potential cultural coping strategy that may reduce psychological distress related to stress and trauma, this is not a solution to systemic oppression. we assert that the solution lies in recognizing and addressing the historical and ongoing systemic and racial oppression embedded within societal structures. rs can be most effective when there is a committed effort to confront and dismantle systemic racial oppression. conclusion in conclusion, the results of this study provide new insight into the influence of childhood trauma, race-related stress, and rs messages on black emerging adults internalizing symptomology. using some components of the recast framework, we found that black emerging adults experience increased internalizing symptoms when experiencing childhood trauma or race-related stress. we discovered that rs was not a protective factor for this population. in fact, for black emerging adults with childhood trauma histories, a higher endorsement of rs messages, in the absence of race-related stress, was linked to increased internalizing symptoms. these findings call for additional research to investigate all recast framework components, 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(2010). child maltreatment and delinquency onset among african american adolescent males. research on social work practice, 20(3), 253–259. https://doi. org/10.1177/1049731509347865 19 barber & mance table 1. descriptive statistics: main study variables and subscales 20 trauma, race-related stress, and racial socialization table 2 demographics of the sample 21 barber & mance table 3 all in multiple regression with internalizing symptoms as outcome variable, and childhood trauma, race-related stress, and racial socialization messages as predictor variables note. *p<.05. **p < .01. ***p< .001 22 trauma, race-related stress, and racial socialization table 4 hayes process model 3: childhood trauma (x), race-related stress (w), racial socialization messages (z), internalizing symptomology (y) note. *p<.05. **p < .01. ***p< .001 23 barber & mance figure 1 statistical framework of childhood trauma, racial socialization race-related stress, and internalizing symptoms note. andrew hayes’ process model 3 (moderated moderation analysis) is the statistical framework presented. x = childhood trauma (independent variable; ctq score), y = internalizing symptoms (dependent variable; bsi-18 score), w = race-related stress (moderator 1; irrs-b score), and z =racial socialization (rs) messages (moderator 2; rsq-t score). 24 figure 2 two-way interaction between combined childhood trauma and combined racial socialization messages trauma, race-related stress, and racial socialization 88 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university sociocultural constructs in the conceptualization of adjustment disorder in an undocumented mexican female selina mangassarian, m.a. and lekeisha sumner, ph.d. alliant international university latino immigrants of mexican descent comprise the largest segment of the undocumented population in the united states and experience heightened risk for emotional distress. despite this knowledge, psychological treatment for this group has received limited clinical attention regarding research and treatment options specific to this subpopulation. this case study describes the treatment of a young, undocumented, mexican female diagnosed with adjustment disorder. treatment was based on a cognitive-behavioral framework, which integrated cultural values within a socio-political context. because treatment methods for adjustment disorder were found to be culturally inappropriate, outdated, or lacking empirical evidence, the clinician integrated various empirically supported methods. treatment incorporated cultural values into cognitive-behavioral therapy methods. the sensitivity and awareness to culture by the clinician led to a successful treatment outcome. theoretical and research basis for treatment in 2011, latino immigrants in the united states represented 80% of the approximately 11.2 million undocumented immigrants, and more than six million of these individuals were of mexican descent (gonzalezbarrera, lopez, passel, & taylor, 2013; passel & cohn, 2009). latino immigrants, especially those who have resided in the united states for an extended period of time, are at heightened vulnerability for experiencing symptoms of emotional distress (gonzales, suarezorozco, & dedios-sanguineti, 2013). furthermore, undocumented immigrants are more likely than documented immigrants to meet diagnostic criteria for anxiety and adjustment disorders (ad; gonzalezramos & gonzalez, 2005). while several explanations for these findings have been offered, there is general consensus among researchers and clinicians that factors stemming from immigration-related and acculturative stressors (gonzales et al., 2013). among undocumented latino immigrants, unique factors that may complicate treatment and increase risk of ad and anxiety include the legal issues that surround undocumented status (sullivan & rehm, 2005). smith (2001) reviewed mental health issues among individuals who recently immigrated to the united states mainland and found that many immigrants chose not to seek mental health or medical treatment. smith (2001) concluded that this finding was due to fear of deportation, discrimination, lack of financial means, limited access to healthcare, as well as cultural factors including language barriers, stigma of seeking mental health treatment, and lack of education regarding what treatment entails. since mental health professionals vary in their case conceptualizations, subjective opinions, and creativity, the use of evidence-based practices (ebp) increase effectiveness of patient services and improve public health (norcross, beutler, & levant, 2006). interventions based on ebps have shown scientific evidence of consistent client improvement (drake et al., 2001). evidence-based practices allow for a level of uniformity in providing care to a broad base of clients; therefore, promoting a systematic approach to treatment is beneficial for researchers and practitioners in order to measure efficacy among various populations (bernal, jiménez-chafey, & rodriguez, 2009). unfortunately, there is currently a lack of evidence-based research to inform the necessary treatment for undocumented immigrants of mexican descent. override (hidden running head text): mangassarian, sumner adjustment disorder in an undocumented immigrant please address correspondence regarding this article to: selina.mangassarian@gmail.com 89 adjustment disorder in an undocumented immigrant from the available literature, it appears that common coping strategies among some people in this population are: (a) the internalization of emotional distress, and (b) the avoidance and apprehension of seeking mental health treatment. o’connor and cartwright (2012) provided general recommendations that included symptom relief, restoration of functioning, and the prevention of developing more serious mental disorders. cognitive-behavioral therapy (cbt) is one treatment modality that has demonstrated effectiveness in the treatment of ad (o’connor & cartwright, 2012). although additional treatments can be supplemented, ultimately, the basic offering of ebps should not be displaced for interventions of unknown or lesser effectiveness (drake et al., 2001). cognitive behavioral therapy has been shown to be effective for immigrant latino populations because it aligns well with many cultural values, including the expectation that treatment leads to immediate symptom relief, a focus on the present, a problem-centered approach, and direct and active interventions from someone who is considered an expert (organista, 2006). since cbt approaches quickly orient patients to the therapy process, this demystification of treatment allows for latino immigrant populations to lessen their hesitancy toward treatment (orlinsky & howard, 1986). the collaborative and engaging approach of cbt, embodied in activities such as psychoeducation and homework assignments, may be better received by clients than other therapy orientations (organista & muñoz, 1996). given this emerging knowledge and the limited availability of empirically supported, culturally-tailored treatments, there is a pressing need for clinicians to consider the unique challenges faced by this population. the ethical use of culturally-tailored treatments have been debated because of the possibility that ebps were developed with a particular linguistic and cultural context in mind. thus, they may not be appropriate for ethnocultural groups that do not share the same language or cultural values (bernal et al., 2009). although cbt is most effective for latino undocumented immigrants suffering from ad, not all components of cbt need to be followed. for example, the assertiveness of cbt is conceptualized to be based in a more individualistic society as opposed to a collectivist one (hinton, hofmann, rivera, otto, & pollack, 2011; organista, 2006; organista & muñoz, 1996). the subject of the following case study, eva, is from a collectivist culture, thus treatment. integrated cultural values within a cognitive-behavioral perspective. the treatment did not strictly adhere to a manualized treatment. given the multi-level societal systems (e.g., political, education, occupational, and social) that contribute to the marginalization of undocumented immigrants in the united states, especially those of color, the role of socio-political factors was considered in conceptualization and treatment. culturally-modified trauma-focused cbt for latinos is a new treatment method that has been shown to improve engagement by those who were resistant to previous, non-culturally modified therapy options (hinton et al., 2011). thus, cbt was chosen for several reasons, including the client’s desire for immediate symptom relief and preference for structured sessions. the purpose of this case study is to increase awareness of not only the lack of ebp methods available for ad, specifically to an undocumented immigrant population, but also to provide a framework for determining appropriate treatment options when systemized treatments are unavailable. case study introduction “eva,” a 20-year-old undocumented single mexicanamerican female living in southern california, self-referred to individual therapy at a community mental health center for symptoms of anxiety. she presented as well-groomed and appropriately dressed, with a dark complexion, dark brown hair and eyes, and was noticeably overweight for her height. eva had chosen to continue therapy after family therapy at the agency had unfavorable outcomes, as her parents felt that it was shameful to share their family troubles with an outsider. since she was still living at home, where she experienced considerable family conflict, she wanted to process her anxiety. in mexican cultures, seeking mental health treatment is viewed to be inappropriate due to values like familisimo, which views voicing family issues as a betrayal of loyalty to the family (flores & kaplan, 2009), and thus a disruption to the collective good (martinez, polo, & carter, 2012). however, eva was experiencing a clash between her cultural duties and her personal well-being, which was influenced by her american ideals. when this interplay of biculturalism, of or relating to two distinct cultures, occurs for 90 mangassarian, sumner a mexican-american immigrant youth, vulnerability to mental distress is heightened (gonzales et al., 2013). eva was born in mexico and moved to southern california at age two with her mother and older sister to join her father. at the time of therapy, she lived with her parents and younger sister, with whom she began to experience considerable conflict. she also described financial strain. she had recently deferred from a local prestigious university in order to dedicate her time to work. she enjoyed her job and had developed strong supportive relationships with her co-workers. her goal was to re-enroll in university once she saved enough money, as her undocumented status would not allow for financial assistance. eva was diagnosed with adjustment disorder, chronic, with anxiety to reflect the severity of her psychological distress over the previous six months. at the community mental health center, eva was assigned to a student clinician, who is the author of this case study. the student clinician was a secondyear caucasian female graduate student supervised by a licensed mental health care professional. the clinic was located in a main city in southern california where there was a varied client population of all ages, low to moderate socioeconomic income, low to high levels of education, and minimal undocumented immigrants. the following sections describe the case history, assessment of eva’s anxiety regarding the situation with her parents, course of treatment, a thought journal plus evidence, and assertiveness training. case history stressors eva presented with symptoms of anxiety, which she indicated that she had experienced for the past five years. her adjustment issues began eight months prior to therapy when she encountered an unexpected stressor regarding her family system: she discovered that her father had an affair when she was two years of age that resulted in a half-brother for eva. her father asked that she keep this knowledge confidential. eva respected his wishes for four months until she could no longer deal with the guilt of keeping this secret from the rest of her family. she had been severely affected by her family members’ denial, verbal fights, and avoidance about the stressor. for example, with regard to her father, eva felt that he was much kinder and attentive toward her when she was keeping his secret. she stated that their family only communicated when they were all watching tv together. her mother, conversely, was more extroverted and outspoken about the family’s conflicts. eva stated that her mother had been acting “childish,” “immature,” and “pathetically.” because eva believed that this news would lead to her parents’ separation, she deferred from university and began to work full-time in order to support her mother and sister if needed. eva’s disbelief regarding her parents’ decision to stay together despite their unhappiness represents a common bicultural clash between older and younger immigrant generations (gonzales et al., 2013). she coped maladaptively by avoiding interactions with her parents, staying at work longer, and spending time with co-workers after work hours. physical manifestations of her anxiety reportedly included bodily tension, especially in the upper back area, and frequent headaches. family obligations eva is the second child of four children: three daughters and one son. her family moved to southern california from mexico when she was two years of age to live with her father, who immigrated to the united states two years earlier for safety reasons stemming from a financial dispute in mexico. when the family reunited in the u.s., there were no reported problems other than eva’s undocumented status, apparently because her immigration paperwork had not been completed and submitted. her mother was a homemaker and her father had intermittent jobs in construction, which resulted in chronic financial strain for the family. eva’s family held traditional mexican beliefs, such as a concern for the image of the family in the community and gender-stereotyped machismo and marianismo roles of the father as a physical provider and the mother as a caretaker (flores & kaplan, 2009). she explained that if her mother were to work, it would be considered disrespectful. because her mother was invested in this traditional gender role stereotype, eva felt pressured to assume more financial responsibilities. eva’s impulsive decision to defer her attendance at the university was a reaction to what she perceived as her parents’ imminent separation. however, her parents decided to stay together for the sake of their family image—albeit in a dysfunctional uncommunicative relationship. moreover, they continued to depend on eva’s earnings for their expenses. 91 adjustment disorder in an undocumented immigrant cultural vs. personal goals eva disclosed her difficulty establishing and maintaining boundaries with her parents and felt torn between her cultural obligation to demonstrate deference to her parents and her personal, academic, and financial goals (flores & kaplan, 2009). at the time of treatment, eva worked at a non-profit human and immigration rights organization with undocumented high school students who were applying for college. eva had worked with immigration lawyers for many years to receive legal status in the u.s., without success. thus, she planned to take classes at a city college while she saved money so that she could complete general education courses that would transfer to the university she previously attended. as an undocumented citizen without a social security number, eva was ineligible to receive financial aid for school. cognitive-behavioral therapy the psychosocial aspects of the case made cbt a good fit for treatment. eva had been internalizing her emotional distress and avoiding communication with her parents. she and her family required direct interventions, which can be obtained using cbt (o’connor & cartwright, 2012; organista, 2006). cbt is effective when one’s distorted views can be altered by interpreting the background of a misinterpretation, recognizing the difference between the self and the ideal self, and recognizing that some fears are unrealistic (beck, 1976). this internal dialogue of labeling experiences as positive or negative is what beck (1976) referred to as “automatic thoughts,” which are often impulsive and perceived as true (mckay et al., 2007). beck aimed to challenge these spontaneous, learned, and idiosyncratic thoughts by confronting the limited thought patterns through cognitive therapy (mckay et al., 2007) and having the clients discover the meanings and functions behind the thoughts (corey, 2009). initial assessment and conceptualization eva was cooperative during the initial assessment session. she presented as slightly overweight, generally healthy, dressed appropriately, and well-groomed. her movement was unremarkable. her speech took on a soft volume with moments of slowed speech when providing negatively emotionally charged information, yet pressured and sarcastic when speaking about upsetting and frustrating information. she displayed a broad range of affect that was congruent with thought content and her mood was generally anxious. she denied the presence of hallucinations and delusions, suicidal and/or homicidal ideation, and her sensorium appeared to be intact. she was oriented to person, place, time, and situation. her intelligence and memory appeared to be average, and she demonstrated adequate judgment and insight. throughout treatment, eva was observed to be committed to psychotherapy and eager to alleviate her distress, as demonstrated by not missing any appointments, remaining punctual, open to the therapeutic process, and completing assignments. throughout the initial intake sessions, the therapist assessed for symptoms of generalized anxiety, depression, and alcohol use for differential diagnoses and to rule out disorders. eva denied ever experiencing symptoms of anxiety of this severity before the current stressors (e.g., financial strains, deferring from university, family communication style). based upon data revealed during the clinical interview, it was determined that symptoms reflective of adjustment disorder along with some symptoms of anxiety were causing the most interference and distress in eva’s life. she was relatively relaxed during the clinical interview and demonstrated a constricted affect; however, when discussing her family, a sharp change in demeanor would occur. for example, when discussing her father and her finances eva became animated in her discussion—rolling her eyes, flaying her arms about, trembling with her hands, and shaking her right leg up and down uncontrollably. due to the mental health center’s policies, the therapist was unable to use self-assessment measures to assess for these diagnoses further. although the situation with her father’s affair caused much anxiety, eva’s behaviors due to her anxiety had greatly interfered with her social and academic life. this anxiety likely interfered with her ability to create a logical plan regarding her university attendance and completion. as more people in her family discovered the situation, her worries grew and her tendency to want to control all outcomes within relationships increased, thus precipitating her issues with adjusting to the stressor further, resulting in ad with anxiety. 92 mangassarian, sumner course of treatment and assessment of progress goals the specific goals of treatment were (a) to provide cognitive-behavioral psychoeducation, (b) to learn to identify, challenge, and alter automatic thoughts, and (c) to engage in assertiveness training in order to set boundaries with eva’s parents in an attempt to decrease her financial burden. cbt is a theoretical orientation that has been adapted for patients with varying levels of education, socioeconomic status, ethnic and cultural identities, and developmental stages (corey, 2009). these were key aspects taken into consideration while choosing the best approach for this case since the client was an undocumented mexican immigrant youth from a lower socioeconomic background. structure of cbt treatment treatment with eva was once per week for 50-minute sessions for four months, totaling sixteen sessions with the clinician. her symptoms were monitored throughout the course of treatment via clinical interview questions at the beginning of each session. the initial sessions were focused on establishing a healthy rapport and strong therapeutic alliance between eva and the clinician. she and the clinician discussed relevant cultural differences between them; the clinician was armenian-american, born in america, and a second year graduate student from upper-middle socioeconomic class, whereas eva was mexican-born, undocumented, unable to attend university, and from a lower socioeconomic class. once they discussed the potential challenge of cultural dissimilarities between the two parties, the therapeutic alliance was easily established and was characterized by trust, comfort, and ease of conversation. eva was rarely hesitant to share information and discussed her problems openly and effortlessly. although cbt methods served as the foundation for treatment, a formal treatment guide was not followed due to the lack of empirically supported methods for ad. in conjunction with o’connor and cartwright’s (2012) previously described general guidelines for treatment, the clinician used portions of thoughts and feelings: taking control of your moods and your life workbook by mckay and colleagues (2007). resources utilized for sessions included providing psychoeducational cbt worksheets, blank thought journal worksheets, blank thought and evidence journal worksheets, and relevant and appropriate assertiveness training handouts. the first phase of treatment was used to gather information regarding symptom frequency and severity, personal data, and diagnostic information in order to determine diagnosis and appropriate treatment. additionally, the clinician and eva clarified realistic expectations for change from treatment and the obstacles that may reroute some planned sessions due to the possibility of refocusing sessions based on her needs from that week. the second phase of treatment involved psychoeducation for the cbt orientation, the cbt thought triangle proposed by beck (1976), and cultural implications of cbt. the clinician explained the general process of cbt as one that was structured, required homework assignments, and was based on the premise that an individual’s behaviors and feelings lead to his or her thoughts. eva displayed excitement to begin this plan because she preferred a structured treatment. the third segment of treatment explored the nature and function of her automatic thoughts and schemas and how they informed her symptoms. this segment included homework assignments from mckay and colleagues’ (2007) workbook, which promoted listening to the meanings behind automatic thoughts. for two weeks, eva kept a thought journal of the presenting situations she encountered, which included (a) a one-word description of the feeling caused by the situation, (b) a distress rating from 0–100 (0 = no distress, 100 = most distress possible), and (c) the automatic thought she had just before and during the unpleasant feeling. the fourth phase of treatment focused on how to label and challenge automatic thoughts by keeping a thought and evidence journal. this included the previous three thought journal columns (one-word feeling, distress rating, and automatic thought) and added three more columns that (a) labeled which limited thought pattern eva experienced, (b) identified what techniques she could use to balance or alternate the thoughts, and (c) re-rated her feelings after working through them. eva was provided with a handout of the main eight automatic thought patterns and their explanations as reference along with practice exercises of sample statements matched to the correct automatic thought. 93 adjustment disorder in an undocumented immigrant after keeping these records for two weeks and processing them for repeated themes and patterns in sessions, it was determined that “catastrophizing,” “shoulds,” and “personalization” were the most frequent automatic thought patterns in which eva would engage. as explained by mckay and colleagues (2007), catastrophizing is when an individual assumes that the worst will happen, shoulds are the arbitrary rules for behavior that one sets for themselves and others, and personalization is when an individual compares themselves to others or assumes that the reactions of others always relate to him or her. automatic thought pattern: catastrophizing. when eva thought in a catastrophizing manner, she would feel anxious, fearful, guilty, and self-loathsome. an example of her catastrophizing was when she felt she could never save enough money to go back to university because of her inability to set boundaries with her parents about finances, without disrespecting them. during treatment, the clinician and eva deconstructed the meaning behind this automatic thought: eva was uncertain of her ability to both support her family’s finances and save money for herself to use to return to university. to challenge these thoughts, eva would answer, “what are the odds?” of her automatic thought. eva realized that she had been making her situation catastrophic in her mind when she knew if she approached her parents in an appropriate manner and voiced her concern, which she had not been able to do before, they would understand her struggle and decrease the amount of money they requested from her. automatic thought pattern: personalization. an example of eva’s automatic personalization thought would typically occur when she tried to decrease the amount of money she gave to her family and perceived that they acted cold with her when she did not give enough. thus her behavior was to continue to give them the exact amount of money they requested in order to avoid conflict. when the automatic thought was processed, it was determined that it was a function of her cultural belief that she was obligated to take care of her family before herself. fitting with this belief, eva had reported that her reason to achieve a higher education degree was not only to gain an education for herself but in order to secure a higher paying job and better provide for her family. when eva explored this consideration and combined it with other cultural factors, such as her conflicting level of biculturalism with her parents, she realized that the purpose behind her desire to give her family less money now was so that she could provide more financial assistance to her family in the future. automatic thought pattern: shoulds. when eva judged her parents for their dysfunctional communication style, she would automatically reflect, “i shouldn’t be thinking like this about my parents, i’m such a horrible daughter,” indicating some overlap with shoulds and catastrophizing. the meaning behind this automatic thought was processed to understand that values are personal and so her judgment of her parents as “immature” and “irresponsible parents,” is her right. she may feel guilty for such thoughts; however, the meanings behind them were not false accusations. her avoidance of her parents exacerbated her guilt for judging them and led to other shoulds, such as “i should be able to handle their issues; my sisters are okay so why am i so affected by them?” regarding comparing herself to her sisters (personalization), the clinician encouraged eva to engage in positive psychological methods that would allow her to recognize that all individuals have their strong and weak points. she was not expected to think and behave like her sisters because she was not the same person as her sisters. also, the clinician and eva discussed the fact that she played a different role than her sisters since she was the first to know about their father’s affair, as well as being the one to break this news to the family. assertiveness program although eva alleviated her adjustment issues using these cbt techniques, she still needed to improve her financial situation, which would involve reducing her financial assistance to her family from $600 to $250 per month. thus, the fifth phase of treatment was a 10-week module-based assertiveness program developed by the government of western australia’s centre for clinical interventions (2008). although this program was created in australia, it was the only easily available, empirically based resource for the clinician due to the clinic’s limited cbt resources. this program was deemed appropriate by the clinician and her supervisor for an undocumented mexican immigrant in the u.s., since its modules were broad, allowing for necessary cultural adaptations. the modules completed by 94 mangassarian, sumner eva consisted of psychoeducation on the meaning of assertiveness, how to recognize and engage in assertive behavior, how to reduce physical tension, and how to deal assertively with criticism and disappointment. in conjunction with these weekly modules, the clinician and eva participated in role-playing situations to prepare eva to approach her parents and respond to their reactions. the outcome of this was successful: eva assertively approached her parents with her request to reduce the money she gave to them and used a chart to show them her budget and her plan for returning to university. eva created this chart as a personal project outside of therapy, but she brought the chart into session after she unveiled it to her parents in order to process the experience. during assertiveness sessions the clinician and eva drew attention to the value differences between eva and her parents, contextualized the difference, reframed the problem, and previewed the future possible bicultural challenges (gonzales suarez-orozco & dedios-sanguineti, 2013). this way, eva was able to present her argument to provide less money to her parents in a sensitive and thoughtful manner so they did not feel blamed for her struggles. modifications made to the modules to fit cultural considerations included issues such as tone of voice, body language, and eye contact. outcome of treatment eva reached the goals she had set for therapy and terminated at the same time that the clinician’s training at the clinic was ending. by the end of treatment, eva was able to identify her limited thought patterns and had challenged them by continuing to keep a thought and evidence journal. due to the assertiveness training, she was able to limit her financial contributions to her family and was able to say “no” when they asked her for money that she could not allot from her budget. thus, by saving this money, eva was able to achieve her financial goals and return to university. since eva’s goals for therapy at the time of treatment were short-term and solution-focused, she did not always have the opportunity to process the weekly communication that occurred within her household. this was not detrimental to treatment because there was a mutual agreement that the session goals were oriented to solution-focused problem-solving more so than a processing style. although she had a much lower amount of anxiety regarding the situations at home, there were some issues that she could not control, such as her parents’ employment status. therefore, it was recommended that eva continue treatment as a transfer client to a new student clinician who would be joining the clinic in the coming year. she had acquired new tools to understand and process her emotions and thoughts, but the accountability presented by seeing a clinician, especially one trained in multiculturalism, would provide a good support system in order to continue to facilitate the development of eva’s coping strategies. case conceptualization eva’s case conceptualization was divided into two main domains, which influenced her presentation and treatment. the first domain involved mexican cultural norms dictating parenting practices, regardless of children’s age. in mexican families there is an expectation to respect parents, to put the needs of the family above the needs of the individual, and to be obedient to family requests (luis, varela, & moore, 2007). although it has been reported that anxiety manifests itself as somatic complaints among latinos more so than any other ethnic minority in the united states (martinez et al., 2012), eva’s anxiety manifested as avoidance and internalized self-loathing. eva’s engagement in her selfless accommodating behaviors for her family conflicted with her thoughts regarding her own well-being; this reflected cognitive dissonance. that said, the clinician incorporated eva’s culturally-based inclination to protect her mother and sister from financial strain into treatment via validation and affirmation. this collectivist value was positively reinforced in session and was understood as a positive quality—reflective of eva’s thoughtful and dedicated character. moreover, the clinician worked to help eva utilize this strength in more adaptive ways that would not interfere with her personal goals. the second domain considered while conceptualizing eva’s case involved her self-efficacy. eva’s diagnosis of adjustment disorder with anxiety was precipitated by eva’s difficulties with her father’s affair and pressure to keep the secret. her automatic thoughts of personalization, catastrophizing, and shoulds, as well as an emotional, behavioral, or physiological reaction served 95 adjustment disorder in an undocumented immigrant as the basis for her diagnosis (beck, 2011). her symptoms were exacerbated by her limited coping strategies and self-schemas relating to self-efficacy. more specifically, she engaged in maladaptive coping (e.g., avoiding her parents) and believed that she had limited capacity to problem-solve and assert her needs to her family. three problematic situations triggered eva’s maladaptive and automatic thoughts. according to cbt, these automatic thoughts lead to symptoms of anxiety due to feelings of vulnerability (beck, emery, & greenberg, 1985). beck and colleagues (1985) defined vulnerability as the perceived internal or external danger a person feels, which cannot be controlled by his or her own efforts to feel safe. this vulnerability to learned, automatic thoughts leads to cognitive dysregulation, where the increased threat to security results in a decreased ability to cope and feel protected (clark & beck, 2010). eva’s symptoms were not solely due to cognitive processing but also due to a faulty information-processing system where situations presented were processed to have more meaning and perceived threat than necessary (clark & beck, 2010). when the news of the affair first broke out in her family, eva would perceive any form of communication between her parents as an opportunity for them to inflict verbal and emotional pain on one another, thus affecting her as well. in reality, her parents’ communication style at the beginning of this adjustment process was expected behavior for a couple working through relational issues. eva attempted to alleviate her anxiety by making plans to “fix” her problems, such as mentally rehearsing what she would say to her parents about her financial stress. however, when those strategies failed, she would cycle back to relying on her effortless, involuntary, and automatic information-processing system. eva’s compensatory behavioral strategies for these automatic thoughts included avoidant behaviors. consistent with the literature, these behaviors served as safety measures that shielded eva from unpleasant feelings and feared outcomes; however, they also exacerbated symptom severity (helbig-lang & petermann, 2010). eva used emotional avoidance strategies to escape undesirable emotions, which negatively reinforced feelings of anxiety and adjustment issues since they provided temporary relief (barlow, allen, & choat, 2004; helbig-lang & petermann, 2010). more specifically, eva engaged in what barlow and colleagues (2004) defined as preventative and restorative safety behaviors. preventative safety behaviors are those that aim to prevent future distressing emotional events. this was exemplified in eva’s case by her act of deferring from university to prevent the financial strains that would have occurred if her mother were to leave her father. restorative safety behaviors include those that attempt to control or alleviate emotional responses. this was evident in eva’s avoidance of her family home due to the conflict. undocumented immigrants of mexican descent suffer a paradox because they require treatment for ad (gonzales et al., 2013; gonzalez-ramos & gonzalez, 2005; sullivan & rehm, 2005), but this specific population is unlikely to seek mental health treatment (flores & kaplan, 2009; martinez et al., 2012; smith, 2011). moreover, evidence-based practices are necessary for effective and systematic treatment of ad; however, this is lacking for an undocumented mexican immigrant population. thus, this treatment took into consideration the cultural norms in mexican parenting, collectivist cultural values, the self-concept and maladaptive coping of the client, and the preventative and restorative safety behaviors in which the client engaged. the clinician’s sensitivity and awareness to culture led to a successful treatment outcome. eva was able to identify limited thought patterns and challenge them, the assertiveness training was successful, and as a result, eva achieved her financial goals and was able to return to university. treatment implications of the case mexican immigrants who have lived in the united states for longer than approximately thirteen years are at heightened risk for mental health disorders than those who have resided in the united states fewer years (vega et al., 1998). further, the circumstances by which individuals immigrate may render them socially vulnerable to experiencing distress. eva’s case was unique because she presented with a diagnosis for which treatment was lacking, especially among undocumented mexican immigrant populations. the presenting case study illustrates the successful subjective integration of varying empirically supported cbt methods for ad with anxiety for an undocumented, immigrant, mexican female. 96 mangassarian, sumner important considerations made for this successful outcome were (a) the awareness and sensitivity to the cultural clash, not only within the therapy room but also within eva’s family, and (b) the need to modify cbt methods to fit eva’s cultural background. the clinician was constantly aware of eva’s people-pleasing tendencies due to her cultural obligation influencing obedience to authority. to ensure that eva would not simply try to please the clinician, as an authority figure, the clinician was cognizant of the directive language she used during sessions, especially since cbt sessions tend to be instructional. additionally, when making modifications to empirically based programs, the clinician had to take all measures necessary to not completely alter the modules. recommendations to clinicians and students it is important for clinicians to thoroughly research all available treatment options for diagnoses that lack suggested treatment methods. if research is lacking, it is the responsibility of the clinician to make an informed, rational, and competent treatment decision. a limitation of the treatment for this case was the use of an assertiveness training module based on research statistics among australian adults. given the limitations of resources to the clinician and the treatment setting, this program was deemed adequate for the goals at hand, especially since the modules left room for professionals to incorporate relevant factors, such as culture. for students, and even licensed clinicians, if a case is beyond the scope of practice, the safety and well-being of the patient should take precedence and consideration should be made for a referral to a more experienced therapist. although not extreme, the therapist did face some countertransference issues that required additional supervision. in order to maintain sociocultural sensitivity and a healthy therapeutic alliance with cbt techniques, therapists need to be cognizant of (a) their own reactions to clients, (b) their competence regarding sociocultural differences that can influence the therapeutic relationship, and (c) their competence concerning the specific norms and needs of the client’s cultural background (wright, basco, & thase, 2006). because the therapist in this case was also from a collectivistic culture, she could understand eva’s rationale on many issues. however, the therapist had a hard time accepting that one’s parents would put their child in a financially difficult situation where education would be a secondary goal. since the therapist was raised in an environment where education was priority, it was necessary for her to come to terms with the differences in cultural expectations of children within a mexican-american family. the cultural factors presented in such a case as eva’s must be given the utmost attention so as not to jeopardize the therapeutic alliance. issues of immigration, documentation, barriers to education, healthcare, and legal systems, biculturalism, conflicting family dynamics, and socioeconomic status have important implications for treatment. if the clinician had not considered the differences between herself and eva, the clash between eva’s mexican and american values, and the importance of respecting authority figures, eva may have never felt fully understood by her clinician. lastly, given that therapy may be terminated (in this case, due to the end of the clinician’s training), the clinician should be aware of and address the patient’s potential feelings of abandonment and create a plan for continued support outside of therapy. the recommendations to other clinicians and clinical students are to research all methods, consult with colleagues and experts, and make an informed decision on the best form of treatment when limited ebps are available. references barlow, d. h., allen, l. b., & choate, m. l. 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(1998). lifetime prevalence of dsm-iii-r psychiatric disorders among urban and rural mexican americans in california. archives of general psychiatry, 55(9), 771–778. doi:10.1001/archpsyc.55.9.771 wright, j. h., basco, m. r., & thase, m. e. (2006). learning cognitive behavior therapy: an illustrated guide. arlington, va: american psychiatric publishing. 45 graduate student journal of psychology 2018, vol. 17 copyright 2018 by the department of counseling and clinical psychology teachers college, columbia university remote behavioral sampling for psychological assessment: using interactive technologies to detect depression jacob edward thomas, m.a. and randall richardson-vejlgaard, ph.d. teachers college, columbia university the us national comorbidity survey indicates that up to 47% of major depressive disorder (mdd) patients receive treatment predominately in a primary care setting. the screening methods primary care physicians use to monitor treatment response offer low time-sensitivity, and thus hinder the provider’s ability to adjust or augment treatment effectively. contemporary technologies that directly capture behavioral data may offer objective insight into an individual’s mental health status, with little burden. the current study tracks 12 participants over two weeks to evaluate the convergent validity of a clinician administered measure of depression with physical activity and sleep measured by an actigraph, linguistic style present in facebook content, and repeated brief assessments of mood delivered via a smartphone. feasibility analysis showed that 91.7% of participants completed the study, with 83.6% of targeted data captured. correlations were found between depression symptoms and physical activity (r = -.501, p = .058), restful sleep (r = -.536, p = .045), ecologically assessed affect (r = -.582, p = .03), and 3 linguistic styles present in social media content (‘future focused’ (r = -.539, p = .043), ‘feeling’ (r = .532, p = .046), and ‘masculine’ (r = .590, p = .028)). the study suggests that data collected from interactive technologies offers an easily accessible inventory of patient’s behaviors which is highly correlated with traditional mdd assessment. depressed patients who are not seeing a specialist regularly are at high risk for nonadherence with medication during the latency period between antidepressant initiation and mdd remission. a monitoring platform utilizing interactive technologies would be useful in identifying patients who need treatment. introduction currently, 10% of the american population is clinically depressed, and nearly 20% will experience a depressive episode at some point in their life (kessler, berglund, demler, et al., 2005). epidemiologists estimate that major depressive disorder (mdd) will be the leading cause of life years lost due to ill-health, disability, or early death by 2030 (mathers, fat, & boerma, 2008). this disorder is debilitating and recurrent. longitudinal economic analyses indicate that being depressed leads to immense individual burden, including diminished educational accomplishments, annual family income reduction of 20%, seven fewer weeks worked per year, and an 11% decrease in probability of getting married (smith, & smith, 2010). cumulatively, depression is estimated to cause an $83 billion annual american economic loss (greenberg, kessler, birnbaum, et al., 2003); almost triple what the national institutes of health (nih) invests in all medical research each year (nih, 2015). as evidenced by these staggering numbers, depression is one of the most prevalent and destructive psychological forces in present society. up to 47% of mdd patients receive treatment predominately in a primary care setting (kessler, berglund, demler, et al., 2003). healthcare providers often monitor antidepressant treatment response using self-report questionnaires such as the beck depression inventory (bdi; beck, steer, & brown, 1996) or the patient health questionnaire-9 (phq-9; kroenke, spitzer, & williams, 2001). these screening tools are only validated to be sensitive to changes over two-week intervals (lowe, kroenke, herzog, & grafe, 2004; beck, et al., 1996; kroenke, et al., 2001). with an average onset of antidepressant action in pharmacological intervention of 20 days (stassen, delini-stula, & angst, 1993), systematically administered self-report screeners therefore fail to identify many patients’ antidepressant response trajectories until day 28 of treatment. clinical improvement during the first month is one of override (hidden running head text): thomas, richardson-vejlgaard detecting depression symptoms using interactive technologies please address correspondence to: jet2173@tc.columbia.edu 46 thomas, richardson-vejlgaard the strongest predictors of long-term stability in mdd, and mounting evidence suggests that dosage modification and treatment augmentation are key in achieving this (trivedi, fava, wisniewski, et al., 2006). in order to more effectively modulate depressive symptoms during this critical window, primary care providers are in need of a novel and more time-sensitive screening method that allows them to identify patients refractory to treatment for earlier outreach (see figure 1). the present study recent technological advances have ushered in a new era of data availability and access. americans are densely interconnected with online social networks and carry a powerful computer capable of internet access in their pockets. polls indicate that 65% of american adults use social networking sites (pew research center, 2015a), and nearly 70% own a smartphone (pew research center, 2015b). wearable devices, such as fitness trackers and smart watches, provide users with real-time behavioral data. ten million of such devices are sold annually, and this industry is trending rapidly (wei, 2014). hidden within the way we interact with our technology is a map of our lives. our watches track the way we move, our phones geo-tag our locations, our cameras record what we see, and our online habits offer an abstract narrative of our thoughts. all of this data is recorded, stored, time stamped, and easily transmitted. the present study seeks to use data captured by interactive technologies to make inferences about depression symptoms. first, discrete behavioral domains that are passively monitored by existing technology are identified, and then the evidence linking these domains to depression is reviewed. next, a platform that integrates these domains into a data collection system intended to remotely monitor the presence of depression-related behaviors is deployed in a two-week study of 12 participants to test (1) the platform’s feasibility for implementation, and (2) the convergent validity of data generated in each domain with a clinician administered assessment of mdd. in closing, discussion is presented on how the platform can impact antidepressant treatment response monitoring in primary care, as well as limitations to the present study, and directions for future research. measurable behavioral domains and their association with depression population-based studies assessing physical activity levels indicate that people who are more active are less likely to be depressed (stathopoulou, powers, berry, smits, & otto, 2006). meta-analyses of intervention studies using exercise as a treatment for depression show moderate to large effect sizes consistent across multiple participant variables and exercise types (cooney, dawn, greg, et al., 2013). furthermore, mdd patients figure 1. the current model of antidepressant treatment response monitoring in primary care. 47 detecting depression symptoms using interactive technologies often report increases in desire and ability to exercise as symptoms remit (otto, church, craft, et al, 2007). actigraphs present in wrist-worn technology provide accurate reports of physical activity, often reporting step counts and distance traversed (tudor-locke, williams, reis, pluto, 2002). discreet by nature, these devices automatically pair with user’s smartphone to upload data to a target server, which is accessible remotely. up to 90% of depressed individuals report sleep disturbances, commonly including insomnia, frequent nighttime wakefulness, hypersomnia, and recurrent daily fatigue despite sleeping throughout the night (franzen, & buysse, 2008). a good indicator of mdd symptom improvement is a reduction in these issues (keller, 2003). wrist-worn actigraphs provide accurate assessments of sleep duration and quality, with outputs highly correlated to metrics of traditional laboratory sleep studies (ferguson, rowlands, olds, & maher, 2015; slater, botsis, walsh, et al., 2015). similar to physical activity monitoring, sleep data is passively collected and remotely accessible after syncing with a smartphone. as social media usage has grown in recent years, social scientists have utilized the forum to generate new findings. researchers at stanford university have shown that status updates accurately reflect dimensions of life satisfaction (lui, tov, kosinski, stillwell, & qui, 2015). an italian team has demonstrated that emotionally positive or negative linguistic styles in facebook content is closely related to emotional well-being (settanni, & marengo, 2015). positive psychosocial dimensions such as these have a long history in depression research, universally having strong discriminant validity with depression (pavot, & diener, 1993). users generate their social media content naturalistically, curating it for remote access on their social media profile. the majority of screening and diagnostic traditions conceptualize depression as the persistent experience of symptoms (e.g., american psychiatric association, 2013). a proposed way to record the experience of symptoms as they occur is by repeatedly sampling subjects’ current behaviors and experiences in real time, in their natural environment—a strategy known as ecological momentary assessment (ema; shiffman, stone, & hufford, 2008). ema mitigates recall biases, which greatly affect the accuracy of retrospective reports (porta, greenland, hernan, dos santon, & last, 2014; hunt, auriemma, & cashaw, 2003). with the exponential growth of smartphone use, ema becomes highly feasible, as assessments can be sent to subjects’ cell phones instantaneously. if the assessment is designed in an extremely brief and intuitive manner, capturing this data can become an unintrusive part of one’s day, similar to sliding a finger across a screen to unlock a smartphone or replying to a short text message. the proposed platform & research objectives physical activity, sleep, social media interaction, and moment-to-moment experiences are all intricately linked to depression. these data are captured with minimal burden using existing technologies. we propose a data collection system that combines physical activity and sleep variables from an actigraph, linguistic style present in facebook posts, and repeated brief assessments of mood delivered via a smartphone into a single, multimodal diagnostic tool. the study that follows compares outputs from the platform to a clinician administered mdd assessment. we have two primary aims. first, to assess the feasibility of implementing the platform by monitoring adherence and attrition. adherence reports will be based on percentage of targeted data collected: daily outputs of physical activity, nightly outputs of sleep duration, presence of facebook content, and number of responses to ema. second, to test the convergent validity of each behavioral output generated by the platform with mdd symptom ratings using bivariate pearson correlation tests. we hypothesize that lower physical activity levels, less sleep, and lower ema reported mood will be associated with higher mdd symptom rating. additionally, we hypothesize that by mining facebook content, significant correlations between the content’s linguistic styles and mdd symptom rating can be extrapolated. methods participants participants (n = 12) were four men (mean age = 29.5; range = 24–34) and eight women (mean age = 24.4; range = 22–28) who were recruited through advertisements posted online and on the teachers college, columbia university campus. nine of the participants were students, four were professionals. 48 thomas, richardson-vejlgaard of the 12 participants, one was lost to follow-up, and thus, excluded from the final analysis. inclusion criteria were as follows: (1) men and women aged 18–65; (2) has a facebook profile and is a self-reported “active” user, defined as making at least 1–2 interactions every few days; (3) possesses a smartphone that is activated on a cellular network; (4) willing and able to provide informed consent; (5) willing and able to complete a follow-up assessment two weeks after consent. exclusion criteria were as follows: (1) substantial physical injury or disability that prevents the participant from exercising should they wish to; (2) english illiteracy; (3) prior diagnosis of mental retardation or acute psychosis. materials actigraph. participants wore a misfit flash™ (by misfit inc., burlingame, ca) for the duration of the study. this device utilizes an accelerometer to continuously monitor wrist movement. a six-month battery life and an open-source application program interface make this device ideal for use in research. the device is inexpensive, costing less than $25. data is output into five interval time-stamped variables: steps per day, distance traversed, total sleep duration, restful sleep duration, and light sleep duration. facebook web application (facebook, 2016). participants granted the investigators access to all public activity conducted on their facebook account for the duration of the study. all content generated by the user that was viewable by their social network was recorded. thus, private messages were not included. when web articles, videos, songs, or other content not explicitly composed by the participant were posted, the material’s title and subtitle was captured as relevant data. this decision was made because the title and subtitle is viewable directly by the participant’s social network without being redirected to a different webpage. that is, the title and subtitle are expressed in full and may capture something about what the participant was doing or thinking at the time of the post. all content was compiled into a single text document for each participant, which was then analyzed for linguistic style. linguistic inquiry and word count 2015 (liwc) software. liwc is a text analysis program that outputs percentages of words in a given document which fall into over 80 linguistic categories (pennebaker, francis, & booth, 2001). the program allows for users to develop custom dictionaries tailored to their interest, or use the internal dictionary which was built from decades of the developer, dr. james pennebaker’s, own work on psycholinguistics. linguistic style has been investigated extensively in social science research. it can be utilized to explore a vast array of constructs from emotional tone to intelligence (kess, 1992). pennebaker’s internal dictionary was utilized for the present analysis. google voice web application. all ema correspondence was conducted through the google voice text messaging service. google voice is a secure webbased telephone service offered to google users (about google voice, 2016). transmissions are composed on the user’s computer and forwarded to a target cellular number. responses are received by the user’s google account. measures beck depression inventory-ii (bdi). the bdi (beck, et al., 1996) was used to provide a stratified depression rating, wherein higher scores indicate more severe depression symptoms. this scale has been extensively used in research and repeatedly shown to have strong validity and reliability in multiple populations, with a recent comprehensive review reporting concurrent validity to other depression scales ranging from r = 0.66–0.86, and reliability ranging from α = 0.83–0.96 (wang, & gorenstein, 2013). the bdi was administered during the follow-up assessment. the affect grid. the affect grid is a single item measurement of current affective state, constructed on two continuous dimensions of hedonic valence (level of pleasure) and arousal (see figure 2; russell, weiss, & mendelsohn, 1989). from these two dimensions, higher-order emotional states can be inferred. for example, high arousal with pleasant feelings is often conceptualized as happy or excited. the measure has been independently validated for accuracy on the hedonic valence arousal dimensions (killgore, 1998). the affect grid was utilized as the ema variable in the present study. preliminary analysis has shown the affect grid to be sensitive to emotionally salient events, and thus a prime measure for use in ema (renaud, & thomas 2016). the assessment was administered twice daily via text message. participants received a picture 49 detecting depression symptoms using interactive technologies of the grid with numbers 1–9 plotted on the x and y axis. coordinates (x,y) of the response were recorded. times of assessments were determined randomly, between 9am and 9pm. procedure each participant provided informed consent, as approved by the institutional review board at teachers college, columbia university. participants completed a basic contact/demographic information sheet and were fitted with a misfit flash™ device. they were instructed to keep the device on for the remainder of the study, including while they sleep. if the participant needed to remove the device (e.g., for comfort while bathing), they were instructed to replace it on their wrist as soon as possible. they were then trained to complete the affect grid assessment (see appendix a). participants were told that they would receive two text messages per day that contained a picture of the affect grid with numbers 1–9 plotted on the x and y axis. they were instructed to respond to each text message with coordinates of their square’s location (e.g., feelings-5, arousal-6) as soon as they safely could. a two-week follow-up appointment was then scheduled. for the subsequent two weeks, participant’s physical activity and sleep was continuously sampled, and they received two text message ema’s each day. when the participant returned to the lab, the misfit flash data was collected, and the bdi assessment was administered. participants were then asked to temporarily log onto their facebook profile on a study computer in order to extract their facebook data. data analysis descriptive statistics were used to generate adherence reports. daily physical activity and sleep variables were averaged over two-weeks to provide discrete stepsper-day and sleep-duration values. hedonic valence and arousal ratings on the affect grid were each averaged over 26 assessments to generate two discrete global ratings. liwc generated content percentages of 44 linguistic variables (see appendix b). for tests comparing these behavioral domain outputs to bdi score pearson product-moment correlation coefficients were calculated. all analyses were carried out on ibm spss (2011), and g*power 3 (faul, erdfelder, lang, & buchner, 2007). figure 2. the affect grid (russel, et al., 1989). the x-axis is hedonic valence. the y-axis is level of arousal. the four corners display emotional landmarks. 50 thomas, richardson-vejlgaard results feasibility the observation period lasted an average of 14 days (range = 13–15). attrition was low, as 91% of the participants completed the study protocol through to the follow-up. physical activity data was captured for 86.4% of all days observed; sleep data was captured 79.3% of all nights. all participants received one ema on intake and follow-up days, and two emas on all other days of observation, up to 14 days total. on average, 70.6% of the emas were responded to. facebook content composed during the observation period consisted of an average of 189 words (range = 14–468, sd = 142.47). adherence was high—cumulatively 83.6% of targeted data was collected. participants reported minimal interference with daily life and had generally positive commentary about the design. a systematic review of previous studies using experience sampling methods comparable to ours reported similar participant compliance rates, with an average of 73–90% of targeted data acquired, and an 82–86% completion rate (csikszentmihalyi, & larson, 2014). the platform has shown to be highly feasible. convergent validity indeed, evidence suggests that physical activity, sleep, social media activity, and momentary affect change concurrently with mdd status. theoretically, as depression severity increases, physical activity levels and sleep quality should decrease. as psychologically positive social media content dissolves, and psychologically negative social-media content surfaces, depression severity is expected to increase. as momentary negative affect is more frequently reported, depression severity is anticipated to increase as well. here we report if the behavioral data collected by the platform is reflective of these theories. physical activity. a bivariate correlation was conducted comparing average steps per day and bdi score. a moderate inverse correlation was very near significant (r = -.501, p = .058), suggesting a trend of higher levels of physical activity being associated with lower levels of depression. in agreement with the anticipated association, physical activity levels measured by actigraph, and bdi score validly converge. sleep. bivariate correlations were conducted independently comparing minutes of total sleep, minutes of light sleep, and minutes of restful sleep to bdi score. restful sleep duration and bdi score were found to be moderately inversely correlated (r = -.536, p = .045). getting more restful sleep was associated with lower levels of depression. in agreement with the anticipated association, sleep quality measured by actigraph, and bdi score validly converge. facebook content. bivariate correlations were conducted independently comparing each of the 44 linguistic variables mined from liwc with bdi score. a moderate correlation with bdi was found in the percentage of masculine linguistic content (e.g., boy, man, he) (r = .590, p = .028). composing more masculine words during the observation period was associated with higher levels of depression. a moderate inverse correlation with bdi was also found in the percentage of future-tense linguistics (e.g., will, soon, going to) (r = -.539, p = .043). composing more future focused words during the observation period was associated with lower levels of depression. a third moderate correlation with bdi was found in the presence of perceptualprocessing through ‘feeling’ linguistics, including emotion-focused words (e.g., feel, sad, angry) (r = .532, p = .046). composing more words in the ‘feeling’ category during the observation period was associated with higher levels of depression. surprisingly, explicitly positive or negative linguistic content (e.g., positive emotional tone and negative emotional tone) was unrelated to bdi score. instead, more dynamic associations were found. masculine content being associated with depression is perplexing. it may be an artifact that emerged, in part, because of the 2016 presidential election. these data were collected from february–may of 2016, during which a blitz of negative content circulated social media concerning “him”—donald trump—which may be a confounding variable. the relationships between future-tense linguistics and depression, and feeling linguists and depression are not surprising. rumination, particularly about the past, is a common attribute in the self-regulatory executive function (s-ref) model of depression (wells, & matthews, 1996). participants with more symptoms of depression may have used facebook as a vehicle to express their ruminative or retrospective thoughts. the correlation we found is reflective 51 detecting depression symptoms using interactive technologies of the s-ref model. furthermore, billings, & moos (1984) demonstrated that recruiting social resources for emotional-discharge—that is, expressing your emotional problems to others—is a common coping strategy used by individuals with mdd. participants may have utilized their social networks on facebook to engage in emotional-discharge. in line with these theories, two of the linguistic variables that emerged from the behavioral data that the platform collected validly converge with bdi score. ema affect grid. bivariate correlations were conducted independently comparing global hedonic valence, and arousal to bdi score. a moderate inverse correlation was found between global hedonic valence and bdi score (r = -.582, p = .03). lower average ratings of hedonic valence—that is, repeatedly reporting unpleasant feelings—was associated with higher bdi scores. in agreement with the anticipated association, ecologically assessed negative affect and bdi score validly converge. ancillary analysis given the good convergent validity of each of our behavioral domains with depression rating, we attempted a multiple linear regression to predict bdi score based on average daily steps, average nightly minutes of restful sleep, global hedonic valence, and percentage of future-focused, feeling, and masculine linguistics in facebook content. the underpowered model (β-1 = .46) was unable to achieve significance (f(6,4) = 1.450, p = .375, r2 = .685). with r2 = .685, α = .05, and six predictor variables, the model needs n = 18 to achieve >95% power. discussion using data generated by interactive technologies, the platform was able to identify six discrete behavioral measures that have good convergent validity with the bdi for assessing depression symptoms (five were significant, one was trending towards significance). if deployed in a primary care setting, providers would be able to remotely monitor patients from the onset of their prescribed antidepressant regimen. the presented evidence suggests that the platform is capable of detecting behaviors reminiscent of remission, or more importantly, lack thereof, in real time. thus, the platform can supply healthcare providers with valuable information that helps identify patients who require medication adjustment or augmentation. with further research to achieve more statistical power, the regression model tested in the ancillary analysis has the potential to have unprecedented predictive ability of depression rating, explaining 68.5% of felt symptom variance. limitations we believe the platform is in its infancy. we have presented evidence that suggests it can validly monitor depression symptoms; however, we have not yet developed the software infrastructure needed to deploy the platform on a large scale. to achieve large scale deployment, we must collaborate with software developers to automate the platform’s back-end data aggregation methods. our analyses were inherently limited by our sample size, and bdi range (0–15). in order to strengthen the validity of the platform, our findings must be replicated with a larger sample size, and an expanded bdi range, which requires studying more severely depressed individuals. as this range and the sample size grows, it is imperative to be iterative in re-mining liwc and re-testing other available variables for new correlations. ethical considerations are important when providing clinicians with access to personal information that is not traditionally considered related to healthcare. some patients may be uncomfortable with having their behaviors tracked in the manner that the platform does. as we further develop the platform, all back-end software development will need to be secured to federally mandated privacy standards for patient data, and all identifiable data will need to be classified as protected health information. additionally, patients will need to provide consent prior to enrolling in the platform. cost of implementation is another potential limiting factor. although designed to consider cost, some patients will inevitably have economic restrictions that limit their enrollment in the platform. the actigraph we utilized retails for $19.99. it may be possible to mitigate this expense by capitalizing on select health insurance benefits (e.g., humana, 2016) which provide activity trackers to customers at no cost; however, this option is not available to everyone. perhaps the most substantial limiting economic factor is that enrolment requires easy access to a computer or smartphone for social media 52 thomas, richardson-vejlgaard participation, and the ema requires a smartphone. a shrinking minority of americans either don’t use social media, or don’t possess a smartphone and hence, the platform will be unavailable to these individuals. the presented study only establishes preliminary validity of the constructs that the platform monitors. this does not necessarily mean that the platform will assist real-life identification of patients in need of treatment adjustment/augmentation. testing this requires a randomized controlled field implementation study comparing the platform versus a sham monitoring system. all of the presented findings must be considered alongside these limitations. substantial further research and development is needed. references about google voice. 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(1996). modelling cognition in emotional disorder: the s-ref model. behaviour research and therapy, 34(11), 881–888. 54 thomas, richardson-vejlgaard appendix a affect grid training with the grid in front of them, participants were read the following passage: this is the affect grid. it is intended to capture how you feel in a given moment. first you orient yourself with the horizontal axis. on the left side of the grid represents unpleasant feelings, on the right are pleasant feelings, and in the middle is neutral. after you have located your place on this axis, you then adjust either up or down on the vertical axis according to your current energy level. at the top represents high arousal or high energy, and the bottom represents sleepiness or low arousal. again, the middle is neutral. in the four corners you will find landmarks to help you navigate the grid. these landmarks are emotions that many people conceptualize certain couplings of feelings and arousal. for example, someone with unpleasant feelings and high arousal may view that state as stress. inversely, pleasant feelings with low arousal may feel like relaxation. these landmarks are there to help you navigate the grid; however, you may conceptualize the feelings differently than other people. that is ok. please more so focus on your location along the horizontal and vertical axis. when you are ready, please indicate so by touching the center of the square associated with where you are located. 55 detecting depression symptoms using interactive technologies appendix b list of liwc variables analyzed summary dimensions word count analytic clout authentic tone words per sentence words longer than six letters dictionary word count perceptual processes see hear feel biological processes body health sexual ingest drives affiliation achieve power reward risk time orientation past focus present focus future focus affect positive emotional tone negative emotional tone relativity: motion space time social family friend feminine masculine cognitive processes insight casual discrepancies tentative certainty differentiation personal concerns work leisure home money religion death 33 graduate student journal of psychology fall 2024 vol. 23 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university exploring the relationship between attentional bias towards threat and symptoms of adult separation nikki kaiser & michael g. wheaton department of psychology, barnard college of columbia university, new york, ny, united states purpose: research has identified attentional bias towards threatening stimuli as a contributing factor to anxiety disorders, and treatment targeting this bias has been shown to reduce symptoms of anxiety (azriel & bar-haim, 2020). studies have found attentional bias to threats among children with separation anxiety disorder (sad) when tested with dot-probe tasks, with a stronger bias seen when threats are disorder-congruent (pergamin-hight et al., 2015). no study has yet investigated this relationship among adults, despite growing recognition that separation anxiety is frequent in this population. therefore, we investigated the relationship between sad symptoms and attentional bias toward threatening stimuli (general and separation-specific) on a dot-probe task in a sample of adults, with the goal of informing targeted treatment for adult separation anxiety disorder (asad). methods: undergraduate participants (n = 57) completed a measure of asad symptom severity (asa-27) and two versions of the dot-probe task, one with separation-specific threatening words and one with generally threatening words. attentional bias was tested using detection latency. results: spearman’s rho correlations between asa-27 and separation-specific threat trials (rs = -.07; p = .62) and general threat trials (rs = .07; p = .60) were not significant. however, asad symptoms were correlated with reduced accuracy on trials following asad-specific threat words (rs = -.38, p = .004), but not general threat words (rs = -.16, p = .22). conclusions: we did not find that asad symptoms related to attentional bias. however, individuals with more asad symptoms were less accurate on trials that involved asad-threat words, suggesting an emotional interference effect of disorder-specific threats on task performance. keywords: separation anxiety, attentional bias, interference effects separation anxiety disorder (sad) is characterized by persistent and excessive distress or worry related to separation from home or significant attachment figures (american psychiatric association [apa], 2022). an attachment figure is often a parent when the disorder is present in a child, but when seen in adults, the figure may be a parent, partner, child, or spouse. whether seen in a child or adult, symptoms can include fears about harm befalling the attachment figure, nightmares about separation, somatic complaints when separated, and a reluctance to leave the attachment figure even for short periods of time. in prior editions of the diagnostic and statistical manual of mental disorders (dsm), sad was categorized under “disorders first diagnosed in infancy, childhood, or adolescence” and included a required diagnostic criterion of onset prior to the age of 18 years old (apa, 1994). the 5th edition of the dsm (apa, 2013) removed this criterion and amended features of the disorder, reflecting the growing recognition that sad frequently occurs among adults, which has been referred to in the literature as adult separation anxiety disorder (asad). empirical support for the notion of asad continues to grow, with data establishing high prevalence rates, high comorbidity with anxiety and mood disorders, and most notably, evidence of poor prognoses for those diagnosed (manicavasagar & silove, 2020; shear et al., 2006). asad can be debilitating in a variety of functional areas, many of which can lead to long-term impairment (apa, 2022). for example, individuals may be unable to leave their homes out of fear of leaving their attachment figure during the day, or they may be unable to form or maintain healthy relationships due to the pervasive need to be with their attachment figure. given that sad was formally seen as primarily a childhood disorder, the bulk of studies and treatment explorations surrounding sad centers on children and adolescents (bogels et al., 2013). although sad is characterized by the same symptoms in both children and adults, the attachment figure and the impairment in daily functioning differ between the two populations (apa, 2022). for example, a child with sad might wish to stay home with their parent and therefore have poor school attendance. an adult with sad may be unable to leave their spouse and therefore repeatedly miss work, leading to loss of employment. to date, very little research exists on asad, creating a gap in not only the understanding of the disorder’s mechanisms, but also in the possibility of creating tailored treatments (baldwin et al., 2016; bogels et al., 2013). a rich area of literature has investigated attentional bias towards threat as a prominent maintenance for many anxiety disorders, with a premise that modifying biases in attention may be foundational to anxiety disorder treatment (barry et al., 2015). attentional bias is the phenomenon of a person’s attention being more 34 kaiser & wheaton focused toward or away from a threatening stimulus in comparison to a neutral stimulus (azriel & barhaim, 2020). when an individual has an attentional bias towards a threat, they may excessively focus on potentially threatening stimuli, leading to heightened anxiety and distress. having a bias to direct attention toward threats may result in difficulties with concentration, decision-making, and problem-solving. for example, an individual with asad may need to immediately check their phone after the arrival of every new notification, worried it may be about their loved one. this bias towards potential threats can distract from important duties or responsibilities and may impair daily functioning. furthermore, by repeatedly attending to threatening cues, individuals may amplify and sustain their anxiety responses, causing heightened sensitivity towards potential threats and further reinforcing a cycle (azriel & bar-haim, 2020). the presence of attentional bias is often tested with a visual dot-probe task (price et al., 2013). in this task, participants are presented with an emotionally neutral stimulus and an emotionally threatening stimulus, such as a neutral face and an angry face, on a computer monitor for a set display length of milliseconds (bantin et al., 2016). a target probe, such as a dot or arrow, then appears behind either the neutral or threatening stimulus, and the participant is asked to identify the probe's shape or location by a key press or mouse click. detection latency, the time from the target’s arrival to the participant’s detection of the target, as indicated by a key press or mouse click, is recorded for each trial. a shorter detection latency on trials in which the target is behind the threatening stimulus would indicate an attentional bias toward threatening stimuli. specifically, decreased response latency to detect the probe when it is located behind a threatening word or image implies the person’s attention was drawn to the area of the threatening stimulus compared to the neutral stimulus (bantin et al., 2016). another task utilized to study the effect of threat cues on attention and information process is the emotional stroop task, a modified version of the classic stroop task, in which participants are asked to name the color of a shown word (bar-haim et al., 2007). in the original stroop task, the presented word is either congruent with a color (such as the word “green” shown in the color green) or incongruent with a color (such as the word “green” shown in the color red). the emotional stroop task displays words relating to threatening and neutral stimuli instead of the names of colors (i.e., death and harm instead of blue and green). a slower response to identifying the color of threatening words as compared to neutral words indicates biased processing of the threat. it is inferred that the participant is unable to focus exclusively on processing the color of the word as their attention is distracted by the presence of a threatening stimulus (bar-haim et al., 2007). a meta-analysis conducted by bair-haim et al. (2007) examined 172 studies that tested attentional bias, most of which used either the dot-probe task or the emotional stroop task. overall, a significant attentional bias towards threat was found in anxious individuals and was absent in non-anxious individuals. furthermore, no difference in threat bias was found when comparing results from studies that used the dotprobe task measure to studies that used the emotional stroop task measure. within analyses of the dot-probe task, attentional bias toward threat was found in trials that used pairs of faces as well as pairs of words, with no significant difference between the two stimuli. these results were shown to be true for both adult and child participants, with no significant difference between the two populations. attentional bias was found in all anxiety disorders analyzed: panic disorder, post-traumatic stress disorder, social phobia (social anxiety disorder), and specific phobia (bar-haim et al., 2007). sad was not specifically analyzed as a discrete diagnostic category in bar-haim et al.’s (2007) meta-analysis, as research on the relationship between attentional bias and sad was extremely limited. only a handful of studies that examined attentional bias have included participants with sad, all of which were conducted with children given the previous categorization of this disorder (roy et al., 2008; salum et al., 2013; waters et al., 2014). however, given asad and sad in children overlap in symptomatology, it is important to review the existing literature on sad and attentional processes to better inform study design when researching this phenomenon in adults. to present an overview of the current literature regarding sad and attentional bias, the results of these studies are summarized below. in perhaps the largest sad and attentional bias study, roy et al. (2008) assessed attentional bias in 101 clinically anxious children, 59 of whom met the criteria for sad. the study used a visual dotprobe task that showed pairs of angry/neutral and 35 attentional bias and symptoms of adult sad happy/neutral faces and compared detection latency between a clinically anxious group and a non-anxious control group. results indicated that clinically anxious children more quickly detected the probe located behind an angry face, suggesting an attentional bias toward threatening stimuli. furthermore, no significant differences were found in attentional bias toward threat between anxiety disorders. another study analyzed the dot-probe task performance of 363 children in three disorder groups: fear-related, distress-related, and behavioral (salum et al., 2013). the fear-related sample was comprised of 86 children, 30 of whom met the criteria for sad. of the three disorder groups, only the ‘fear’ group showed attentional bias directed away from the threat rather than toward the threat. this finding was explained through the theoretical lens of the fear versus distress structural model of emotional disorders. anxiety disorders categorized by distress are more likely to result in hypervigilance toward threat, such as general anxiety disorder and post-traumatic stress disorder, whereas anxiety disorders categorized by fear (such as sad and social phobia) would result in an avoidance of fearful stimuli and therefore a bias away from threat. in line with this model, this study found that high internalizing symptoms in the ‘distress’ group resulted in a greater bias towards threatening stimuli, whereas in the ‘fear’ group, high internalizing symptoms resulted in a greater bias away from threatening stimuli. a study conducted by waters et al. (2014) found similar results among a sample of anxious children, some of whom had a primary diagnosis of sad. although these studies included children with sad, results were presented in aggregate in which these participants were combined with those suffering from other anxiety disorders. importantly, the extant studies have not yet accounted for specific threat-related content for sad. the dot-probe task and the emotional stroop task can be conducted with general threatening stimuli or disorder-specific threatening stimuli (pergamin-hight et al., 2015). specific threatening stimuli refer to pictures or words that are congruent to the disorder being analyzed, such as social-related words for social anxiety disorder. general threatening stimuli refer to pictures or words that are disorder-incongruent and related to an anxiety disorder different from that of the person being tested. to illustrate, for a person with sad, generally threatening words might be disease and danger, and specific threatening words, or disorder-congruent words, might include “alone” and “abandoned”, which have specific content relevant to the notion of separation from loved ones. a recent meta-analysis examining attentional bias in youth and adults with measures including disorder-congruent threats versus disorder-incongruent threats found that clinically anxious participants displayed a larger bias toward disorder-congruent threats (pergamin-hight et al., 2015). the analysis included studies that used the emotional stroop task as well as studies that used the dot-probe task, and effect sizes were combined to reach an overall effect of threat bias. when the combined effect sizes of the two tasks were compared, the difference between the two tasks was not statistically significant. this meta-analysis only included one study that examined attentional bias in participants with sad (exclusively in children): a single study that found no evidence of attentional bias in general-threat trials or specific-threat trials (kindt et al., 2003). the primary takeaway from the literature available is ultimately that it has been scarce and inconclusive (roy et al., 2008; salum et al., 2013; waters et al., 2014). though meta-analyses have shown evidence for attentional bias toward threat in children and adults with various anxiety disorders, the limited number of studies involving participants with sad has left the field with less than substantial answers regarding attentional processes in those with sad. this is an important topic for study, as prior research has investigated attentional training as a treatment for other forms of anxiety, and therefore extending research on attention in asad might be used to develop new interventions for this condition. moreover, the studies discussed above were conducted with children; no studies have yet examined the role of attentional bias in adults with sad. though results have been mixed, the bulk of previous research has shown that children with sad show an attentional bias in regard to threat, and adults with other anxiety disorders show an attentional bias toward threat, with a greater bias towards disorder-specific threat (barhaim et al., 2007; pergamin-hight et al., 2015). attentional bias has been shown to be a pivotal mechanism in maintaining anxiety disorders, and treatment targeting this bias has proven successful in reducing anxiety (azriel & bar-haim, 2020; hakamata et al., 2010). it is 36 kaiser & wheaton reasonable to assume that asad, which overlaps considerably with sad in children and is often comorbid with other anxiety disorders, might also be maintained by an attentional bias mechanism. therefore, understanding attentional bias in asad is crucial to informing targeted treatment. the present study aimed to address this important gap in the literature. we sought to determine if adults with greater levels of asad symptoms would also display greater attentional bias to threatening stimuli (general and disorder-specific) when tested with versions of the dot-probe task. we elected to use the dot-probe task to test this aim because, unlike the stroop task, it is possible to measure if attentional bias is directed towards or away from threatening stimuli by calculating how long it takes for participants to detect the probe behind threatening words compared to neutral words (with a slower response indicating bias directed away from threat and a faster response indicating bias towards threat). furthermore, we included trials with facial stimuli and trials with word stimuli to replicate the methods of past sad and attentional bias studies (roy et al., 2008; salum et al., 2013; waters et al., 2014), and to test both general threats and disorder-specific threats via word pairs. based on previous research findings, it was hypothesized that higher asad symptom severity would correlate with greater attentional bias to threat, with a stronger bias toward threat in trials with disorder-relevant stimuli. methods participants this study received approval from the institutional review board (irb) of barnard college. all ethics guidelines were adhered to while conducting this study. participants were given a written consent form to sign prior to beginning participation. fifty-seven participants were recruited through barnard college’s sona system. each participant received laboratory credit for their introduction to psychology course after completing the study. the sample was 89% female and had a mean age of 18.92 years (sd = 0.98, range 18-21). the racial-ethnic composition was as follows: 55.9% non-hispanic white, 5.1% african american, 6.8% hispanic, 27.1% asian/pacific islander, and 5.1% “other.” measures adult separation anxiety questionnaire (asa-27): this 27-item questionnaire is used to determine asad symptom severity. each item states a symptom or feature of asad and participants choose a response on a 4-point scale from 0, “this has never happened to me,” to 3, “this happens very often” (manicavasagar et al., 2003). scores on the asa-27 were treated as a continuous variable, with a higher score indicating greater symptoms of asad. dot-probe task: a plus sign was fixed in the center of a display to focus participants’ attention. emotionally neutral stimuli and emotionally threatening stimuli were then displayed on the screen in pairs. after 500ms, an arrow appeared behind either the neutral or threatening stimulus, and the participant was instructed to indicate which direction the arrow was pointing by clicking the corresponding mouse button (i.e., right-click for a right-pointing arrow). detection latency was then recorded, with a shorter detection latency on threatening trials indicating an attentional bias toward threatening stimuli (macleod et al., 1986). the following three versions of the dot-probe task were administered: 1) facial stimuli: a pair of faces were displayed on the screen for 500ms. pairs either depicted two happy faces, or an angry face and a happy face. 30 pairs were displayed in total; 15 pairs contained only happy faces and 15 pairs contained an angry face. the faces shown were black-and-white pictures of white men and women; the stimuli were not altered based on the gender or racial appearance of the participants. 2) general threat word stimuli: a pair of words were displayed on the screen for 500ms (see fig. 1). on threatening trials, one word was neutral (i.e., signature), and one word was a randomly selected generally threatening word (i.e., strangled). 30 pairs were displayed in total; 15 pairs contained only neutral words and 15 pairs contained a generally threatening word (see table 1 for examples). 3) specific threat word stimuli: a pair of words were displayed on the screen for 500ms (see fig. 1). on threatening trials, one word was neutral (i.e., hotel), and one word was a randomly selected specifically threatening word (i.e., alone). 30 pairs were displayed in total; 15 pairs contained only neutral words and 15 pairs contained a specifically threatening word (see table 1 for examples). procedure the design of this study was cross-sectional. after signing a written consent form, each participant was seated at a desk in a quiet laboratory testing room and asked to complete an online survey which included a demographics section inquiring about gender, age, race, and ethnicity, and the asa-27 questionnaire. upon finishing 37 attentional bias and symptoms of adult sad the surveys, participants completed three dot-probe tasks: one consisting of facial pairs, one consisting of general threat words and neutral words, and one consisting of specific threat words and neutral words. for each trial, words and faces were displayed in a randomized order to reduce bias. after completing all study measures, participants were debriefed. statistical analysis each participant’s total score on the asa-27 (asatotal) was calculated, as well as any attentional bias toward threatening faces, specifically threatening words (i.e., asad-congruent words), or generally threatening words. to calculate attentional bias for each type of threat (facialthreatbias, specificthreatbias, generalthreatbias), reaction time on trials during which the target followed an angry face, specifically threatening word, or generally threatening word (threat trials) was subtracted from reaction time on trials during which the target followed a neutral word (neutral trials). due to the presence of outlier responses on the asa-27, spearman’s rho was used to test for associations between asatotal and threat bias on all tasks. within-subject accuracy between specific word task threat trials and specific word task neutral trials, and between general word task threat trials and general word task neutral trials, was calculated by subtracting accuracy on threat trials from accuracy on neutral trials and was then correlated with participants’ total score on the asa-27 using spearman’s rho. results the sample mean on the asa-27 (m = 12.93, sd = 7.82) was similar to that reported in other undergraduate samples, while the observed range (minimum = 1, maximum = 33) indicated a sufficient range of asad symptom severity to consider this variable as a continuous marker of asad symptoms. no significant correlations were found between asatotal and generalthreatbias (rs = .07; p = .60), between asatotal and specificthreatbias (rs = -.07; p = .62), or between asatotal and facialthreatbias (rs = .12, p = .37). average accuracy at detecting the arrow direction on all trials within the specific word task and the general word task was high (see table 2 for individual task accuracy percentages). to determine whether participants might be less accurate on trials that contained threatening stimuli (as compared to neutral-only trials) which would represent a marker of emotional interference effects, we calculated intra-individual difference scores in accuracy for these trial types by subtracting accuracy on threat trials from accuracy on neutral trials. the within-subject difference in accuracy, as calculated, was then correlated with participants’ total score on the asa-27. spearman’s rho showed a weak to moderate negative correlation between differences in accuracy on specific word task trials and total score on the asa-27 (rs = -.38, p = .004), which was statistically significant. in contrast, there was no relationship between asad symptoms and the difference in accuracy comparing trials involving general threat words to neutral words as there was no significant correlation found between the difference in accuracy on general word task trials and total score on the asa-27 (rs = -.16, p = .22). discussion this study sought to determine if adults with greater levels of asad symptoms would also display greater attentional bias to threatening stimuli (general and separation-specific). the hypothesis that those who score higher on a measure of asad would have a greater attentional bias toward specifically threatening words was not supported, as the correlations between reaction time on dot-probe tasks and total scores on the asa-27 were not significant. however, the significant correlation between difference in accuracy on specific word task trials and total score on the asa-27 indicates that participants with higher levels of asad symptoms had a greater reduction in accuracy on separation-specific threat trials than on neutral trials. this reduction in accuracy would suggest that seeing the words related to separation caused impaired accuracy in identifying the target, possibly an emotional interference effect specific to words related to separation that did not extend to general threat. one possible explanation for these results is the vigilance-avoidance theory of attentional bias (in-albon et al., 2010). the vigilance-avoidance theory of attention theorizes that anxious individuals may initially be vigilant towards threat in their surroundings, but upon detecting threat, subsequently avoid the threat and divert attention away from it. in-albon et al. (2010) found that in the first 1000ms of a task, both anxious and non-anxious participants gazed at threatening images and neutral images for a similar length of time, but after 1000ms, anxious participants gazed at 38 kaiser & wheaton threatening images longer than at the neutral images. after 3000ms, anxious participants gazed at threatening images for a shorter duration than they did the neutral images, indicating that within the duration of 1000ms to 3000ms anxious individuals may be vigilant toward threat before subsequently disengaging from the threat and avoiding it. the display duration of the dot-probe task word pairs used in this study was 500ms, which may have been too short a duration to assess attentional bias away from threat. if the display duration was longer than 1000ms, it is possible that vigilance toward threatening words would have been seen. though the original hypothesis of this paper was not supported by the results, there was a significant correlation between a reduction in accuracy on the dot-probe tasks and asad symptom levels. participants who scored higher on the asa-27 performed less accurately on trials that included an asad-specific threat rather than a general threat. based on these results, we hypothesize that asad-specific threats may have led to an emotional trigger that resulted in poorer task performance. however, it is important to note that these findings are correlational, and additional research is needed to further understand the nature of this relationship and any potential causal factors involved. limitations of this study included a small sample size, a limited participant age range of 18-21, and using convenience sampling to recruit participants, which may have resulted in bias. this was a non-clinical sample, and therefore all results are based on asad symptom levels rather than a clinical diagnosis. furthermore, we recognize a major limitation in the fact that we did not screen participants for any comorbid disorders, and it is possible that subjects had co-occurring anxiety disorders. another limitation was including only one length of our dot-probe task trials, which as discussed above, may have impacted our findings. in addition, our facial stimuli were limited and did not include images from all racial-ethnic groups. future studies should seek to investigate the role of attentional bias in a large population of adults with varying ages and a primary diagnosis of asad, as a greater sample size and clinical sample are both necessary to replicate and extend these findings. this study was also limited by its correlational design; future studies should investigate this topic with experimental approaches. additionally, testing the use of dot-probe tasks with varying display duration could provide additional understanding of how attentional bias operates in asad and provide insight into what specific factors may impede cognitive processes. for example, dotprobe tasks with a duration greater than 3000ms on trials may show an attentional bias towards specific threats but not general threats. results of the current study suggest that there may be a negative effect of disorder-specific threats on task performance, which should be further researched due to its possible applications, such as informing treatment. for instance, in work settings, individuals with asad may struggle to perform well on tasks when exposed to stimuli related to their separation anxiety, such as reminders of separation from attachment figures. this can affect job performance and overall success. through cognitive restructuring and attentional training exercises, individuals can learn to redirect their attention away from threat cues and develop more adaptive coping strategies (hakamata et al., 2010). this highlights the importance of considering disorder-specific threats and attentional biases in the assessment and treatment planning for asad, enhancing the effectiveness of interventions and improving overall outcomes for individuals experiencing separation anxiety. researchers might test the effects of asad-specific threat words in a clinical sample on various tasks, including the stroop task which has been previously used to assess emotional interference effects. future work could also investigate if disorder-specific triggers affect task performance in those with other anxiety disorders in the same manner. conclusion this study examined attentional bias in a sample of adults, some of whom experienced symptoms of asad, using the dot-probe task. the aim was to elucidate the relationship between these two variables and inform the creation of targeted treatment. although the initial hypothesis that higher asad symptom severity would correlate with greater attentional bias toward threatening stimuli was not supported, there was a significant correlation between asad symptom levels and reduced accuracy in trials involving asad-specific threat words. these results suggest that there may be emotional interference occurring in asad-specific threat trials which affects task performance. however, this study’s findings were correlational, and additional research is needed to better understand the relationship and mechanisms. 39 attentional bias and symptoms of adult sad references american psychiatric association. 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teachers college, columbia university exploring the relationship between maladaptive daydreaming and adverse childhood experiences lauren moment department of psychology, university of colorado denver maladaptive daydreaming (md) is an intriguing yet underexplored phenomenon within psychology. it is characterized by extensive and immersive daydreaming that may disrupt daily functioning and overall well-being (mariani et al., 2021). despite growing recognition, the diagnostic and statistical manual of mental disorders (dsm-5) does not classify md as a disorder, leaving a gap in its formal conceptualization. nevertheless, recent research has begun associating md with adverse childhood experiences (aces), positioning md as a potential coping mechanism for trauma (pietkiewicz et al., 2018; sándor et al., 2020). this intersection between aces and md remains an underdeveloped area of inquiry, with a lack of studies comprehensively exploring the psychological and neurobiological mechanisms underlying this relationship. the existing literature often compares md and other psychological constructs, such as fantasy proneness (fp), which involves immersive fantasies that may mimic real-life experiences. however, fp includes dissociative mystical and religious experiences not typically associated with md, suggesting nuanced differences between these constructs (wilson & barber, 1982). while daydreaming can serve adaptive functions— such as enhancing creativity, planning, or cognitive relief—md is characterized as persistent and immersive, potentially impairing academic, interpersonal, and professional functioning (klinger, 2012; singer, 1975). a gap in the current body of research is the limited understanding of how aces, as severe early life stressors, may influence the development and persistence of md. studies have shown that individuals with a history of aces—such as childhood bullying, abuse, or neglect—are more likely to engage in md as a coping strategy to escape from distressing realities (somer et al., 2021). however, more nuanced research is needed to explore whether md exacerbates trauma-related symptoms or provides temporary relief. recent estimates suggest that approximately 4% of the general population may meet the criteria for md, underscoring its prevalence (soffer-dudek & theodor-katz, 2022). however, the precise mechanisms by which aces contribute to md's development remain unclear, as does the bidirectional relationship between md and trauma (ross et al., 2020). current neurobiological research into md is still in its infancy, though some studies have begun exploring alterations in brain regions related to emotion regulation and self-referential processing (bigelsen et al., 2016). this leaves a significant gap in understanding how md and trauma influence each other over time and how this relationship affects mental and physical health outcomes across the lifespan. this study addresses these gaps by examining the relationship between adverse childhood experiences (aces) and maladaptive daydreaming (md), hypothesizing that individuals who experience more aces will exhibit a higher prevalence of md. the research aims to distinguish md from related constructs and explore the psychological and neurobiological mechanisms underlying this relationship. by focusing on this intersection, the study seeks to contribute this study explores the intricate relationship between maladaptive daydreaming (md) and adverse childhood experiences (aces). md, characterized by immersive daydreaming that may disrupt daily functioning, has garnered attention as a potential coping mechanism for trauma. aces encompass a range of traumatic experiences, such as abuse, neglect, and family dysfunction, which have been associated with various mental health challenges. using the md scale (mds-16) and the aces scale, data were collected from a sample of n = 386 individuals. significant positive correlations were found between md and specific aces, including verbal abuse, mental illness or suicide, sexual abuse, and physical neglect. regression analyses revealed that individuals with higher levels of aces were more likely to engage in md. the relationship between aces and md may involve md serving as a psychological escape or coping strategy for the emotional and psychological impacts of trauma. conversely, separation or divorce was found to have a negative association with md scores, suggesting that different types of aces may affect md tendencies differently. these findings highlight the importance of addressing childhood trauma in interventions targeting md behaviors. future research should delve deeper into the specific types of aces and their differential impacts on md to better inform targeted interventions. this study highlights the critical role of childhood experiences in shaping md behaviors and emphasizes the need for trauma-informed approaches in clinical practice. keywords: maladaptive daydreaming, trauma, adverse childhood experiences 44 moment to the literature by offering a more precise conceptualization of md and its association with childhood trauma. this approach could pave the way for more effective interventions targeting both md and the longterm impacts of aces on mental and physical health. methods recruitment these data were collected during the summer of 2020. the study aimed to assemble a representative sample of participants, as outlined in table 1. to achieve this, the researcher employed various recruitment strategies. initially, an advertisement was crafted using canva, a popular graphic design tool known for its user-friendly interface and versatile templates. subsequently, recruitment efforts were undertaken across multiple online platforms, including canvas, facebook, twitter, instagram, and reddit. each platform contributed differently to the overall sample. the primary recruitment source, facebook md groups, was particularly effective in engaging respondents. these targeted groups proved highly effective in reaching individuals actively discussing and identifying with maladaptive daydreaming. on reddit, recruitment was carried out in relevant subreddits that focus on mental health and maladaptive daydreaming, providing access to a diverse audience sharing their experiences with md. twitter was utilized for recruitment by posting targeted advertisements and engaging with hashtags and discussions related to maladaptive daydreaming and childhood trauma. announcements and recruitment efforts on canvas were made within university courses, targeting students with relevant interests in maladaptive daydreaming and childhood adversity. on instagram, recruitment involves using posts and stories to connect with users interested in mental health topics. the visual and interactive nature of the platform helped engage potential participants effectively. the most significant number of participants, totaling 250, were recruited from facebook md groups, representing approximately 65% of the total sample. reddit contributed 60 participants, accounting for about 15% of the total. twitter provided 30 participants, which is around 8% of the sample. canvas, used for recruitment within university courses, yielded 20 participants, making up about 5% of the total. instagram recruited 26 participants through posts and stories, approximately 7% of the sample. participants in this study must be 18 years of age or older and must score 50 or higher on the maladaptive daydreaming scale (mds-16), indicating significant maladaptive daydreaming. they must also report at least one adverse childhood experience (ace) based on responses to the ace questionnaire. all participants must be proficient in english and provide informed consent to participate in the study. individuals with severe cognitive impairments, such as intellectual disabilities or dementia, will be excluded, as well as those with active psychosis or severe dissociative disorders. participants currently experiencing severe substance abuse or ongoing traumatic experiences will also be excluded. additionally, those who do not meet the threshold for maladaptive daydreaming or do not report any significant aces will not be eligible for inclusion. a total sample size of n = 386 individuals participated in the study. prospective participants were required to meet specific eligibility criteria, including 18 years or older and proficient in english. participants were asked their age when completing the survey to ensure age criteria were met. these criteria were established to ensure that participants could effectively engage with the study materials and provide accurate responses, thereby enhancing the validity and reliability of the data collected. measures the primary measure utilized in this study was the maladaptive daydreaming scale (mds16), a self-report instrument specifically designed to assess md behaviors among individuals. developed by somer et al. (2016), the mds-16 consists of 16 items (see appendix g), it has emerged as a valuable tool in clinical and research settings for comprehensively understanding and quantifying the extent of md tendencies within populations. the mds-16 prompts participants to reflect on and report the frequency and intensity of their daydreaming episodes. unlike dichotomous assessments, this scale delves into the qualitative aspects of daydreaming, allowing for an understanding of normative daydreaming versus md behaviors. furthermore, the scale encompasses items exploring md's emotional and functional dimensions. participants are asked to rate the emotional content of their daydreams, shedding light on the affective expe45 evaluating the relationship between maladaptive daydreaming riences associated with their daydreaming episodes. the scale examines the impact of daydreaming on various aspects of individuals' daily functioning, such as work, relationships, or academic pursuits. the mds-16's psychometric properties contribute to its credibility as a reliable and valid measure. it showed appropriate internal consistency and reliability with a cronbach’s alpha of 0.957. through rigorous validation, the scale has demonstrated its ability to effectively discriminate between individuals with and without md tendencies. its reliability ensures consistency in measuring the construct over time and across different populations, facilitating robust comparisons and generalizability of findings. furthermore, the study employed the adverse childhood experiences scale (aces), a widely recognized and extensively utilized self-report measure designed to assess the prevalence and impact of various childhood adversities (see appendix f). it showed appropriate internal consistency and reliability with a cronbach’s alpha of 0.70. developed by felitti et al. (1998), the aces scale encompasses ten distinct categories, each representing a specific form of adversity individuals may have encountered during their formative years. these categories include emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, as well as family-related adversities such as separation or divorce, witnessing domestic violence, having a drug or alcohol-addicted family member, having a mentally ill family member, and having an incarcerated family member. the aces scale enables researchers and clinicians to evaluate and address the multifaceted nature of childhood adversities, providing valuable insights into the cumulative impact of early life stressors on individuals' well-being. the survey measures aces within families in adolescents and has internal consistency, validity, and criterion validity when used with relevant measures. procedures the research conducted for this study was overseen and approved by the colorado multiple institutional review board (comirb) at the university of colorado—denver | anschutz medical school. the study was assigned the comirb identification number 20-2870 to ensure compliance with ethical guidelines for human subject research. participants provided informed consent before completing online surveys, which lasted approximately 30 minutes each. responses were anonymized throughout the study. participants were informed that they would be entered into a raffle to win one of three $50 amazon gift cards. using spss statistics v29, 10 participants identified as mders were randomly selected for follow-up interviews. they had previously consented to be contacted for further studies and were informed via email about the interview process and compensation, agreeing through a second consent form sent electronically. remote interviews lasting around 30 minutes each were conducted via zoom, focusing on various aspects of daydreaming, guided by questions crafted based on prior research by bigelsen et al. (2016) (see appendix e). participants' responses were transcribed verbatim for accurate documentation. quantitative data collected through qualtrics and exported to spss underwent systematic analysis. data were recorded according to specified scales, cleaned to remove incomplete cases, and descriptive statistics were computed to summarize critical characteristics. regression and correlation analyses were performed to explore relationships between variables. qualitative data from interview recordings were analyzed using nvivo release 1.5.1. the thematic analysis involved transcribing responses, identifying recurring themes, and categorizing them to facilitate exploration. thematic nodes were created to capture key concepts, and visualization techniques aided in interpreting and presenting findings. this systematic analysis approach provided an understanding of quantitative and qualitative data, illuminating the research phenomena under investigation. results the analysis presents descriptive statistics and correlations for aces and total md in table 2. the variables examined include verbal abuse, emotional neglect, physical abuse, mental illness or suicide, separation or divorce, sexual abuse, witness abuse, drugs or alcohol, physical neglect, prison, and total aces. the mean (m) and standard deviation (sd) for each adverse childhood experience variable are as follows: verbal abuse (m = 0.59, sd = 0.49), emotional neglect (m = 0.37, sd = 0.48), physical abuse (m = 0.29, sd = 0.45), mental illness or suicide (m = 0.47, sd = 0.50), separation or divorce (m = 0.18, sd = 0.39), sexual abuse (m = 0.33, sd = 0.47), 46 moment witness abuse (m = 0.23, sd = 0.42), drugs or alcohol (m = 0.22, sd = 0.41), physical neglect (m = 0.34, sd = 0.47), and prison (m = 0.07, sd = 0.25). correlation coefficients between each adverse childhood experience variable and total md are provided. significant correlations (p < .05) are observed for verbal abuse (r = .32), mental illness or suicide (r = .31), sexual abuse (r = .25), witness abuse (r = .15), drugs or alcohol (r = .16), physical neglect (r = .35), and total aces (r = .33). these results suggest that specific aces, such as verbal abuse, mental illness or suicide, sexual abuse, witness abuse, drugs or alcohol, physical neglect, and the overall accumulation of adverse experiences, are positively correlated with higher levels of md. emotional neglect, physical abuse, separation or divorce, and prison do not show significant correlations with md. the study investigated the relationship between aces and total md scores. the model included multiple independent variables, each with their respective unstandardized coefficients (b), standardized coefficients (β), standard errors, and 95% confidence intervals for b. see table 3. the analysis revealed several significant findings. the constant term had a coefficient of b = 34.148 (se = 2.391), indicating the expected total md score when all independent variables are zero, which was statistically significant (t = 14.281, p < .001, 95% ci [29.439, 38.858]). verbal abuse significantly correlated with total md scores (b = 7.93, se = 3.64, β = 0.16, t = 2.18, p = .03, 95% ci [0.768, 15.084]). mental illness or suicide also showed a significant positive association (b = 12.359, se = 3.131, β = 0.247, t = 3.948, p < .001, 95% ci [6.193, 18.524]). separation or divorce exhibited a significant negative relationship with total md scores (b = -13.076, se = 4.238, β = -0.201, t = -3.086, p = .002, 95% ci [-21.423, -4.73]), indicating lower total md scores in individuals experiencing separation or divorce. sexual abuse also showed a significant positive association (b = 8.401, se = 3.396, β = 0.159, t = 2.473, p = .014, 95% ci [1.712, 15.09]). physical neglect was positively associated with total md scores (b = 11.836, se = 3.29, β = 0.226, t = 3.598, p < .001, 95% ci [5.357, 18.315]). variables such as emotional neglect (b = -0.671, se = 3.699, β = -0.013, t = -0.181, p = .856, 95% ci [-7.957, 6.614]), physical abuse (b = -1.076, se = 3.713, β = -0.019, t = -0.29, p = .772, 95% ci [-8.389, 6.237]), witness abuse (b = 1.604, se = 3.819, β = 0.027, t = 0.42, p = .675, 95% ci [-5.918, 9.126]), drugs or alcohol (b = 0.886, se = 3.842, β = 0.015, t = 0.231, p = .818, 95% ci [-6.682, 8.453]), and prison (b = -8.919, se = 5.821, β = -0.088, t = -1.532, p = .127, 95% ci [-20.384, 2.546]) did not show statistically significant associations with total md scores. these findings suggest that experiences of verbal abuse, mental illness or suicide, sexual abuse, and physical neglect are significant predictors of higher total md scores. separation or divorce is associated with lower total md scores. other variables examined did not show significant relationships with md. in the regression analysis examining the relationship between total aces and md, the total aces yielded a significant effect on md scores (b = 3.40, se = 0.60, β = 0.33, t = 5.64, p < .001**). the 95% confidence interval for the coefficient of total aces ranged from 2.21 to 4.59 (see table 4). these findings convey the importance of total aces in predicting md behaviors. case studies the case studies illustrate individuals' experiences with md and its association with aces. each case highlights the impact of childhood trauma on personality traits and coping mechanisms, such as excessive daydreaming. common themes across the cases include emotional distress, difficulties forming relationships, and coping mechanisms involving vivid daydreaming. in case #1, a ph.d. candidate's trauma history includes bullying and a physical assault by a peer. they cope with past trauma through daydreaming, which both alleviates stress and interferes with academic responsibilities. they state, "i often find myself lost in a world of my creation, where i am in control, and everything is perfect." similarly, case #2 portrays an individual using md to escape their painful reality, experiencing emotional exhaustion and social difficulties as a result. as a child, they experienced the trauma of witnessing domestic abuse and two car accidents, one of which left them permanently injured. the interviewee said, "sometimes i feel like i am daydreaming more than other people. several hours have passed before i realize how long i have been daydreaming." case #3 depicts an individual with elaborate daydreams, developed as a coping mechanism for child47 evaluating the relationship between maladaptive daydreaming hood abuse and neglect, which persist into adulthood. they experienced an assault as a young child. they mention, "my daydreams are a refuge, a place where i can be myself without fear of judgment or harm." in case #4, an individual's childhood trauma leads to intense daydreaming, impairing their focus and relationships in adulthood. as a child, they were diagnosed with adhd. they were bullied for having this diagnosis. their peers often avoided them and made disparaging comments about their intellectual abilities. the participant says, "i often daydream to cope with negative emotions, stress, and anxiety." case #5 highlights how childhood adversity can fuel excessive daydreaming. the interviewee mentions that, as a child, they did not have adequate resources. their childhood consisted of scarce food and clothing. this led to the interviewee needing help to focus on school and making friends. thus, they were often alone. they say, "in my daydreams, i can rewrite my past and create a happier, more fulfilling narrative for myself." case #6 portrays a student overwhelmed by daydreaming, stemming from past abuse and isolation, affecting academic and social functioning. this case is a student who spends most of their time alone, like their childhood. as a child, they often moved to different locations, which made them unable to make and keep friends. they state, "i struggle to stay grounded in reality because my daydreams feel more vivid and exciting." case #7 illustrates how childhood emotional abuse and neglect contribute to dissociative daydreams and disconnection from reality. parents and peers often insulted and disparaged them as a child. this caused them to have feelings of inadequacy. they mention, "i feel guilty for spending so much time daydreaming, but it helps me cope." in case #8, aces manifest in low self-esteem and avoidance behaviors, prompting the individual to seek solace in daydreams. as a child, this patient was bullied for having acne by parents and peers. they often utilized daydreaming to escape into a world where their appearance reflected their ideal. they say, "my daydreams often feature characters who protect and comfort me, fulfilling the roles i lacked in real life." case #9 portrays an individual using daydreaming as a coping mechanism for childhood trauma despite efforts to manage it through therapy and social engagement. this case experienced several assaults as a child. they have since sought therapy but still used md as a coping mechanism. they mention, "i feel that my daydreaming is becoming an addiction, but i do not know how else to cope." in case #10, childhood sexual trauma leads to md accompanied by hallucinations, highlighting the severe impact of aces on cognitive processes and mental health. they state: "even though i know my daydreams are not real, they feel more comforting and real than anything in my life." these cases collectively emphasize the complex interplay between childhood trauma, personality development, and maladaptive coping mechanisms like excessive daydreaming. future research should further explore how childhood trauma influences md severity and associated symptoms, such as dissociation and hallucinations, to inform targeted interventions for individuals affected by both aces and md. discussion the findings from the present study shed light on the complex relationship between aces and md. this discussion section will delve into the implications of the results obtained from the descriptive statistics, correlations, and regression analyses. descriptive statistics and correlations unveiled specific patterns in the relationship between individual aces and md. notably, significant positive correlations were observed between md and several aces, including verbal abuse, mental illness or suicide, sexual abuse, witness abuse, drugs or alcohol, and physical neglect. these findings suggest that individuals who have experienced these adverse events during childhood may be more likely to engage in md behaviors. on the contrary, emotional neglect, physical abuse, separation or divorce, and prison did not show significant correlations with md. while this may seem unexpected, it underscores the multifaceted nature of the relationship between childhood experiences and md, indicating that not all adverse experiences may contribute equally to the development of md. further insights were gained through regression analyses, which aimed to identify the unique contribution of each ace and the cumulative effect of total aces on md. results revealed significant associations between certain aces and md scores. specifically, verbal abuse, mental illness or suicide, sexual abuse, and physical neglect emerged as signif48 moment icant predictors of higher md scores. conversely, separation or divorce showed a negative association with md scores, suggesting that individuals who have experienced these circumstances may exhibit lower levels of md. these findings accentuate the differential impact of various aces on md and emphasize the importance of considering the specific nature of adverse experiences in understanding md behaviors. of particular significance is the role of total aces in predicting md. the regression analysis demonstrated a robust positive relationship between total aces and md scores, indicating that individuals with more aces are more likely to engage in md. this highlights the cumulative effect of childhood adversities on md and emphasizes the importance of addressing broader adverse experiences in interventions targeting md tendencies. the present study contributes to understanding the intricate interplay between childhood experiences and md behaviors. by identifying specific aces and their cumulative impact on md, these findings provide valuable insights for the development of targeted interventions aimed at mitigating md tendencies and promoting mental well-being in individuals with a history of aces. future directions the present study offers valuable insights into the relationship between aces and md, but further exploration is necessary to deepen our understanding of this complex phenomenon. future research should focus on clarifying the mechanisms through which aces contribute to the development and persistence of md. specifically, studies could investigate how trauma-related factors, such as emotional regulation difficulties or dissociation, mediate the relationship between early adversity and md tendencies. exploring potential interventions aimed at addressing trauma could be a fruitful avenue for further investigation. trauma-informed therapeutic approaches, such as cognitive-behavioral therapy (cbt) or eye movement desensitization and reprocessing (emdr), might offer promising avenues for mitigating the impact of aces on md. investigating whether such interventions reduce the severity or frequency of md could provide critical information for clinicians working with individuals affected by both trauma and md. additionally, research could benefit from examining the long-term mental and physical health consequences of md in individuals with aces. studies that track the trajectory of md over time, focusing on trauma-related outcomes like depression, anxiety, or somatic symptoms, may shed light on how md evolves and interacts with other mental health conditions. this could help inform early intervention strategies, particularly for individuals at high risk for maladaptive coping mechanisms due to their trauma history. by building on the established link between aces and md, future research can contribute to developing more effective interventions and preventative strategies, ultimately improving outcomes for individuals experiencing both childhood trauma and md. limitations this study has limitations that warrant acknowledgment. the data collection occurred during the covid-19 pandemic, potentially introducing bias due to the unique circumstances surrounding this period. factors such as increased stress levels, social isolation, and disruptions to daily routines may have influenced participants' experiences of maladaptive daydreaming and recollection of adverse childhood experiences. in addition, there is an overrepresentation of women in the sample. this gender disparity may skew the results and overlook potential differences in the relationship between maladaptive daydreaming and adverse childhood experiences among men. reliance on self-report measures introduces the possibility of response bias and inaccuracies in participants' responses. social desirability bias, memory recall errors, and interpretation discrepancies may affect the validity and reliability of the data collected. lastly, the adverse childhood experiences scale can vary widely from person to person. it is not a diagnostic tool to assess the biology of stress, yet it is a tool to evaluate potential outcomes due to adversity experienced in childhood. conclusion the results of this study provide valuable insights into the complex relationship between aces and md, with significant implications for clinical practice. the findings underscore the importance of assessing childhood trauma history in individuals presenting with symptoms of md. clinicians should recognize that specific types of aces, such as verbal abuse, mental illness or suicide, sexual abuse, and physical neglect, are associated with higher levels of md. therefore, incorporating routine screening for aces into clinical assessments can help 49 evaluating the relationship between maladaptive daydreaming identify individuals at heightened risk for md and guide the development of tailored interventions. the negative association observed between separation or divorce and md scores suggests that individuals who have experienced these circumstances may exhibit lower levels of md. clinicians should explore the protective factors associated with separation or divorce, such as social support networks or adaptive coping strategies, to inform interventions aimed at reducing md symptoms in this population. the cumulative effect of total aces on md emphasizes the importance of addressing broader adverse experiences in interventions targeting md tendencies. clinicians should adopt a holistic approach to treatment, addressing both the specific aces contributing to md and the overall impact of childhood trauma on individuals' mental health. this may involve incorporating trauma-informed therapy modalities, such as cognitive-behavioral therapy (cbt) or eye movement desensitization and reprocessing (emdr), to address underlying trauma and develop healthier coping mechanisms. these findings highlight the need for greater awareness and understanding of the interplay between childhood trauma and md in both clinical and lay settings. educating clinicians and the public about the potential psychological consequences of aces, including their association with md, can facilitate early intervention and support for affected individuals. by fostering a trauma-informed approach to mental health care and promoting resilience-building strategies, clinicians can empower individuals to overcome the adverse effects of childhood trauma and lead healthier, more fulfilling lives. this study emphasizes the critical role of childhood experiences in shaping md behaviors and elucidates the importance of trauma-informed care in clinical practice. by addressing the underlying trauma and providing targeted interventions, clinicians can help individuals affected by aces navigate their journey toward healing and recovery from md. acknowledgments the author thanks dr. timothy benke and dr. erik oleson for their invaluable guidance and unwavering support throughout the research endeavor. their expertise and dedication significantly enriched the development and execution of the study. the author is sincerely grateful for their mentorship and scholarly insights, which greatly enhanced the quality of the work. dr. benke and dr. oleson's steadfast belief in the research, continuous encouragement, and commitment to academic excellence were pivotal in overcoming obstacles. the author acknowledges the profound impact of their mentors on the study and extends heartfelt appreciation for the privilege of collaborating with such exceptional mentors. declarations competing interests. the author declares no competing interests related to this research. funding. the authors did not receive any financial or non-financial support for this work. ethical approval. this study obtained approval from the colorado multiple institutional review board (comirb) of the university of colorado-denver| anschutz medical school by the principles outlined in the declaration of helsinki. consent to participate. informed consent was obtained from all individual participants included in the study. consent to publish. prior informed consent was obtained from all individual participants included in the study. references anda, r. f., whitfield, c. l., felitti, v. j., chapman, d., edwards, v. j., dube, s. r., & williamson, d. f. 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(1982). the fantasy-prone personality: implications for understanding imagery, hypnosis, and parapsychological phenomena. psi research. 51 evaluating the relationship between maladaptive daydreaming table 1 table of demographic data note: nationality, age, and sex of participants. table 2 descriptive statistics and correlations for adverse childhood experience and total maladaptive daydreaming note. the table includes descriptive statistics and correlations for adverse childhood experiences and total maladaptive daydreaming. the table includes mean (m), standard deviation (sd), and correlations. *p < .05, **p < .01. moment table 3 regression for individual adverse childhood experiences and maladaptive daydreaming note. the table presents unstandardized coefficients (b), standardized coefficients (β), lower limit (ll), upper limit (ul), t-values, p-values, and 95% confidence intervals for each adverse childhood experience in relation to maladaptive daydreaming. *p < .05, **p < .01. table 4 regression for total adverse childhood experiences and maladaptive daydreaming note. the table presents unstandardized coefficients (b), standardized coefficients (β), lower limit (ll), upper limit (ul), t-values, p-values, and 95% confidence intervals for each total adverse childhood experiences in relation to maladaptive daydreaming. *p < .05, **p < .01 53 evaluating the relationship between maladaptive daydreaming appendix a 54 moment appendix a (cont.) 55 evaluating the relationship between maladaptive daydreaming appendix a (cont.) 56 moment appendix b adverse childhood experiences (aces) instructions: below is a list of 10 categories of adverse childhood experiences (aces). from the list below, please place a checkmark next to each ace category that you experienced prior to your 18th birthday. then, please add up the number of categories of aces you experienced and put the total number at the bottom. 1. did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you? 2. did you lose a parent through divorce, abandonment, death, or other reason? 3. did you live with anyone who was depressed, mentally ill, or attempted suicide? 4. did you live with anyone who had a problem with drinking or using drugs, including prescription drugs? 5. did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other? 6. did you live with anyone who went to jail or prison? 7. did a parent or adult in your home ever swear at you, insult you, or put you down? 8. did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? 9. did you feel that no one in your family loved you or thought you were special? 10. did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)? 57 evaluating the relationship between maladaptive daydreaming appendix c interview questions 1. how much time do you spend daydreaming on a typical day? 2. how much time do you spend daydreaming on a high daydreaming day? 3. how much time do you spend daydreaming while in a moving vehicle? 4. how much time do you spend daydreaming when you are alone? 5. how much time do you spend daydreaming when you are in public? 6. how often do your daydreams include fictional characters or plots? 7. how often do your daydreams include people you do not personally know? 8. how often do you return to daydreams involving similar people or plots? 9. how often is the content of your daydreams positive or pleasurable? 10. how often is the content of your daydreams negative or disturbing? 11. how often are your current daydreams accompanied by physical activity? 12. how often were your childhood daydreams accompanied by physical activity? 13. how often are your current daydreams accompanied by vocal noises? 14. how often were your childhood daydreams accompanied by vocal noises? 15. how often do you confuse your daydreams with reality? 16. how difficult is it for you to keep your daydreaming under control? 17. how strong is the urge to return to a daydream that was interrupted? 18. how much influence do you have over the direction of your daydreams? 19. how strong is the urge to start daydreaming after waking up? 20. how difficult is it for you to stay on-task for something important while daydreaming? 21. how difficult is it for you to stay on-task for something boring while daydreaming? 22. how difficult is it for you to focus on what others are saying while you are daydreaming? 23. how annoyed do you feel when your daydreams are interrupted? 24. how distressed are you about the amount of time you spend daydreaming? 25. how distressed are you about your daydreaming in general? 26. how distressed are you by the content of your daydreams? 27. how ashamed are you to tell others about your daydreaming? 28. how distressed are you when you are unable to find time to daydream? 29. would you rather daydream than be social or engage in hobbies? 58 moment 30. does daydreaming add creativity to your life? 31. do you find daydreaming comforting or enjoyable? 32. does daydreaming help you deal with everyday life? 33. is your life more interesting because of your daydreaming? 34. does daydreaming interfere with your sleep? 35. does daydreaming interfere with doing basic chores? 36. does daydreaming interfere with your relationships? 37. does daydreaming interfere with your academic or occupational goals? 38. does daydreaming interfere with your life goals? appendix c (cont.) microsoft word manuscript 5_12.12.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 being one in a world of twos: experiences and consequences of single parenting maitri jain, b.a. teachers college, columbia university venus mahmoodi, ph.d. teachers college, columbia university even though the number of single-parent households has been increasing in recent decades, they still face many challenges, including finances, health, and social stigma. this is a global literature review that aims to understand the experiences and difficulties faced by single-parent families and how cultural and social factors shape these challenges. this review shows that single parents have more negative experiences than coupled parents in most cultures worldwide. certain difficulties like economic challenges are found globally, while others such as relational difficulties are found more in collectivistic cultures (mudau et al., 2018). there are also differences in the types of challenges experienced by single mothers versus single fathers, with mothers facing more economic challenges and fathers facing more caregiving difficulties (d'mello et al., 2016). in more feministic cultures, like swedish, there is a smaller discrepancy between genders as the state creates equal support and opportunities for both single mothers and fathers (barber, 2003). furthermore, single parenthood can significantly impact children’s health during and after birth, academic performance, and psychosocial development (amato & patterson, 2017; sinha & ram, 2018; wang, 2015). this review asserts that most problems faced by single parents are not due to inherent limitations, but rather discrimination and stigma rooted in their respective communities. the paper also discusses the need for further cross-cultural studies on single parents’ experiences and their impact on children while also considering important factors in developing interventions for single-parent families to help manage psychological distress and provide economic support. keywords: single mothers, single fathers, children, social stigma, culture what does the word family mean? the answer to this question has changed over the course of human civilization. traditionally, a family consisted of a heterosexual couple with their biological children. more recently, a family is defined in terms of love and bonding among individuals who live together, who may or may not be married, who may or may not be related by blood (powell, 2014). this new understanding has generated greater acceptance for non-traditional family types such as gay and lesbian couples and single-parent families (powell, 2014). although the definition of the word family has been expanded within the literature, most people still consider a two-parent heterosexual family as the societal ideal. single parents are at a greater disadvantage not only because they have to face social stigma (stavrova & fetchenhauer, 2015) like other non-traditional family types, but they also bear the burden of fulfilling the dual role of both a mother and a father, having no partner with whom to share responsibilities (bhat & patil, 2019). despite these significant social and household challenges, the number of single-parent families is increasing globally (woessmann, 2015). worldwide, between 2000 and 2012, the percentage of fifteen-yearolds living with a single parent increased from 12% to 14% (woessmann, 2015). in the united states, 27% of children lived in single-parent families in 2018 compared to only © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. jain & mahmoodi graduate student journal of psychology 12% in 1970 (smock & shwartz, 2020). in 2011, 5% to 10% of households globally were considered single-parent households (the organization for economic co-operation & development [oecd], 2016), with wide variations around the world. for example, in new zealand, 11% of all households were single-parent, while the percentage in japan was less than 3% (oecd, 2016). although worldwide rates are low, some parts of the world have higher rates of single-parent households. for example, in south africa, 14% of children lived in single-parent households in 2014. many reasons have been proposed for this high number, such as high divorce rates, premarital fertility, increasing educational level of women, mobility due to employment, gendered migration, poverty, high death rate of mothers, and decrease in number of marriageable men (ntoimo & mutanda, 2020). the most recent review on single parenthood was conducted by anderson in 2003. it studied the influence of various external factors, such as poverty, on the experiences of diverse single-parent families, such as those from a minority background. given that this literature was reviewed nearly twenty years ago, the present review aims to provide a more recent analysis of the experiences of single-parent households. the objective of this paper is to understand the demographic and socio-emotional challenges faced by singleparent households. the effect of social factors, specifically gender and culture, on singleparent families’ experiences are also explored. this review will help clarify the experiences of single-parent households and the factors that impact their overall functioning. in turn, this will inform the development of appropriate interventions to support such families (figure 1). methods eligibility criteria this review encompasses studies on single-parent households. a single-parent household is defined as a family in which a mother or father cares for one or more children without the physical assistance of the other parent in the home, irrespective of the reasons for such a situation (ganesha & venkatesan, 2012). this includes single parents due to divorce, a partner's death, artificial insemination, adoption, surrogacy, or pregnancy in a short-term relationship. only studies conducted between 2000 and 2020 were incorporated to prevent the inclusion of outdated and irrelevant literature. the exclusion criteria included studies that were more than 20 years old and those discussing experiences of non-binary parents. while the single parenthood experiences of diverse gender identities are important to highlight, the present review focuses on experiences of households with either a cisfemale (single-mothers) or a cis-male (single-fathers) parent. although we acknowledge that non-binary parents also experience distress due to single parenthood, their gender identity creates additional stigma, which is outside the scope of this paper. search terms we conducted a search on pubmed and google scholar, using the following search terms: “single parents”, “single mother”, “single father”, “children with single parent”, “challenges of single parent”, “challenges of single mother”, “challenges of single father”, “experience of single parents”, “experience of single mothers”, “experience of single fathers”, “qualitative single parent”, “cultural stigma against single parent”, and “culture and single parents”. of the 150 studies found, 70 abstracts were screened at the title and abstract level. in this initial reading, 16 studies were removed because they did not fit the inclusion criteria. the remaining 54 studies were included in the full article screening, and all were included in this review. results being one in a world of twos graduate student journal of psychology included study characteristics of the 54 studies included, 11 were conducted in the united states, 12 were conducted in africa, (south africa, zimbabwe, cameroon, nigeria, democratic republic of congo, ethiopia,ghana). nine of the studies were conducted in europe (great britain, sweden, italy, finland, new zealand, croatia), five in india, three in china, four in japan, and one each in iran, korea, and taiwan. three of the studies included samples from across different continents. four of the studies focused on multiple countries within the same continent—one was conducted in europe and the other three in africa. four of the studies found were narrative reviews. many of the studies (17 out of 54) focused on children's well-being in single-parent households. eighteen of the studies explored the experiences of both single mothers and fathers. eleven studies focused solely on single mothers, while only six looked exclusively at single fathers' experiences. further details about the studies can be found in table 1. sociodemographic factors associated with single-parent households focus on parents. although single-parent households share many characteristics demographically, they differ on the gender of the parent and the cultural milieu. barber (2003) compared 85 countries around the world and found that single parenthood rates declined as fathers became more involved in their children's upbringing, but the rates increased as urbanization levels, male unemployment, and female literacy increased. the authors hypothesized that more economically powerful women are less likely to marry because they do not need a husband for economic support (barber, 2003). furthermore, the age of single motherhood was higher in countries with a greater gross national product (gnp) (barber, 2003), which is “an estimate of total value of all the final products and services turned out in a given period by the means of production owned by a country's residents” (barnier, 2021, para. 1). in the us, lansford (2016) showed that single mothers experienced more economic adversity than single fathers, likely due to the higher probability of dropping out of school, holding low-paying jobs, and losing income. in the uk, single parents were shown to have lower income, education, health prospects, and career opportunities than coupled parents (calder, 2018). the same study showed that due to their gender disadvantage, single mothers faced less optimal work-life balance, less flexibility at work, and fewer opportunities to care for their children than single fathers (calder, 2018). in britain, twofifths of mothers spent some time as single parents in their lifetime but tended to have a relatively short duration of single parenthood of 4.6 years or less (ermisch & francesconi, 2000). by building blended families, these mothers' standard of living improved substantially (ermisch & francesconi, 2000). interestingly, these family constellations did not improve the mother-child relationship, especially if these relationships were deteriorated by previous family conflict (ermisch & francesconi, 2000). however, even these stepfamilies were not very stable and dissolved after some time (ermisch & francesconi, 2000). mugove (2017) stated that single mothers in zimbabwe were less educated and, when married, depended on their partners for income and intellectual stimulation of their children; however, upon separation, they faced significant economic disadvantages. lu et al. (2020) similarly showed that single mothers in the us had less income than single fathers; and therefore, they faced higher levels of economic crisis and increased dependence on governmental financial and social support. meier et al. (2017) found that unemployed single mothers in the usa were less happy and more stressed than employed single mothers, showing that employment is important for both financial and jain & mahmoodi graduate student journal of psychology psychological well-being. amoateng et al. (2004) showed that in south-africa, singleparent households were more likely to be poor (67%) as compared to nuclear-families of which only 34% fell into this category. although there are significant income gaps between single mothers and fathers, there has been a reduction in the income gap between 1990 and 2010 in the usa, shifting from 30% to 21% within 20 years (kramer et al., 2016). however, concerning financial status, both genders were found to fare worse than coupled parents (kramer et al., 2016). in contrast to the us, in taiwan, incomes of single-father families have decreased, whereas those of single mothers increased between 1998 and 2006 (cheng & wu, 2016). this is likely because of increasing gender-empowerment in taiwan, where women have more equality and rights as compared to many other industrialized nations (yi & chang, 2020). focus on children. according to the structural family theory, a healthy family structure consists of both parents and their children (mikeal, 2018), and any deviation from this family constellation might cause unhealthy developmental patterns. based on this premise, children growing up in a single-parent household will experience significant negative developmental, social, and psychological consequences. studies have shown that children born to single mothers experienced more negative neonatal outcomes, including low birth weight, preterm birth, small for gestational age, and admission to the neonatal intensive care unit (raatikainen et al., 2005). mothers to these children were more likely to be unmarried and less likely to engage in prenatal care than other women (raatikainen et al., 2005). furthermore, these mothers were also more likely to be primiparous, use alcohol, smoke, and have pregnancy-related diabetes (raatikainen et al., 2005). there are mixed findings of how single-parenting impacts children’s physical health and development. while some studies showed that these differences found were only due to the covarying differences in socioeconomic status (blakely et al., 2003, in new zealand; moncrief et al., 2014, in the usa; noonan & turchi, 2019, in the usa; tian & wang, 2019, in china), others reported that single parenting had a negative impact on factors such as child mortality, homicide, and childhood stunting (amato & patterson, 2017; ntoimo & odimegwu, 2014). however, it is important to note that adequate controls for other sociodemographic factors were not included in the latter set of studies. it is possible that these confounders caused significant results. more extensive and controlled studies should be conducted to understand the impact of single parenting on children's physical health. there is more congruity among findings regarding the academic performance of children living in single-parent homes. for instance, various studies conducted in africa (akinremi et al., 2020; azuka-obieke, 2013; chukwuka, 2018) found a reduction in academic performance, motivation, and creativity among those growing up in single-parent households. in asian countries, including japan (raymo, 2015) and india (rani, 2006), these children were more likely to drop out, have poorer grades, and get a job outside of school. watt (2019) said that this reduction in performance is due to the lower socioeconomic status of single-parent families and the parent's lack of participation in school activities. these results are more promising as they highlight where to intervene to improve access to opportunities for achievement. socioemotional challenges faced by single-parent households focus on parents. psychological strain. in addition to economic difficulties, single mothers face psychological distress. they are also perceived as less successful parents by others in the society. dejean (2012) found that adult, white, married and unmarried, female being one in a world of twos graduate student journal of psychology participants in the usa rated vignettes of single mothers as more insecure, unfortunate, irresponsible, immoral, disreputable, and less satisfied with life when compared to the ratings of single fathers. similar results were found in other areas around the world. in japan, single mothers were more stressed, both at home and work, and spent less time with their children (raymo et al., 2014; shirahase & raymo, 2014). in ethiopia, single mothers experienced many financial problems and psychological challenges such as loneliness, helplessness, and hopelessness (rahel, 2014). single mothers also struggled to provide financial and educational support to their children, limiting their educational achievement due to minimal support from the community and government (rahel, 2014). mothers in south africa also reported working harder to build good relationships with their teenage children and inculcating social skills in them (mudau et al., 2018). khosravan et al. (2010) analyzed iranian widowed mothers' experiences who chose to keep custody of their children after their spouses' death. results showed that these women faced many conflicting and distressing emotions, experiencing despair and a desire to improve their children's lives. many cited their only reason for living was for the sake of their child. they had a sentimental, emotional parenting style, sacrificing their own needs and wants while developing a child-oriented attitude to keep their children's lives as good as possible. this kind of intensive mothering (molander, 2019), where the mother gives all her time, energy, and money to her children, is found worldwide among women of various cultures (molander, 2019). similarly, in the us, many single black mothers felt they were not doing enough for their children, even after giving up things for their protection, such as intimate relationships, financial resources, and their freedom (elliott et al., 2015). social stigma. stigma against single parents is found throughout the world. in china, being a single mother is considered a disgrace, and non-marital childbearing is illegal (zhao & lim, 2020). single unmarried mothers who have a child are not allowed to receive social welfare (zhao & lim, 2020). these women are often forced to adopt various strategies such as using sex, community support groups, online influence, and fake marriages, to fight against the prevalent patriarchal ideals in which they have no social status and lack even the most basic rights (zhao & lim, 2020). in india, single mothers reported a lower social status (d'cruz and bharat, 2001). because they lacked male companions, they found it difficult to engage in many daily tasks such as making purchases and running their homes smoothly (d'cruz and bharat, 2001). they also faced social disapproval from their in-laws and relatives, experienced unwanted sexual advances, and tended to experience many physical and mental health problems (d'cruz and bharat, 2001). moreover, widows were expected to dress soberly and were condemned if thought to act too "happy" (d'cruz and bharat, 2001). similar results were also gathered in africa, where there is much stigma against single mothers, especially teenage single mothers (mulongo, 2006). typically, mothers were deemed irresponsible and deviant; whereas, fathers were not held responsible for a relationship's dissolution and any associated consequences (mulongo, 2006). positives of living in collectivistic cultures. even though stigma against single parents is present in all cultures, some benefits come with living in a collectivistic society. single mothers in korea faced stigma for having a family that deviated from the normative two-parent nuclear family (park, 2014). however, since korea has a collectivistic culture, single mothers' strong family ties helped moderate the negative consequences of single parenting on children (park, 2014). this was also found in india, where single mothers could leave their children with other family and community members, which provided free, quality childcare (rani, 2006). jain & mahmoodi graduate student journal of psychology feministic cultures. the picture for single parents looks slightly different in feministic cultures that believe in a more equal society. in sweden, being a single mother is correlated to the parent’s lack of commitment to developing a permanent relationship (barber, 2003). this phenomenon reduces the time fathers typically spend with their children (barber, 2003). moreover, sweden is a welfare state, and because single mothers and children receive high levels of economic support from the government, there is more childbearing before marriage (barber, 2003). this has also made it easier for single women to manage their families without facing conflicts with their workplace or without economic cooperation from former partners (barber, 2003). despite such good policies, single parents still reported worse health outcomes than coupled parents in sweden, especially single mothers, who were less likely to go to physicians (westin & westerling, 2006). the reasons for this are currently unknown and should be studied further. single fathers. although single mothers face more difficulties in the areas discussed above as compared to single fathers, men are still vulnerable to difficulties and challenges related to single parenthood. one such challenge is that single fathers face many stereotypes, including being poor caregivers or not wanting children. d'mello et al. (2016) showed that indian single mothers, although stigmatized more than single fathers, tended to have a more extensive support system to help with childcare. however, unlike the prevailing social myth, research shows that men have a strong desire to have children (hadley & hanley, 2011). coles (2003) found that black men voluntarily took full custody of their child following non-marital birth, divorce, adoption, or widowhood because they wanted to become a positive influence in their children's lives. unfortunately, single fathers are also at risk of succumbing to these stereotypes. carone et al. (2017) found that even though fathers wished to bring up their child, they worried about the quality of caregiving they could provide, both in terms of social and material resources. single fathers in new york city, an urban setting, mentioned that living near family helped them work, run errands, and answer parenting questions, whereas single fathers living in suburban areas were able to provide more security and recreational resources for their children (carone et al., 2017). yet, no matter where they lived, they still experienced challenges that negatively influenced their parenting experiences, including difficulty finding adequate childcare, the absence of the mother, limited finances, finding adequate housing, acquiring adequate medical insurance, and communication (melhado, 2017). single fathers from hong kong and taiwan who immigrated to canada also faced many challenges, worsened by the lack of social support in the new country (waters, 2010). these men went from being businessmen to homemakers. this phenomenon impacted their identity and self-worth. their authority at home was contested, and they felt as if their identity as a man was being challenged. however, they still cared for their children's well-being, and their relationship with their long-distance wives remained the same after separation (waters, 2010). studies found that there was more support for single fathers in feministic cultures, such as sweden, to take on caregiving roles by providing them with resources to spend time with their children without the social stigma (molander, 2019). unlike the prevailing global ideology of intensive mothering, sweden has a state policy that seeks a more gender-equal situation promoting a more sensitive, caring, present, and home-oriented masculinity ideal (molander, 2019). this allows fathers to engage in caregiving behavior that is traditionally considered "feminine," such as cooking and cleaning, and still avoid tensions related to these activities being so-called low status (molander, 2019). being one in a world of twos graduate student journal of psychology cross-cultural comparisons. there were very few studies that compared the experiences of single parents across different cultures and countries. heinonen (2019) conducted a study on a cross-national sample from the usa, uk, canada, australia, new zealand, south africa, and ecuador to study the experiences of divorced mothers. the findings revealed that despite facing increased demands of childrearing and financial challenges, a divorced life also gave mothers more flexibility and opportunities to build a better life. the stress of excessive demands was offset by the joy they received from playing with their children. it was better than being in an inharmonious marriage where they are constantly stressed because of conflicts with their spouse (heinonen, 2019). however, heinonen (2019) did not compare the experiences of divorced mothers in different countries. thus, while the study presents a positive angle of the lives of divorced mothers, it does not give us any information on how culture and socialization impact these experiences. stavrova & fetchenhauer (2015) compared experiences of single parents across different countries in europe. they found that the number of challenges faced by single parents varied based on the country being studied. in countries with a more collectivistic culture and a stronger two-parent norm, single parents experienced less life satisfaction and happiness. the social stigma and expectations in such countries influenced self-stigma in single parents, often leading them to feel like they are not good enough parents to their children (stavrova & fetchenhauer, 2015). the experience of nonmarried parents has also been shown to depend on the gender norms of countries. where these norms are more traditional, mothers are expected to put in time at home, while fathers are expected to invest in their careers (stavrova et al., 2012). if these expectations are not met, stigma, social-disapproval, and discrimination follow (stavrova et al., 2012). focus on children. much research has looked at the psychosocial outcomes of children of single parents across different countries and cultures. wang (2015) found that fourth to eighth-graders in china who lived with only one parent had less psychological capital such as resilience, self-esteem, and social competence available to them compared to children living in dual-parent households. they were also less developed psychologically in terms of their social and emotional competence. students who had better relationships with their teachers and peers had greater self-esteem, social and emotional competence, and resilience in both types of families. those children who were on good terms with their neighbors were more prosocial than children who did not interact with their neighbors, especially in single-parent families. the findings highlight how the school environment can help improve issues that arise as a result of growing up in a single-parent household. lower psychological and emotional development of children growing up in single-parent households has been found in multiple countries. in african countries, azuka-obieke (2013) and mikeal (2018) showed that children growing up in single-parent families scored lower on assessments of psychological well-being, such as happiness and selfesteem, than children from dual-parent households. these children faced psychological disorders such as depression (ntumi et al., 2016), suicide, and substance abuse at higher rates (weitoft et al., 2003). in india, children from single-parent households, especially those headed by a single father, had a higher intensity of externalizing and internalizing problem behaviors (ganesha & ventakesan, 2012). specifically, girls from single-father households had the greatest problem behaviors, followed by boys from single-father households. in contrast, girls in single-mother households were most well-behaved. sinha and ram (2018) also found that children growing up in single-parent households in india tended to hide more from their parents, had higher rates of dropping out of high school, and had higher rates of alcohol and substance abuse. nonoyama-tarumi (2017) said that female-headed households in japan face problems because of a lack of economic jain & mahmoodi graduate student journal of psychology resources, while father-headed households face challenges due to limited parenting resources. erdelja et al. (2013) suggest that higher rates of delinquency among children from single-parent households in croatia are likely due to attention-seeking and yearning for affection. these studies highlight the various challenges both adults and children in single-parent households experience, ranging from social stigma to psychological distress. it also brings attention to how these challenges are experienced differently in cultures with differing norms. one finding of concern is the intergenerational transmission of distress that occurs in single-parent families. the negative impact on children’s education and psychosocial well-being may have a long-lasting effect and even have consequences for the generation to come, creating a vicious cycle. discussion culture and gender in single parenting this relevant review highlights many important points about single parents' experiences throughout the world. we find that single parents from all cultures experience many challenges, including economic difficulties and psychosocial distress. however, when considering different countries around the world, single parents experience and engage with these challenges based on their value systems. for instance, there are both advantages and disadvantages to living in a collectivistic culture for single parents. on the one hand, collectivistic cultures can be more prejudiced towards single parents and create more social and relational challenges. on the other hand, as found by rani (2006), these cultures also provide opportunities for help with caregiving and parenting, which can reduce the burden on a single parent. cultural factors interacting with the gender of a parent significantly influence parenting experience. single mothers were found to fare worse in terms of financial capabilities, whereas single fathers struggled more with caregiving and parenting skills (d'mello et al., 2016). this can be explained by the structural functionalism theory of gender (wienclaw, 2011), which says that society has divided different roles between genders to promote efficient functioning. from birth, boys and girls are socialized differently to take on these specific roles (wienclaw, 2011), including heterosexual coupling. however, this gender divide can break down when families do not follow these traditional ideals. when a single parent is raising a child, this parent takes on the role of multiple genders, which can be problematic in a traditional society where the parent has not been socialized to take on these additional roles. for instance, if a mother takes on the role of a full-time worker while caring for her children, she might be judged or scorned for taking on the "earner" role and not focusing exclusively on caretaking. overall, single mothers tend to be ostracized because they are not seen as competent to run their households independently and are expected only to provide caregiving (zhao & lim, 2020). another cultural factor that impacts single parenting is a culture's level of adherence to feministic ideals. in countries like sweden, where gender norms are not as stringent, males and females are equally able to engage in caregiving tasks without facing stigma and shame from society (molander, 2019). however, this is not the case for many other cultures. for instance, in the us, black men are often questioned for deciding to take sole custody of their child (d'mello et al., 2016). this may be because the us is a predominantly judeo-christian country where most people follow less feministic and more traditional roles (d'mello et al., 2016). in india, single fathers tend to have less extensive social support as compared to single mothers for childcare assistance (d'mello et al., 2016). being one in a world of twos graduate student journal of psychology intergenerational transmission of harm this review showed that the negative social norms against single parents might create consequences that last for multiple generations (raatikainen et al., 2005). these challenges not only affect single parents but also their children's physical, academic, and psychosocial wellbeing (amato & patterson, 2017; sinha & ram, 2018; wang, 2015). girls in single-father households tend to struggle the most since fathers have limited knowledge of raising their daughters (sinha & ram, 2018). finally, there are intergenerational implications when single parents face economic and social difficulties, putting their children at increased risk of similar sociodemographic and psychological issues due to poor resources, time, and parental care provided to the child (raatikainen et al., 2005). the study by wang (2015) highlights how teachers, peers, and neighbors can be a source to offset these risks and create a healthier environment for children growing up in single-parent families. implications for interventions these findings highlight the need for interventions for single-parent families to improve their sociodemographic and psychosocial wellbeing. due to the prevailing social biases and traditional gender roles, where fathers are earners and mothers are responsible for emotional support, single parents' support programs focus only on fulfilling these gendered roles. these programs focus on single fathers' job situations, while for single mothers, the focus is on the lack of a social network (kullberg, 2005). however, rather than focusing on traditional gender roles, there is a need for more holistic interventions that tackle the wide-ranging problems that single parents face, particularly related to childcare. the efficacy of one such intervention was highlighted by taylor & conger (2017). they showed that improving social support and internal strengths of single mothers, such as positive coping strategies, optimism, self-efficacy, and self-esteem, improved mothers' and children's well-being. newkirk et al. (2020) found that positive workplace policies, such as schedule flexibility, also reduce depressive symptoms in single mothers. in the case of women who faced conflicts in managing both the demands of work and home, with work impinging on their home life, a more extended time off work postpartum can reduce depressive symptoms. briggs et al. (2013) highlighted the utility of a group training program in reducing parent-child dyad conflicts in single-parent families. this type of behavioral training program aimed at increasing parenting skills, such as dealing with child non-compliance and assessing triggers for undesirable behavior. however, examples of such interventions are limited and are bound to western cultures. building more of such interventions to support single-parent families and testing their efficacy with families from different ethnic or cultural backgrounds will be beneficial in improving the lives and conditions of single-parent families. limitations and future directions a limitation of this review is the inclusion of studies focusing solely on the experiences of cis-gendered single parents. other genders were not included in this review as it was beyond the scope of this paper. further studies are needed to understand the experiences of non-binary parents to see how they navigate the world of single parenthood and determine both the challenges and strengths in the parenting role as related to their identities. further, there need to be more studies that compare experiences across different cultures. currently, there are very few studies that compare single-parent experiences in different graduate student journal of psychology jain & mahmoodi cultures, and the ones that do are limited to specific regions. such comparative studies will help clarify protective and challenging factors for single parents. another area in which studies seemed to be lacking is the internal, subjective experiences of single fathers. while demographic and psychological correlates of single fathers have been assessed, very few studies have looked at the emotional experiences and perceptions of the challenges of bringing up a child on their own. to provide specialized support to single fathers, developing an understanding of these topics can contribute to the development of interventions for this particular population. conclusion the present review aimed to understand how cultural and gender factors impact the experiences of single parents, and how they influence children’s health. across different cultures, single parents have negative experiences, which can be due to economic difficulties and social stigma. this was found to be more applicable to single mothers than fathers. it also impacted children’s development in areas of academics, health, and psychosocial well-being. finally, this study calls for more global studies on single parenthood experiences while also considering essential factors in developing interventions for single-parent families to help manage psychological distress and provide economic support. acknowledgements the authors declare no conflict of interest associated with the publication, and no significant financial support for this work that could have influenced its outcome. correspondence concerning this article should be addressed to maitri jain, k-14 f, new delhi, india, 110017. telephone number: +91-9811421490. email: mj3002@tc.columbia.edu references akinremi, b. s., akinremi, o. v., akintewe, b. n., famuagun, k. s., & oloyedeakinsulure, a. i. 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(2020). online patriarchal bargains and social support: struggles and strategies of unwed single mothers in china. television and new media, 00(0), 1–20. https://doi.org/10.1177/1527476420942743 appendix table 1 characteristics of studies included in the review author (year) method countries population of interest sample size stavrova and fetchenhaue r (2015) survey 27 european countries male and female single parents 85,051 ntoimo and mutanda (2020) survey 31 african countries never married single mothers 36,122 heinonen (2019) survey uk, usa, canada, australia, new zealand, south africa, ecuador single parents with multiple children 520 lansford (2016) narrative review single parents and their children calder (2018) narrative review europe single parent families mudau et al. (2018) qualitative interviews south africa single parents with teenage children single mothers = 5 single fathers =5 rani (2006) structured interviews india single mothers living in slums 214 lu et al. (2020) survey usa working, single parent head of households n=1135 single mothers = 86.5% single fathers = 13.5% meier et al. (2017) survey usa single and partnered mothers with children under 18 in the household n=7,074 partnered = 76.86% single = 23.14% kramer et al. (2016) survey usa working single parent householders 554,633 being one in a world of twos graduate student journal of psychology single mother = 83.7 % single father = 16.3 % cheng and wu (2016) survey taiwan single mothers and fathers single fathers = 641 single mothers = 730 khosravan et al. (2010) subjective interviews iran single parent widows 24 molander (2019) subjective interviews and photo diaries sweden single fathers with full or shared custody 16 elliott et al. (2015) subjective interviews usa low income, black single mothers 16 mugove (2017) questionnair es, observation checklist, document analysis zimbabw e single mothers, single fathers, children growing up in single parent households school teachers = 30 school heads = 18 parents = 20 children = 20 dejean (2012) survey usa never married custodial single mothers and fathers n=1,350 single fathers = 670 single mothers = 692 zhao and lim (2020) semistructured interviews china unwed single mothers 30 d’cruz and bharat (2001) narrative review india different family types d’mello et al. (2016) narrative review india single parent families coles (2003) quantitative and qualitative surveys usa african american single custodial fathers 10 carone et al. (2017) survey italy single father families created by surrogacy 33 raatikainen et al. (2005) interviews, clinical records, surveys finland unmarried pregnant women unmarried women = 8235 married women = 17,138 blakely et al. (2003) survey new zealand children in single parent families 742,587 jain & mahmoodi graduate student journal of psychology moncrief et al. (2014) clinical records usa children of single parents hospitalized for asthma or bronchodilatorresponsive wheezing 526 noonan and turchi (2019) survey usa children living in single parent families children in single-father families = 239 families, children in single mother families = 2,989 children in two-parent families = 10,178 tian and wang (2019) survey china children living in single parent households. n= 1114: 974 dual-parent children = 974 single mother children = 97 single father children = 43 amato and patterson (2017) longitudinal survey data usa children in single parent households with health risks children who faced accidents = 1910 children who faced homicide = 1802 children who faced suicide = 1796 children with neoplasms = 1828 ntoimo and omidegwu (2014) survey subsaharan africa (cameroo n, nigeria & democrati c republic of congo) single women and their under-5 children cameroon = 11,748 nigeria = 28,100 drc = 8,999 akinremi et al. (2020) survey nigeria children of single parents 50 students in 5 different being one in a world of twos graduate student journal of psychology secondary schools azukaobieke (2013) survey and testing nigeria adolescent children of single parents 100 chukwuka (2018) survey nigeria children in primary school of single parents n = 240 teachers = 80 students = 160 raymo (2015) longitudinal survey japan children in single mother families as compared to those living with both parents unmarried mothers = 1,937 married mothers = 3,838 watt (2019) survey usa single parents and their children parents = 7 elementary teachers = 3 wang (2015) survey china children from both single and two parent families single parent children = 431 two-parent children = 544 mikeal (2018) semistructured interviews, focus groups, surveys ethiopia children growing up in single-mother, single-father, and intact households single mother headed families= 33 single father headed families= 10 dual-parent families = 63 children raised by some other relative = 9 ntumi et al. (2016) survey ghana children living under single parents 47 weitoft et al. (2003) survey sweden children living with single parents 65,085 children with single parents = 65,085 children with two parents = 921,257 ganesha and venkatesan (2012) survey india children growing up in single and dual parent households single parent households = 150 jain & mahmoodi graduate student journal of psychology dual parent households =150 sinha and ram (2018) survey india unmarried youth having both or only one parent alive n = 28,637 married men = 8.052 married women =13,912 unmarried men = 11,522 unmarried women = 17,362 erdelja et al. (2013) survey croatia delinquent children delinquent, incarcerated male adolescents = 100 matched school children = 100 nonoyamatarumi (2017) survey japan children in singlemother, single father, and two parent families 14,383 students in 391 schools melhado (2017) semistructured interviews usa single fathers 14 amoateng et al. (2004) survey policy report southafrica family structures stavrova et al. (2012) survey 30 countries around the world co-habilitating families 21,821 ermisch and francesconi (2000) survey great britain single mothers 9,459 barber (2003) survey 85 countries around the world single parents park (2014) longitudinal survey korea single parents and their children 3,357 families being one in a world of twos graduate student journal of psychology raymo et al. (2014) survey japan single mothers dual-parent families = 2000 single-parent families = 2000 shirahase and raymo (2014) survey japan single mothers 60,070,09 waters (2010) interview china and canada immigrated and left behind single fathers 4 westin and westerling (2006) survey sweden single parents single parents = 150 couple parents = 891 mulongo (2006) interviews, focus group discussions kenya teenage single mothers 9 rahel (2014) interviews ethiopia single mothers and their children single mothers = 11 children of single mothers = 11 hadley and hanley (2011) interviews england biologically childless men 10 figure 1 objectives and structure of the study gender single-parent households (demographics & socioemotional challenges) interventions culture gsjp volume 16 final graduate student journal of psychology 2015, vol. 16 copyright 2015 by the department of counseling and clinical psychology teachers college, columbia university 63 an exploratory study of posttraumatic stress disorder, sleep disturbances, and executive functioning in veterans shannon edwards, m.a. the chicago school of professional psychology laurie benton, psyd associate professor the chicago school of professional psychology anne germain, phd assistant professor university of pittsburgh james iaccino, phd associate professor the chicago school of professional psychology introduction: hypervigilance, hyperarousal, and sleep disturbances are components in the diagnosis and treatment of posttraumatic stress disorder (ptsd) and other trauma-related diagnoses. the current study explores the relationships between ptsd, sleep, and executive functioning among military veterans. method: the immediate post-concussion assessment and cognitive testing battery (impact) is utilized to examine the cognitive performance of 18 veterans. dependent measures included composite scores of verbal memory, visual memory, processing speed, and reaction time from the impact computerized test battery, as well as total symptom scores from the clinician administered ptsd scale (caps), the pittsburgh sleep quality index, and the pittsburgh sleep quality index – addendum for ptsd (psqi-a). 5hvxowv�� � 9hwhudqv� vkrzhg� vljqlàfdqw� ghàflwv� lq� yhuedo� phpru\� dqg� vorzhu� uhdfwlrq� wlphv� uhodwlyh� wr� qrumative data. the veterans did not differ from the normative group on visual memory and processlqj� vshhg� lqglfhv�� $iwhu� dgmxvwlqj� iru� vohhs� glvwxuedqfhv�� uhdfwlrq� wlph� uhpdlqhg� vljqlàfdqwo\� fruuhodwhg� zlwk� 376'� v\pswrp� vhyhulw\� lq� yhwhudqv�� &rqfoxvlrqv�� ([hfxwlyh� ixqfwlrqlqj� ghàflwv� lq� yhuedo� phpru\� and reaction time are detectable in veterans who endorse clinical and subthreshold symptoms of ptsd. trauma and the military researchers have estimated that 50-60% of individuals will experience a type of serious trauma (via military combat, sexual assault, perceived horror or threat, or another major accident) during their lifetime. additionally, 5-10% of individuals have been estimated to develop symptomology which qualiàhv� wkhp� iru� d� folqlfdo� gldjqrvlv� ri � 3rvwwudxpdwlf� stress disorder (ptsd) (aupperle, melrose, stein, & paulus, 2011). furthermore, aupperle et al., have suggested that neuropsychological approaches to research, which address the frontal lobe or executive function/dysfunction, may offer additional insight regarding cognitive processes that could potentially be affected by traumatic events and ptsd. to date, much of the research has focused on learning and memory, which may not necessarily have the same impact on ptsd susceptibility, resiliency, and development as executive functioning. the prevalence of traumatic brain injury (tbi), its relationship to veterans diagnosed with ptsd, and its impact on frontal lobe or executive functioning is also a presently debated topic. data from a veteran affairs polytrauma rehabilitation facility involving oef/oif veterans receiving care was studied in which the va research group compared combat-related tbi (74%) to noncombat tbi (71%). veterans with combat-exposed tbis reported higher sleep disturbances (>50% vs. <30%) and symptoms of acute stress reaction or ptsd (taber & hurley, 2010). � 7kh� frqálfwv� lq� $ijkdqlvwdq� �2shudwlrq� (qduring freedom [oef]) and iraq (operation iraqi freedom [oif]) have resulted in the highest rates of military troop mobilization and deployment since the contact: sme1724@ego.thechicagoschool.edu 64 vietnam war (gewirtz, polusny, degarmo, khaylis, & erbes, 2010). an exceptional amount of reliance is also being placed on national guard/reserve (ng/r) groups. service members returning from oef/oif have been shown to be at greater risk for developing or presenting with mental health issues �)uxhk��*uxedxjk��(okdl�� �%xfnoh\���������6shflàcally, tbi, ptsd, and major depressive disorder are distinct post-combat health outcomes (ozer, best, lipsey, & weiss, 2003). additionally, research revealed self-reports from the ng/r troops of mental health issues (depression, relational issues, and ptsd) are more than double those of active duty service members (42.4% versus 20.3%). ng/r troops also double the amount of mental health issues regarding (ptsd) screenings both post-deployment (12.7%) and 6 months thereafter (24.5%) when compared to active duty service members (gewirtz et al, 2010). statistics collected by gewirtz et al., (2010), regarding active duty troops versus ng/r troops, supports ongoing research efforts which hypothesize that non-combat exposed veterans face similar traumatic and psychological risks to combat-exposed veterans. importance of executive functioning executive functioning is a set of mental processes that helps connect past experience with present action. individuals use executive functioning to perform activities such as planning, organizing, strategizing, paying attention to and remembering details, and managing time and space (aupperle, melrose, stein, & paulus, 2011). individuals with executive ixqfwlrqlqj� ghàflwv�pd\� dovr� kdyh� d�zhdnqhvv�zlwk� their working memory. working memory is the ability to actively maintain and manipulate information of one’s mind over a short period of time. working memory is an important component of executive functioning, and is typically affected following a traumatic event due to the quick task demand that is necessary to encode, retrieve, and manipulate various stimuli while functioning in daily life (aupperle et al., 2011). samuelson et al (2006) noted that decreased performance on measures of working memory have been found in combatand sexual assaultrelated ptsd when compared to victims without ptsd and non-trauma controls. furthermore, working memory is needed to transfer information to long-term memory. when working memory is impaired, the process of transferring information is likely to be impaired as well (brenner et al., 2010). verbal memory refers to the memory of words and other abstractions of language, while visual memory describes the relationship between perceptual processing and the encoding, storage, and retrieval of the resulting neural representations (apperle et al., 2011). reaction time, also referred to as ‘mental chronometry,’ is the use of response time in perceptual-motor tasks to infer the content, duration, and temporal sequencing of cognitive operations. processing speed is one of the measures of cogniwlyh� hiàflhqf\� ru� frjqlwlyh� suràflhqf\�� ,w� lqyroyhv� wkh�delolw\�wr�dxwrpdwlfdoo\�dqg�áxhqwo\�shuirup�uhoatively over-learned cognitive tasks, especially when kljk�phqwdo�hiàflhqf\�lv�uhtxluhg��6wudxvv��6khupdq�� & spreen, 2006). ptsd effects memory recall and accuracy (lezak, 2008). while ptsd affects various areas of executive functioning, it has been shown wr�prvw� vljqlàfdqwo\� diihfw�yhuedo�phpru\� �6wudxvv�� sherman, & spreen, 2006). researchers have indicated that verbal memory impairment is found to be the most consistent cognitive impairment related to ptsd. verbal memory has also been shown to be a vshflàfdoo\�surqrxqfhg�ghàflw� lq�frpsdulvrq�wr�ylsual memory or processing speed in individuals diagnosed with ptsd (johnsen & asbjornsen, 2008). short-term memory is another processes involved with working memory. short-term memory is needed for disposal, integration, processing, and retrieval aspects of memory functioning to ensure the working memory aspect of the cognitive process is effective (turner, salamat, drummond, & brown, 2007). in the general population, the executive functioning component involved with working memory elicits a controlled response to stimuli (e.g., impulse control). in individuals diagnosed with ptsd, executive functioning may be compromised. individuals with ptsd may respond to stimuli with hypervigilance, hyperarousal, and impulsivity (turner et al., ������� � ,qglylgxdov� zlwk� 376'�pd\� kdyh� gliàfxow\� with an inability to consolidate memories due to trauma, which is also linked to increased autonomic arousal and inhibition of the hippocampus (aupperle et. edwards, benton, germain, iaccino 65 do����������([hfxwlyh�ixqfwlrqlqj�ghàflwv�duh�olnho\�wr� affect the daily functioning of individuals with ptsd, and may also play a prominent role in sleep patterns and nightmare production (levin & nielsen, 2007). neurobiological aspects of nightmares nightmares are a core re-experiencing feature ri � 376'��1ljkwpduhv� duh� folqlfdoo\� ghàqhg� dv� ´lqtensely disturbing dreams that awaken the dreamer to a fully conscious state and generally occur in the latter half of the sleep period” (hasler & germain, 2009, p. 2). as many as 90% of trauma-exposed individuals who develop ptsd report disturbing dreams that bear varying degrees of resemblance to the actual traumatic event (oscar et al., 2010). additionally, dream-related disorders such as posttraumatic dreams, nightmares, bad dreams, and recurrent dreams are the most frequently reported and most persistent symptoms exhibited by trauma victims (kobayashi, boarts, & delahanty, 2007). according to stickgold (2005), explicit rapid eye movement (rem) sleep models of the neurobiological states of nightmares potentially provide emotional processing and integration of trauma-related memories. rem sleep provides a unique neurobiological state that allows for the transfer of hippocampus-mediated episodic traumatic memories and related amygdala-dependent affect into the cortically distributed semantic networks of the brain. the amygdala is hyperreactive to traumatic images during the sleep cycle in persons with ptsd, which then produces a nightmare as a response to the threat-related stimuli, thus interfering with the transfer of traumatic memories to higher cortical areas (germain & zadra, 2009). a meta-analysis of 20 ptsd studies by koed\dvkl��������irxqg�wkdw�gliàfxowlhv�idoolqj�ru�vwd\lqj� asleep were reported by 44%-90% of veterans with ptsd, and that 52%-87% reported having recurrent nightmares. additionally, a recent study was completed in which 304 of 316 veterans reported combat-related nightmares (germain & zadra, 2009). over half of the veterans in this sample reported realistic combat dreams, 21% reported conceivable war sequences they had not actually experienced, and 26% reported dreams that mention or relate to the war, but also included fantasy and everyday factors. furthermore, only 21% of the dreams reported by veterans in the study were precise replications of their experienced traumatic event, while the majority of dreams contained contrived distortions related to the traumatic event. the current study explores the relationships between ptsd, sleep, and executive functioning. hypotheses the presence and severity of ptsd symptoms was assessed by the clinician administered ptsd scale (caps), and executive functions were assessed by different modules of the immediate post-concussion assessment and cognitive testing (impact), and results were compared to norms from age and sex-similar groups. the hypotheses were (1) that the overall participant group, exhibiting varying symptom severity, would score lower on visual memory, verbal memory, reaction time, and processing speed domains compared to normative values; (2) veterans with ptsd would show greater impairments than veterans without ptsd on the impact domains when respectively compared to the normative group; and 3) the relationship between ptsd severity and h[hfxwlyh� g\vixqfwlrqv�zrxog� uhpdlq� vljqlàfdqw� diter adjusting for the severity of sleep disturbances. method participants between january 2011 and january 2012, participants were actively recruited though media advertising in a northwestern metropolitan area. participants were combat-exposed military veterans diagnosed with posttraumatic stress disorder (ptsd) (n = 11) and without ptsd (n = 7), all of whom had self-reported nightmares or nocturnal sleep disturbances. fifteen participants were male and three were female between the ages of 18 and 50 years old (m = 24 years, sd = 2.4). the racial/ethnic composition of the participants was fairly homogenous with fourteen participants identifying as caucasian, three as asian-american, and one as african-american. participants were assessed via a detailed screening process as part of a concurrent sleep study. veterans were excluded if they were over 55 years of age, or if they had been excluded from the initial study due to medical conditions or medication known to affect sleep. ptsd, sleep disturbances, and executive functioning 66 measures as a part of the parent study, participants also completed the clinician-administered ptsd scale (caps; blake, weathers, nagy, kaloupek, gusman, charney & keane, 1995), the pittsburgh sleep quality index (psqi; buysse, reynolds, monk, berman & kupfer, 1989) and the pittsburgh sleep quality index addendum (psqi-a; germain, hall, krakow, shear, & buysse, 2005). the clinician-administered ptsd scale (caps) is a structured interview that measures severity of symptomology and diagnosis of ptsd. the caps assesses the frequency and intensity of seventeen symptoms using standard questions and behaviorally anchored rating scales. questions include assessing for nightmares associated with ptsd. the caps is considered to be the gold standard in ptsd assessment (blake et al., 1995). the inter-rater reliability of the caps is high, ranging from 0.92 to 1.00 for “frequency” and 0.93 to .98 for “intensity” ratings with the global severity correlation equating 0.89. the caps test-retest reliability ranges from .77.96 for the three symptom clusters and from .90-.98 for the 17-item core symptom scale (blake et.al, 1995). the pittsburgh quality sleep index (psqi) was employed as a measure of disturbing nocturnal behavior (sleep disturbances). the psqi has ten queswlrqv�� dqg� lv� d� àoo�lq�wkh� eodqn� txhvwlrqqdluh�� 7kh� psqi was developed to qualitatively measure sleep quality during the previous month. the instrument also discriminates between good and poor sleepers. 7kh�364,�kdv�d�joredo�vfruh�fruuhodwlrq�frhiàflhqw� for test-retest reliability of (.87). similarly, the pittsburgh quality sleep index addendum (psqi-a) is a self-report instrument designed to assess the frequency of seven disruptive nocturnal behaviors (dnb) or sleep disturbances commonly associated with ptsd. participants completed the immediate post-concussion assessment and cognitive testing (impact), which is a computerized neuropsychological test (iverson, lovell, & collins, 2003). the impact measures several executive functioning composite index scores. this study made use of four: verbal memory, visual memory, processing speed, and reaction time. the composite scores are made up of six modules designed to test verbal recognition, visual memory, processing speed, impulse control, and working memory. � ,qwudfodvv� fruuhodwlrq� frhiàflhqwv� iru� wkh� ,ppact include processing speed (.85), reaction time (.76), visual memory (.70), and verbal memory (.62) (elbin, schatz, covassin, 2011). resch et.al (2013) compared two performance groups, with the second group also completing a test of effort. the researchers found that composite score intraclass fruuhodwlrq� frhiàflhqwv� udqjhg� iurp� ���� wr� ���� iru� the 4 scores in group 1 and .37 to .76 in group 2. for the current study, data was automatically scored with the computerized structure within the impact, which provided composite scores for each category (verbal memory, visual memory, processing speed, and reaction time). the impact generated the particular composite scores for the present study by comparing scores from university male participants to individuals in the overall normative sample, and provided composite scores. the primary populations studied for impact research are typically that of vsruwv�uhodwhg�lqmxulhv��zklfk�vxshuàfldoo\�dsshduhg�wr� differ from our sample of combat-exposed injuries. however, the impact has been investigated within the military population and yielded a .80-.89 test-retest reliability score (cole et al., 2013). individuals in the ptsd group met full diagnostic criteria for symptomology as indicated by the caps. the nptsd group, while self-reporting some symptomology, did not reach criteria threshold for a clinical diagnosis of ptsd. the two veteran groups were separately compared to the normative sample from the impact. procedures one-sample t-designs were used to analyze the composite scores of each subtest score generated from the impact, and were then compared to the mean composite score of the normative sample. the chosen comparison was used due to none of the participants in the current study presenting completely free of symptomology and therefore, they were unable to be utilized as part of a control group. further, the normative group from the impact used for comparison was comprised of university males, which was the group which most closely matched the current study’s participant sample. while not ideedwards, benton, germain, iaccino 67 al, the limitations with power and sample size were recognized and results were interpreted with caution. the impact was administered via computer by the primary investigator while being supervised by a ph.d. clinician, the primary investigator of the concurrent sleep study. participants were informed wkh� vwxg\� zdv� lq� sduwldo� ixoàoophqw� ri � d� grfwrudo� dissertation. the participants navigated through six modules. the impact took approximately thirty wr� iruw\�àyh� plqxwhv� wr� dgplqlvwhu��:khq� wkh� ,ppact concluded, participants were afforded time wr� dvn� txhvwlrqv�� dv�zhoo� dv� jlyhq�gheulhàqj� vkhhwv� results the impact computer-generated printout provided descriptive statistics for each composite score based on their overall normative group of university students. verbal memory composite score (m = 88.2, sd = 12.4), visual memory composite score (m = 72.3, sd = 14.9), processing speed composite score (m = 35.6, sd = 8.3), and reaction time composite score (m = 0.58, sd = .12) averages and standard deviations were all provided to the investigators. h1: the entire sample of veterans showed vwdwlvwlfdoo\� vljqlàfdqw� lpsdluphqwv� frpsduhg� to the normative data for impact, on the verbal memory composite score (t (17) = -2.737, p = .014; m = 81.72). reaction time composite scores among participants were also slower than normative data, t (17) = 2.837, p = .011; m = .61. h2: the verbal memory composite score was vljqlàfdqwo\� orzhu� lq� yhwhudqv�zlwk�376'� (t (11) = -3.001, p = .013; m = 78.73), but not in veterans without ptsd t (6) = -.658, p > .05, m = 86.43. each group was compared to the impact normative group, respectively. further, when compared to the impact normative group, individuals diagnosed zlwk�376'�kdg�vljqlàfdqwo\�vorzhu�uhdfwlrq�wlphv� t (10) = 2.610, p = .026; m = .62, indicating they responded less quickly to tasks that were constructhg� wr�phdvxuh� vshhg� dqg� hiàfdf\�� � ,q� frpsdulvrq�� veterans without ptsd responded as quickly as the normative sample t (6) = 1.224, p > .05; m = .59. both visual memory and processing speed had qrq�vljqlàfdqw�àqglqjv� lq�wkh�ryhudoo�vdpsoh�jurxs� (t (17) = -.948, p > .05; m = 74.72 and t (17) = -.946, p > .05; m = 35.22), when compared to the impact normative group. additionally, the ptsd jurxs� kdg� qrq�vljqlàfdqw� àqglqjv� t (10) = -1.070, p > .05; m = 73.28 and t (10) = -2.229, p > .05; m = 32.36 when compared to the impact normative group, as did the ptsd group t (6) = -.148, p > .05; m = 77.00 and t (6) = .650, p > .05; m = 39.72 when compared to the impact normative group. h3: lastly, results indicated that verbal memory dqg�uhdfwlrq�wlph�zhuh�vljqlàfdqwo\�fruuhodwhg�zlwk�wkh� psqi-a (r = .033, p = < .05) and (r = .031, p = < .05), respectively, when adjusting for sleep symptom severity. conclusion the results of the current study coincide with existing research regarding verbal memory impairments in individuals diagnosed with ptsd. the term verbal memory encompasses both encoding and retrieval of information. verbal memory is necessary for the processing of traumatic memories when considering hyperarousal and the inability to quickly encode and retrieve responses concerning external stimuli (mcclincy, lovell, pardini, collins, & spore, 2006). 'liàfxow\�zlwk�hqfrglqj�dqg�surfhvvlqj�ylvxdo�vwlpuli can lead to increased or prolonged hyper-aroused states, increased physiological responses (high blood pressure), and other psychological symptoms such as increased levels of anxiety (frueh, et al., 2007). reaction time appears to be another area of functioning affected in individuals with ptsd symptompology. research has suggested that individuals diagnosed with ptsd, or individuals with symptoms related to traumatic memories, have slower reaction times, which could be a vicarious consequence of decreased executive functioning (johnsen & asbjornsen, 2008). decreased reaction time can lead to slowed response to external stimuli, reduced agility in response to physical responsibilities, and possibly psychomotor slowing while addressing cognitive tasks in employment or academic settings (aupperle et al., 2011). commonly, traumatic nightmares are among the most treatment-resistant symptoms of ptsd. when utilizing sleep as a correlative variable in the equation, verbal memory and reaction times appeared to ptsd, sleep disturbances, and executive functioning 68 be non-affected in individuals with and without a diagnosis of ptsd. it could be suggested that sleep disturbances can decrease verbal memory and reaction time; however, one could also infer that by increasing executive functioning (i.e., strengthening verbal memory and reaction time via neurocognitive therapeutic interventions), sleep disturbances may decrease and vice versa. this is particularly concerning within the veteran population as they are more likely to underreport psychological symptoms than the general population, which could arguably be due to the military culture and training (port, 2001). within the general population, executive functioning that is involved with working memory elicits a controlled response to stimuli. research has suggested that individuals diagnosed with ptsd are more likely than the general population to have compromised executive functioning (aupperle et al, 2011) (johnsen & asbjornsen, 2008). individudov�zlwk� 376'�pd\� dovr� kdyh� gliàfxow\� frqvrolgdwlqj� phprulhv� gxh� wr� ghàflwv� lq� zrunlqj� phpru\�� which is also linked to increased autonomic arousal and inhibition of the hippocampus (aupperle et. do��� ������� 7kxv�� h[hfxwlyh� ixqfwlrqlqj� ghàflwv� duh� more likely to effect the daily functioning of individuals with ptsd than the general population, and may also play a prominent role in sleep patterns and nightmare production (levin & nielsen, 2007). limitations the primary limitation to the study was the homogeneity of the sample, as well as the sample vl]h��:kloh�zh�zhuh�deoh� wr�rewdlq�vrph�vljqlàfdqw� results on two composite scores with a small sample size, a larger sample would have allowed us to make further inferences, particularly when examining the relationship with sleep disturbances. obwdlqlqj� vrph� vljqlàfdqfh� lv� hqfrxudjlqj� iru� ixwxuh� research, when a larger sample may be possible, as well as a more gender, ethnically diverse sample. this could be sought in future studies in order to provide a broader understanding of how sleep and executive functioning may affect different sociocultural groups within the veteran population. directions for future research the study aspired to determine if there was a relationship between ptsd, sleep, and executive functioning. while there was a power differential and our uhvxowv�zhuh�lqwhusuhwhg�zlwk�fdxwlrq��wkh�àqglqjv�gr� suggest a link between some aspects of executive functioning, which will likely affect individuals with ptsd symptoms. results also suggested verbal memory and reaction times are unaffected by sleep disturbances. future research could include the implementation of an intervention, in a test-retest model, for veterans who are experiencing the aforementioned symptoms. the determination of executive functioning impairments could be measured via broad assessment and evaluation protocols (bromberg, 2003; rutherford et al., 2010). rather than the unaccompanied treatment of the psychological symptomology of ptsd with primarily trauma-based therapeutic interventions, the addition of a neurocognitive wkhudshxwlf� lqwhuyhqwlrq�frxog�eh�ehqhàfldo� li � wkhuh� were present executive dysfunctions to consider. research has suggested that a multi-modal apsurdfk�pd\�eh�pruh�hiàfdflrxv�lq�wkh�wuhdwphqw�ri � co-occurring ptsd and neurocognitive dysfunction (davidson & frances, 1999); although, at this time, there is not a substantial amount of literature that provides empirically based approaches to this ideation. while aupperle and colleagues (2011) validated that increased neuropsychological research is needed to identify the effects of treatment on cognitive function and to potentially characterize mechanisms of current ptsd treatments, the ability to identify areas of focal ghàflwv� lv� d� vwhs� forvhu� wkdq� uhvhdufkhuv� kdyh� ehhq� in the recent past. the option of providing a different type of treatment opportunity to the civilian and military populations could potentially increase their quality of life and afford individuals more opportunities regarding interdisciplinary treatment and options. references american academy of sleep medicine (aasm). ��������7kh�lqwhuqdwlrqdo�fodvvlàfdwlrq��ri �vohhs� disorders, second edition (icsd-2): diagnostic and coding manual. westchester, il: american academy of sleep medicine. edwards, benton, germain, iaccino 69 aupperle, r.l., melrose, a.j., stein, m.b., paulus, m.p. 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(1999). trauma & memory. thousand oaks, ca:sage publications, inc. edwards, benton, germain, iaccino 136 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university beyond language and culture: a qualitative exploration of mental health barriers for chinese international students seeking therapy in the u.s. yuanruo xu derner school of psychology, adelphi university international students are individuals who enroll in educational institutions outside their country of origin (altbach & knight, 2007). the united states continues to be a top destination for international students, hosting 914,095 in the 2020-2021 academic year according to the institute of international education’s open doors 2021 report. chinese students constitute the largest cohort among these, making up 34.7 percent of the total international student. given their sizable representation, chinese international students (cis) bring with them unique cultural, academic, and personal experiences, creating a diverse landscape within u.s. educational institutions. consequently, this significant demographic necessitates in-depth understanding and focus from educators and researchers, especially in addressing the unique challenges faced by this group of students. cis face significant mental health challenges. a recent report revealed that nearly half of these students experience moderate stress, depression, and anxiety. shockingly, 70% have never sought mental health services. furthermore, 40% primarily resort to emotional suppression as a coping mechanism, and one-third report having had suicidal thoughts. of those contemplating suicide, merely 40% have reached out for mental health support. the covid-19 pandemic intensified these problems: 60% noted a decline in their psychological health, and 20% faced challenges accessing mental health services (the white paper on mental health, 2020). despite the evident need for mental health support, existing research has not adequately explored the unique challenges cis encounter when seeking mental health treatment in the u.s. gaining insight into these barriers is critical to devise effective interventions and strategies to support their mental well-being. this study seeks to answer: what barriers do cis face accessing and using psychotherapy services in the u.s., and how do these barriers influence their attitudes toward mental health treatment? a comprehensive meta-analysis conducted by jing et al. (2020) assimilates data from 3,685 pertinent journal articles published between 1900 and 2018, providing invaluable insights into the global landscape of international student studies. this extensive body of work enriches our understanding of the demographic central to our current investigation. the marked increase in articles since 2006 underscores a growing research interest in international students. key topics covered in these articles include second-language acquisition, cultural difference and stigma, and mental health knowledge. these factors dovetail with the challenges that cis frequently face when studying in the u.s. not only do these barriers shape their experience as international students, but they also have potential ramifications on their this qualitative study explores the experiences and attitudes of chinese international students in the u.s. towards psychotherapy, with an emphasis on identifying potential barriers and facilitators to their mental health treatment. data were drawn from individual experiences of undergraduate and graduate chinese international students who had engaged in therapy in the u.s. a grounded theory approach was employed to dissect these experiences and assess their attitudes towards psychotherapy. the grounded theory identified several themes from the students’ therapeutic experiences such as: the inconsequential role of language barriers, the significant yet not prohibitive impact of cultural differences, the critical role of health insurance, the influence of therapists’ professional demeanor, and the correlation between mental health knowledge and attitudes towards therapy. interestingly, the study also unveiled an emergent theme concerning professional boundaries within therapy. these findings suggest that while language and cultural differences might not be direct obstacles to therapy, factors such as therapists’ backgrounds and attitudes, insurance coverage, and accessibility can pose substantial challenges to chinese international students seeking mental health treatment. importantly, a heightened level of mental health knowledge was associated with more positive attitudes towards therapy. as a culmination of these findings, we formulated a triadic model emphasizing cultural understanding within the therapeutic setting, service accessibility, and mental health knowledge as key influences on the psychotherapy experiences of chinese international students. keywords: psychotherapy barriers, attitudes towards treatment, mental health knowledge, chinese international students, grounded theory 137 mental health. this intricate relationship further influences their attitudes towards, and engagement with, mental health treatment in a foreign setting. second-language acquisition while proficiency in the english language is often viewed as a key factor in international students’ adjustment to both life and education in the u.s. (alharbi & smith, 2018; park et al., 2016), many cis still grapple with self-doubt regarding their linguistic capabilities. this persists even after they have demonstrated english fluency through various language tests for college admission. for example, in a focus group study, chinese international graduate students identified english proficiency as a significant issue despite researchers’ observations that the students expressed themselves effectively in english (swagler & ellis, 2003). notably, o’reilly et al. (2010) found that engaging with university’s mental health service— which involves in-depth english conversations with a psychologist or healthcare professionals—could facilitate international students’ adjustment. this finding emphasizes the dual role of second-language acquisition: facilitating not only academic and social adjustment but also accessing mental health care. cultural difference and stigma cultural practices between china and the u.s. are often seen as opposites on a cultural continuum, implying a maximum level of cultural distance (hofstede, 2011; samovar & porter, 1997). consequently, cis are at a heightened risk for psychological issues (lian & wallace, 2018). hofstede’s cultural framework underscores the disparities between chinese and western cultural norms, pointing out how these differences might shape the perspectives of cis towards psychotherapy (juneja, 2015). china is characterized by a large power distance, reflecting a societal structure that considerably values authority. this factor could shape how cis perceive and interact with mental health professionals, who are often regarded as authority figures. the collectivist nature of chinese society might also prompt students to prioritize group harmony over individual mental health issues, potentially discouraging them from seeking help (juneja, 2015). while there are similarities between china and western societies in terms of gender equality, china’s high uncertainty avoidance index indicates a preference for adhering societal norms and expectations (wang, 2021). this tendency might defer cis from seeking therapy, as it can be seen as a departure from traditional values. lastly, the long-term orientation intrinsic to chinese culture, characterized by a focus on future outcomes, perseverance, and respect for tradition, could further impact their perceptions of therapy, making them potentially more hesitant to seek help for mental health challenges (juneja, 2015). in chinese culture, mental illnesses are often linked to personality flaws, moral deficiencies, genetic anomalies, or retribution for misconduct (shi et al., 2020). this perspective contrasts with western views where mental illnesses are often seen as temporarily linked to challenging life events (li et al., 2014). these contrasting belief systems between u.s. and chinese cultures influence attitudes towards mental health help-seeking behaviors. while western beliefs tend to promote a favorable view of mental health services, traditional asian beliefs may deter such behaviors (chen & mak, 2008). chinese cultural values, such as valuing emotional restraint, evading shame, and upholding one’s reputation, could make self-disclosure and emotional expression—central to american therapeutic approaches—more challenging (shea & yeh, 2008). furthermore, de vaus et al. (2017) highlight that cultural disparities between eastern and western societies influence the strategies used to manage negative emotions. the notable underuse of therapy services by cis, despite a clear psychological need, can be attributed to cultural factors. lu et al. (2013) posit that these students often perceive seeking mental health support as a potential source of shame and loss of esteem, especially if their engagement with such services becomes known among peers. this fear of humiliation decreases their likelihood of holding positive attitudes towards seeking help (chen et al., 2014; yakunina, 2011), using mental health services (li et al., 2016), initiating discussions about personal issues (chen & mak, 2008), or conveying personal emotions to mental health professionals (mak & chen, 2006). numerous studies emphasize that stigma linked to mental issues plays a significant role in influencing help-seeking behaviors across diverse samples (corrigan et al., 2014; vogel et al., 2017). as a result, it’s vital to implement programs tailored to chinese cultural perspectives on emotional distress and mental well-being (lian et al., 2020). mental health knowledge mesidor and sly (2016) found that a student’s perception of available resources plays a significant role mental health barriers for chinese international students 138 xu in their intention to seek mental health services. several studies have noted that the level of mental health awareness and knowledge about available help-seeking options within the university student community, especially among international students, is less than optimal (lu et al., 2013; raunic & xenos, 2008; shea & yeh, 2008). ensuring that international students are both knowledgeable about and comfortable with accessing these services is paramount (chen et al., 2020). institutions of higher education must proactively educate international students about the advantages of counseling services (onabule & boes, 2013). yet, there is limited research investigating the determinants that influence international students’ awareness of these services. this gap is noteworthy, given the crucial impact that the availability and accessibility of on-campus mental health services have on shaping students' help-seeking intentions and behaviors (lian et al., 2020). study aims the goal of this study was to investigate the experiences, perceptions, and attitudes of cis toward mental health, mental health treatment, and stigma in the u.s. the study aimed to answer the following questions: (1) what are the barriers cis encounter throughout the treatment process? (2) to what extent do language or cultural differences present obstacles during treatment? (3) how can we enhance their attitudes toward mental health treatment and improve psychotherapy integration for second-language speakers? given the reluctance of cis in seeking mental health help and their suboptimal utilization of such services (lian et al., 2020), it is imperative to continuously address their mental health needs. limited awareness about mental health and available resources within the university community might exacerbate existing psychological challenges. this study emphasizes the significance of addressing communication barriers, chinese cultural attitudes, beliefs, and strategies to elevate mental health services awareness. by examining the factors influencing the therapy experience of cis, this research aims to address their perceived barriers to psychotherapy and foster a more accommodating approach to utilizing mental health services. method the present research adopted a qualitative design, utilizing semi-structured interviews to explore the psychotherapy experiences of cis studying at u.s. universities. participants included undergraduate and graduate individuals who were at least 18 years old, born and raised in china, currently studying full-time in the u.s. on an f-1 student visa as international students. these individuals had engaged in at least one psychotherapy session with a non-chinese therapist while pursuing their education in the u.s. these individuals were reached out to through a coordinated effort between the research team and international student offices at randomly selected universities across the u.s. the international student offices facilitated the recruitment process by forwarding the recruitment email to their respective listservs of international students. the study obtained approval from adelphi university’s institutional review board, with all participants provided written informed consent prior to enrollment in the study. in the initial phase, participants were drawn from respondents to an electronic survey investigating their basic demographic details and the mental health knowledge schedule (maks). the maks is designed to assess knowledge in mental health, encompassing six stigma-related areas: help-seeking, recognition, support, employment, treatment, and recovery. additionally, it includes six items pertaining to knowledge of mental health conditions. the maks uses an ordinal scale from 1 to 5 for scoring. a “agree strongly” with a correct statement yields a score of 5, while a “disagree strongly” receives a score of 1. “don’t know” responses are neutrally scored as 3. notably, items 6, 8, and 12 are reverse-coded. the scale has an overall test-retest reliability of 0.71, as indicated by lin’s concordance statistic. item retest reliability varies between 0.57 to 0.87, suggesting moderate to significant agreement over time. for items 1 to 6, the internal consistency, reflected by a cronbach’s α of 0.65, is moderate (evans-lacko et al., 2010). sample maks items include: “most people with mental health problems seek paid employment” and “most people with mental health issues consult a healthcare professional”. given its focus, maks is particularly apt for our study, aiding in understanding the mental health perceptions of college students, with an emphasis on cis. this survey also contained an invitation for a zoom interview, with participants providing contact details and available schedules. eligible participants were approached via the email provided to schedule zoom interviews. a total of 139 nine individuals participated in the interviews. the interview guide was centered around the participants’ mental health treatment experiences and attitudes. the participants were first asked to recall their past psychotherapy experiences. the following questions were aimed at eliciting their views on the effectiveness of treatment, perceived barriers during treatment, the impact of language and cultural differences, the necessity of psychotherapy, and future psychotherapy intentions. all interviews were conducted in mandarin chinese, the participants' native language, ensuring an open and comfortable space for expression. the interviews were conducted by two research assistants (ras) who were master-level graduate students from a psychology program. both ras identified as chinese international students and were bilingual, with mandarin chinese as their first language and fluent english proficiency. they received rigorous training in conducting semi-structured interviews. all interviews were conducted in mandarin chinese, recorded (with participants’ consent), anonymized, and transcribed verbatim in chinese. to preserve the accuracy of participants’ narratives, the translated english transcripts were prepared only after all coding had been completed, ensuring a faithful representation of the original mandarin chinese responses. upon transcription, the original recordings were deleted. in the analysis of our qualitative data for this study, we employed the grounded theory methodology. grounded theory is a systematic qualitative research methodology that emphasizes generating theory from data (glaser, 1965). we initiated our analysis process with open coding. this phase involved carefully reading the interview transcripts and assigning distinct codes to data segments representing unique concepts (charmaz, 2006). we then proceeded with axial coding, where we sought relationships between the identified open codes, grouping them into categories based on these connections (corbin & strauss, 2008). for instance, if several codes related to various aspects of “language barriers” were identified during the open coding (e.g., ‘misunderstanding concepts’, ‘difficulty expressing emotions in second language’, ‘struggle with cultural translation’), these could be grouped into a broader category titled “language and communication challenges”. this allowed us to organize themes or categories and understand their interrelationships. the subsequent stage of selective coding involved refining these categories into a theoretical framework. we identified a core category, and all other categories were related to this central theme (glaser, 2017). throughout the coding process, we consistently wrote memos capturing emerging ideas, potential hypotheses, and connections (tie et al., 2019). finally, theory development was the last stage, which culminated in an explanatory framework accounting for the identified patterns in the experiences of cis accessing mental health services (glaser, 2017). it’s noteworthy to mention that our analysis process was iterative. insights gained during selective coding often necessitated a return to the data for further open or axial coding. we also employed the constant comparative method throughout the process, continuously comparing new data with prior data and codes to refine our categories (glaser, 1965). by employing grounded theory, we ensured that our analysis was thorough, and our findings were truly reflective of our participants' experiences, thus generating a theory that is grounded in our data. data coding was conducted by a team of 10 ras under the supervision of the principal investigator. each of the ras is a master’s student currently enrolled in a u.s. psychology program, with a shared background of being cis. this distinctive profile—native mandarin chinese speakers who are fluent in english, holding at least 6 years of education in the u.s., and possessing specific training in the field of psychology—equipped them with the ability to connect with the experiences of the participants on a deeper level. this shared cultural perspective facilitated their understanding and interpretation of the data, enabling them to capture subtleties that may be otherwise overlooked, and thus contributing crucial depth to the analysis. to ensure the reliability of our coding, we utilized the concept of inter-rater reliability. each transcript was independently coded by two ras, and any discrepancies in their assigned codes or identified themes were resolved through discussion until consensus was reached. if necessary, the principal investigator would intervene to provide a final judgment. this rigorous process ensured that the resulting codes, categories, and themes accurately represented the participants' experiences and perspectives while minimizing potential individual biases. further, the principal investigator of this study was an international student from china and spent mental health barriers for chinese international students 140 xu a decade studying psychology in the u.s., bringing an essential insider perspective to the research. this shared cultural and educational background with the study participants allows for a profound understanding of their experiences, enabling nuanced interpretation of the data. the researcher’s advanced psychological training further complements this cultural lens, providing robust analytical capabilities and comprehension of the psychological processes in play. nevertheless, the shared experiences of the principal investigator and ras as cis in the u.s. also pose a potential for bias, as prior experiences and cultural backgrounds might influence the interpretation of the findings. to manage potential bias, reflexivity was practiced throughout the research process. this involved weekly team meetings in which the researchers reflected on and discussed their thoughts, reactions, and potential biases that might have arisen during interviews and coding. it is through this continuous self-examination that we aimed to preserve the integrity of the research and maintain a balanced and objective perspective on the participants' experiences. results the following description of themes combines and summaries answers from all interviews. table 1 provides the demographic details of the participants involved in this study. out of the nine participants, seven were female, highlighting a significant gender skew in the sample. age ranged between 18 to 30 years, with a majority falling within the 18-22 and 23-26 age brackets. in terms of socioeconomic status (ses), scores varied from five to seven on our scale. the students hailed from diverse locations, though there was a higher representation from new york. as for their academic details, four were graduate students while the rest were either college seniors or freshmen. the primary academic majors were psychology and social science, though biology and education were also represented. lastly, the duration of their stay in the u.s. varied, with most having spent between two to nine years, and one participant having spent over nine years in the u.s. all participants in this study identified as han chinese, the dominant ethnic group in china, and their preferred language was mandarin chinese without any regional dialects. the participants in our study sought psychotherapy primarily due to distressing events they encountered while studying in the u.s. these experiences, such as ending a romantic relationship, having conflicts with friends, or facing issues with family communication, caused feelings of depression, stress, and anxiety, which prompted their search for professional help. the therapeutic journey for all participants began within their respective university counseling centers. this set the stage for their interaction with an array of therapists, ranging from full-time professionals to interns and externs working at these centers. while these therapists had diverse ethnic and cultural backgrounds, none identified as asian/chinese or fluent in any chinese language. the lack of chinese-speaking therapists provided a unique opportunity to delve into the cultural dynamics and potential language barriers within the therapeutic context. some participants chose to expand their mental health treatment into community resources for ongoing treatment. language barrier dissolution our findings suggested that language, despite not being their native tongue, did not constitute a barrier during psychotherapy for most participants. communication between participants and their therapists, none of whom were conversant in any chinese dialect, transpired entirely in english. this implies that mutual comprehension between client and therapist can potentially neutralize the language impediments in the treatment process: “i don’t think language is not a barrier. i think it’s actually okay. i can tell my own experience in english.” “i did not perceive any language barriers. i can understand the therapist and the therapist can understand what i was talking about.” “in terms of language, i think it’s okay. i came to america at a very young age and since then i use english for all communication. sometimes i feel hard to expressed myself clearly in english, but no major communications barriers. i think it is not a big problem in psychotherapy.” “language is not a big problem, because i have been in the united states for a long time, and now our department has no other chinese students beside me, and there are no chinese speakers around. friends around me, they all speak english, i have no issues with speaking english with my therapist.” we propose that these findings may be influenced by the participants’ length of residency in the u.s., a factor that could affect their language proficiency and comfort in communicating in english. notably, all 141 participants in this study had resided in the u.s. for at least two years before their participation. this tenure, coupled with their academic engagement, likely necessitated substantial english language use, fostering their fluency and comfort in communication. consequently, most participants expressed comfort and relative ease in english-mediated communication, indicating a reduced perception of language as a barrier in their psychotherapy sessions. such findings lead us to hypothesize a potential correlation between the duration of u.s. residency and the perception of language barriers in psychotherapy. specifically, it is plausible that a longer period of residency, and hence greater immersion in an english-speaking environment, may diminish perceived language barriers in psychotherapy. this hypothesis necessitates further exploration in future studies with larger and more diverse sample sizes. importance of therapist's characteristics in therapy selection and perception our findings highlighted that the participants prioritized certain factors such as the therapist's therapeutic orientation, cultural background, and gender when choosing their therapists and evaluating their therapeutic experiences: “i can’t seem to work with a cbt oriented therapist. i might prefer other orientations. i think it is very important to see which orientation the therapist uses. i know which ones are suitable for me and which ones are not suitable for me.” “cbt…is more biased...i am less focused, and i am more resistant to this therapy. and then i didn't stick to it at all.” “i want an asian therapist, someone with an oriental background. i think a therapist with the same cultural background is more useful in terms of the treatment.” “we talked about visas, and then the policy and so on. at that time, it was more difficult to talk to american therapists, they don’t know much about this aspect. ummmm, there are limitations. i prefer someone from relevant to my culture.” “because i was more inclined to choose a female therapist at the time. and i was more inclined to find such therapists who were more experienced in psychodynamics.” “the communication feels a little bit safer with the male therapist, which is what he might have been able to do…” based on our participants’ experiences, the characteristics of therapists, specifically therapeutic orientation, cultural background, and gender, substantially impacted their experience within psychotherapy. these factors shaped how they perceived their therapeutic relationship and, in turn, influenced their overall satisfaction and progress within the treatment. while participants in this study expressed a preference for therapeutic orientations distinct from cbt, it is essential to recognize that efficacy of psychotherapy is not limited to a single orientation. research has shown that both psychodynamic and cbt approaches, among others, have proven effectiveness in various settings (driessen, 2013; julien & connor, 2016). the expressed preference in this study does not undermine the potential effectiveness of cbt or any other orientation. instead, it emphasizes that therapeutic orientation is a significant factor in these participants’ therapy experience and satisfaction levels. it is important to understand that the synergy between therapist and client is integral to therapeutic effectiveness. within this synergy, aspects like therapeutic orientation, understanding of cultural backgrounds, and even therapist’s gender plan a role. therefore, these findings should not be interpreted as a general statement about the superiority or inferiority of particular therapeutic orientations, but rather as an emphasis on the significance of individual alignment in psychotherapy. cultural difference: a significant factor, not a barrier our participants largely did not perceive cultural differences as an impediment to their therapy process. instead, they recognized it as an influential element within their therapeutic experiences. most participants reported that having a therapist from a similar cultural background could potentially enhance the treatment experience, but they did not consider a different cultural background as an obstacle negatively impacting therapy outcome. “cultural differences are not a barrier, because the topic itself is not a relatively cultural specific topic.” “although the therapist is not chinese, they still understand what i said about discrimination.” interestingly, some participants believed that cultural diversity within the therapeutic relationship could potentially yield more positive outcomes. they appreciated the unique perspectives that therapists of different cultural backgrounds could provide. “because my psychologist is an american, and they mental health barriers for chinese international students 142 xu know the american school system very well, they also gave me a lot of useful advice. different cultures are sometimes a good thing.” “he (the therapist) has a unique world view that was not an eastern or traditional chinese view, but i felt that he could understand more of me.” these observations illustrate the nuanced role that cultural differences can assume in the therapeutic relationship. the findings suggest that therapists’ cultural congruity with their clients might foster a deeper, immediate understanding of clients’ culturally specific, thus potentially facilitating rapport building and therapeutic alliance. our findings also highlight that cultural differences, rather than serving as an obstacle, can enrich the therapeutic process. the intersection of diverse cultural backgrounds between the therapists and the clients can foster a milieu of exchange, introducing unique viewpoints, fresh insights, and broadened perspectives. moreover, these cultural differences can offer clients the chance to assimilate new coping techniques not common in their native culture, bolstering their adaptability and resilience. such results emphasize the imperative for therapists to exhibit cultural sensitivity, skillfully harnessing these differences to further therapeutic goals. school counseling services: time limitations and focus concerns participants shared mixed feelings about their experiences with school-provided counseling services. a recurring concern revolved around the limited number of sessions offered by these services. “there is a limit to the sessions that the school offering for each quarter. you can only see a therapist for a couple of times, which cannot be done for a long-term treatment.” “i am less interested in the school provided counseling services due to time restrictions of the sessions. i hope the schedule can be more flexible. most of the time there are only one therapist available.” “but at that time, the school's... emm… the support for students’ mental health was not very strong.” furthermore, some participants expressed concern about what they perceived to be a disproportionate focus on suicide prevention during therapy sessions: “i feel that the therapists from our school only care about the suicidal prevention rather than what i really want to talk about during the session.” “i personally feel that ‘thoughts to hurt others’ or ‘suicidal thoughts’ are key points during the sessions. i think because the school must focus on this.” these findings highlight potential challenges within school-provided counseling services, which could significantly influence students’ therapeutic journeys and eventual outcomes. limiting the number of therapy sessions, for example, might not fully accommodate students needing extended treatment, leading to inadequately care or unachieved therapeutic goals. while the emphasis on certain topics such as suicide prevention is essential, there is a risk of sidelining or diminishing mental health concerns that students want to discuss. such perceptions can cause students to feel misinterpreted or overlooked, potentially affecting the therapeutic alliance. this could result in students feeling dissuaded from seeking help or continuing their therapy, thereby limiting the effectiveness of such services. health insurance: a key player in psychotherapy access and continuity participants unanimously emphasized the pivotal role of health insurance in their therapeutic experiences, highlighting its influence in their choices and decisions at various stages of therapy. this indicates the relevance of financial aspects when accessing mental health services, affecting both the selection of the therapist and the continuity of treatment. “the one therapist i chose at the time was largely influenced by my insurance… our insurance was too limited, so there was not much room for me to choose…… the first three months where i didn't have insurance, so i had to stop it (the previous treatment).” “insurance. they (the therapists) must take my insurance.” “i still want to try it (psychotherapy), but of course if it doesn’t takes my insurance, i’d rather not go if i need to pay for the sessions.” these statements bring attention to the significant impact of health insurance coverage on accessibility to psychotherapy for cis. clearly, the scope of insurance coverage can influence therapist selection, possibly limiting the therapeutic options accessible to students. moreover, the extent of insurance coverage can decide the treatment’s continuity, with a lack of coverage posing a financial burden that may lead to interrupted or discontinued therapy. the fact that all participants mentioned health insurance indicates its crucial role in their psychotherapy journey, 143 suggesting a broader systemic issue at play. access to affordable mental health services is a major concern, highlighting the need for policies and practices that address these financial barriers. this might involve increasing the mental health coverage provided by insurance companies, making therapy more affordable, or exploring alternative funding options that can help cis maintain continuity in their treatment. therapist’s professional boundaries the theme of ‘therapist’s professional boundaries’ emerged in an unexpected way through our participants’ accounts of their previous therapy experiences. several of them shared instances where they perceived their therapists’ behavior as unprofessional, ultimately leading to the termination of treatment. “my therapist may not be very on time for the sessions, he is always may be 10 minutes late., but he will apologize every time.” “he (the therapist) will eat in the middle of my session, and he will drink coffee. coffee is fine because it’s like water. but i noticed he will also eat oatmeal. oatmeal is… is like very solid food. i was surprised at the time, but i didn't say much.” “one time after i left, i forgot to take my backpack, and then i came back…my therapist was crying… and talking to other colleague because she (the therapist) thinks i treat her like an emotional trash can…oh, i heard this accidentally…i felt embarrassed, really...i never went to any therapy after that…it feels wrong.” these incidents underscore the importance of therapists maintaining professional boundaries during therapy sessions. an infringement of these boundaries can significantly affect clients' trust, therapeutic experience, and willingness to continue treatment. limited accessibility to therapy while all participants initially sought treatment through their respective school counseling centers— services that they accessed free of charge—their narratives painted a picture of the considerable challenges they faced as international students in accessing therapeutic services beyond these initial provisions. furthermore, although some participants were able to continue their therapy—either via referral to community resources from their schools or through their insurance—the process was not straightforward for all. “i discontinued the sessions because the semester was almost over. they (the school) said that it is possible to come back and continue in the second year. but it never does.” “yes, i thought about finding a therapist outside of the school, but it is hard to find. it was inconvenient because i do not have a car.” “school counselling is useful and inspiring for future search for psychotherapy. i want to find someone outside the school through insurance. but i do not know how to do it… and i do not think my insurance support it?” these narratives emphasize the need to enhance the accessibility and support structures for cis when they seek and continue therapeutic services beyond initial school counseling. the lack of easy access, as well as potential service fees, could adversely affect their mental health and overall well-being. these insights accentuate the critical role universities and related institutions play in addressing this issue to better support their international student population. knowledge of mental health enhances treatment attitudes the maks is designed to gauge a person's understanding of mental health conditions and awareness of related stigmas (evans-lacko et al., 2010). according to evans-lacko’s work, these higher scores signify a more informed understanding of mental health, potentially including the nature of mental health conditions, recognition of symptoms, and understanding of appropriate treatments and coping strategies. participants with higher maks scores exhibit a greater degree of knowledge and awareness about mental health issues. table 2 reflects participants’ maks scores and attitudes toward mental health treatment. in our study, participants with higher maks scores generally expressed more favorable attitudes toward mental health treatment. their responses reflected a better understanding of the therapeutic process, a greater openness to seeking and continuing therapy, and a more nuanced perspective on its potential benefits and challenges. these attitudes may stem from their higher level of mental health literacy, suggesting that knowledge can enhance individuals' attitudes towards mental health treatment, making it more likely that they seek help and engage actively in their own therapeutic process. this finding underscores the potential benefits of mental health education programs for students. by increasing students’ knowledge about mental health, we may enhance their perceptions of therapy, encourage help-seeking mental health barriers for chinese international students 144 xu behavior, and ultimately improve their mental health outcomes. further research is needed to confirm these findings and explore the most effective ways to increase mental health literacy among students. building on these findings, our subsequent analysis and synthesis of the data revealed a more comprehensive framework that encompassed the broader determinants influencing cis’ perception and engagement with psychotherapy. this led us to the formulation of a triadic model, which we introduce and unpack in the discussion. discussion utilizing grounded theory, our study culminated in the formulation of a triadic model titled “cultural understanding, accessibility, and mental health knowledge: key influences on chinese international students’ perception and engagement in psychotherapy.” this conceptual model proposes that the triad of cultural understanding within the therapeutic setting, service accessibility, and knowledge about mental health collectively shape the psychotherapy experiences of cis. the various themes that emerged from our analysis find resonance within this theoretical structure. our findings challenge traditional assumptions about cultural differences being a barrier in therapy (leong & kalibatseva, 2011). a recent comprehensive literature review demonstrates how culture influences mental health care in multifaceted ways, often posing considerable barriers to effective treatment (ahad, 2023). however, the perspectives shared by our cis participants offer an alternative viewpoint. rather than seeing cultural differences as a barrier in therapy, they viewed them as influential factors that can be either beneficial or detrimental, depending on the issues addressed in sessions. it is vital to differentiate between the notions of “barrier” and “factor” in this context. according to the american psychological association, a “barrier” restricts, impedes, or obstructs progress or the attainment of a goal. in contrast, a “factor” influences an outcome or holds a causal relationship with a phenomenon or event. in psychotherapy, while a “barrier” negatively impacts treatment progress or outcomes, a “factor” can be either adverse or beneficial. this revelation aligns with the principles of culturally responsive therapy (crt), which posits that cultural differences can be harnessed as assets rather than barriers in the therapeutic process (asnaani & hofmann, 2012). crt and similar approaches in multicultural therapy emphasize the significance of understanding, respecting, and integrating clients’ cultural backgrounds into the therapeutic framework (zigarelli et al., 2016). by doing so, therapists can foster a stronger alliance with clients and pave the way for more meaningful therapeutic outcomes (lee, 2010). recent studies further highlight the potential of cultural differences as tools for deeper understanding and richer, tailored psychotherapy experiences (barnett & bivings, 2002). hence, while some view cultural differences as challenges (edge & lemetyinen, 2019), our findings underscore their potential as valuable tools for therapeutic transformation. building on the cultural understanding dimension, our participants stressed the importance of various therapist characteristics during their assessment of therapeutic experiences. these characteristics included cultural background, gender, and therapeutic orientation. a preference for non-cognitive behavioral therapy (cbt) was identified in our study. this reflects a trend identified by huang and kirsner (2020), wherein modern chinese individuals demonstrate an increasing openness towards psychoanalysis and psychodynamic psychotherapy as potential solutions to psychological difficulties and internal conflicts. furthermore, our study found that students with a more sophisticated understanding of mental health treatments exhibited a preference for specific therapist genders and therapeutic orientations, a finding that aligns with prior research (blow et al., 2008). this deepens our understanding of cultural sensitivity in the context of mental health services, highlighting its importance in fostering therapeutic relationships and facilitating meaningful treatment experiences for cis. interestingly, language was not perceived as a barrier in psychotherapy for international students, a finding that contrasts with karp and vögele’s (2016) assertion that language significantly impacts the practice and success of psychological interventions. our participants felt capable of expressing themselves adequately and of understanding their therapists in english. in instances where they lacked the appropriate english words to express their feelings, they found alternate ways to communicate their emotions and thoughts. this contrasts sharply with several studies that emphasize the efficacy of conducting 145 psychotherapy in a patient’s dominant language to access deeper cognitive processes (cofresi & gorman, 2004; marrero et al., 2002; shamsi et al., 2020). however, this finding might be significantly influenced by several factors, including language development, the age at which international students arrived in the u.s., their duration of stay, and english proficiency. a prior linguistic study suggested that second language grammar-learning ability is optimally retained until approximately 17.4 years of age, after which it steadily declines (hartshorne et al., 2018). in our study, we lack specific data on the age at which participants were exposed to a native english-speaking environment and other linguistic context details. various factors could shape these outcomes, highlighting the need for a broader, potentially quantitative, study in future investigations. the second crucial component of the triad shaping cis’ psychotherapy experiences is accessibility. this theme is underpinned by three sub-themes: the role of school counseling services, limited accessibility to therapy, and health insurance. according to the 2019 annual survey conducted by the association for university and college counseling center directors (aucccd), approximately 90% of counseling center directors reported a rise in students seeking services, with about 44% of college counseling centers adding staff in response (leviness et al., 2019). college counseling centers, as primary mental health resources, are often the first point of contact for international students seeking mental health support (lipson et al., 2022). in our study, participants identified two main concerns with school counseling center (scc) services: (1) schools providing a limited number of sessions for international students, which could lead to suboptimal treatment outcome, and (2) a perceived overemphasis on suicide prevention in the interventions of sccs. addressing the first concern regarding the optimal number of therapy sessions, a review of literature reveals varied findings on the optimal number of sessions for psychotherapy outcomes. some studies suggest a minimum of 20 sessions are necessary for students to exhibit noticeable change (hansen, 2002), while others indicate that bi-weekly sessions are more effective than weekly ones (cuijpers et al., 2013). certain research posits that the duration of psychotherapy has minimal correlation with its outcome (king, 2015). given these varied findings, the impact of therapy duration, intensity, and session count on both treatment outcomes and therapeutic experiences is multifaceted (de geest & meganck, 2019). most participants from our study felt the limited sessions provided by their scc adversely impacted their therapeutic experience. however, data from the aucccd (2019) reveals that 54.4% of sccs do not impose session limits on students, and 36.7% have flexible limits. further correlational investigations are needed to fully understand the number of sessions provided by the scc and the therapy experiences of international students. several participants expressed criticism regarding the second point of concern, a perceived overemphasis on suicide prevention within the interventions of sccs. they felt that the sccs overly focused on suicide prevention, often overshadowing their specific concerns and issues. it’s essential to note the limitations of our study, as our sample size may not be sufficient to provide a definitive conclusion on this matter. however, considering the gravity of the issue, the emphasis may not be misplaced. a study by drum et al. (2009) shows that over a 12-month period, 69% of undergraduates and 63% of graduate students reported considering suicide more than once, with a substantial number formulating specific plans or gathering materials for suicide. research indicates that risk management strategies employed by sccs can significantly reduce the incidence of suicide within educational settings (paschall & bersamin, 2018). thus, it is crucial that sccs maintain a vigilant focus on potential suicidal ideation, balancing this concern with addressing the diverse mental health needs of the student population. when sccs are unable to meet students’ needs, they often turn to external resources. due to the high costs associated with psychotherapy, most participants opted to find therapists through their health insurance (cummings, 2015). however, this approach elicited concerns among international students, as many are unfamiliar with navigating u.s. insurance systems. as such, the onus lies with the school’s mental health department to educate students about the importance of mental health and the accessibility of services both on and off campus. the development of initiatives aimed at increasing international students' understanding of available resources within their community could prove highly beneficial. research indicates that increased accessibility to mental health mental health barriers for chinese international students 146 xu treatment promotes greater participation in mental health interventions and encourages self-help behaviors (lattie et al., 2022). potential interventions could include public seminars, informational outreach sessions, comprehensive resources on school websites, and the distribution of informational brochures. in discussing the third element of the triad, mental health knowledge, we observed two clear connections: a distinct link between higher mental health knowledge and more favorable attitudes towards therapy, as well as a similar connection with attitudes towards psychotropic medication. the participants’ understanding and perceptions of mental health significantly shaped their attitudes towards therapeutic interventions. it became evident that a deeper knowledge about mental health can profoundly influence an individual’s attitude towards and engagement with therapeutic services and treatments. prior research, including a survey on cis by lu et al. (2013), indicates that common barriers to seeking professional mental health treatment are multifaceted including: limited knowledge of available mental health services, lack of recognition of psychological distress symptoms, and underestimation of their severity. this finding was echoed in a study by forbes-mewett and sawyer (2016), revealing that international students, due to unfamiliarity with western therapeutic approaches, limited access to local medical systems and facilities (cheng, 2020), and insufficient knowledge about available services (skromanis et al., 2018), were less likely to use mental health services compared to their domestic peers. our findings align with this pre-existing research. higher mental health knowledge in our study population was associated with more positive attitudes towards mental health treatment. students majoring in psychology or those with a greater understanding of mental health reported better experiences with the treatment process and exhibited more positive attitudes towards therapy options. these results not only offer valuable empirical evidence for clinicians working with cis but also inspire us to consider integrating psychoeducation within and prior to the treatment process. such an integration could potentially foster improved attitudes towards mental health treatment. the unexpected emergence of a theme related to therapists’ professional boundaries presents an intriguing dimension for future exploration and could potentially be integrated into our grounded theory with further research. professional boundaries are fundamental to conducting therapy, significantly influencing students' treatment experiences and attitudes toward psychotherapy (wilmots et al., 2019). many of our participants reported instances where they perceived their therapists as unprofessional during sessions, citing behaviors such as eating during the session, leaving the door open, answering phone calls, and being overheard when discussing the client's case. while our findings might be skewed due to the limited sample size, it raises interesting questions. for example, do these situations arise due to underlying factors? would different student populations experience the same issues? does the nature of the session, whether remote or in-person, impact these incidents? future research with larger sample sizes is warranted to address these intriguing questions. to conclude, this grounded theory highlights the interplay between three factors and how they influence the psychotherapy experience for ciss. it emphasizes the need for cultural sensitivity, accessibility, and mental health education in creating a supportive and beneficial therapeutic environment for this population. clinical and research implications based on the findings of our current study, there are several strategies and recommendations to enhance therapeutic engagement with cis in treatment. grounded in our research findings, the following clinical implications are proposed: 1) cultural acknowledgement: therapists should recognize the significance of a student's cultural background. establishing a therapeutic alliance may be facilitated when therapists share a similar cultural background with the student. rather than viewing cultural differences as barriers, therapists can see them as opportunities to better understand and connect with students. 2) language considerations: if mutual understanding exists between the student and therapist, language barriers may not necessarily hinder the treatment process. 3) educational empowerment: encourage students to acquire additional knowledge about mental health through educational resources. this understanding can enhance their engagement in therapy. 4) extended mental health care: many international students require more extensive mental health 147 mental health barriers for chinese international students care than what school counseling centers currently offer. providing additional resources or referrals might bridge this gap. 5) professionalism and compassion: therapists should offer care that extends beyond suicide prevention and always maintain professional boundaries. conducts, such as eating during the session or leaving the door open, can impact student's therapy experience negatively. this study serves as a small-scale exploratory qualitative investigation. to establish the generalizability of these findings, larger-scale quantitative studies will be necessary. as attitudes are known to shift over time based on experiences, future research could benefit from employing a longitudinal approach. this study underscores the potential utility of pre-therapy psychoeducation interventions to improve treatment outcomes and empower school counseling centers to cater to more students with mental health needs. administratively, furnishing additional information about available mental health resources could potentially benefit the international student population. further investigation into the institutional barriers obstructing chinese international students from accessing needed mental health support could prove insightful, providing opportunities for improvements in both governmental and institutional educational policies. future researchers might consider conducting a randomized controlled trial to examine the efficacy of combining psychoeducation with therapy for international students. such a strategy could potentially enhance treatment outcomes and enable school counseling centers to accommodate more students requiring mental health support. additional studies could further explore the accessibility of mental health resources for international students and identify the institutional-level hurdles preventing them from availing mental health support. addressing these challenges could provide valuable insights for improving the mental health outcomes of international students. strengths and limitations our study might face limitations due to its sample size and potential sampling bias. those who volunteered might have had predominantly positive experiences with psychotherapy, making them more inclined to participate and share their insights. such individuals might also be naturally more expressive and perhaps face fewer challenges when accessing psychotherapy services, thus skewing the data towards positive experiences. additionally, the gender imbalance in our sample due to a significant majority being female, further compounds this bias. this disparity could have influenced the results as male perspectives and experiences might be underrepresented. however, we mitigated these limitations by reaching out to as many schools as possible across the u.s., thereby including participants from diverse regions of the country. there is a risk to the validity of the findings if participants were not entirely candid in their responses. to counter this, we employed strategies like allowing participants to use preferred names and 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(2016). culturally responsive cognitive behavioral therapy. clinical case studies, 15(6), 427– 442. https://doi.org/10.1177/1534650116664984 mental health barriers for chinese international students 152 xu table 1 participants’ demographic data 153 mental health barriers for chinese international students table 2 participants’ maks scores and attitudes toward mental health treatment 30 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university a scoping review on energy drink consumption among adolescents and young adults adolescence, defined by the world health organization (who) as individuals aged between 10 and 19 years, is a pivotal stage characterized by rapid physical, cognitive, and psychosocial development, laying the crucial foundations for good health (world health organization, 2019). recently, there has been a discernible global increase in energy drink consumption among adolescents, which has become a subject of significant health concern and professional debate (miller et al., 2018). energy drinks (ed) are beverages that typically contain varying amounts of caffeine, taurine, glucuronolactone, vitamins, herbal extracts, proprietary blends, and amino acids. they are marketed as products capable of enhancing mental alertness and physical endurance (ahuja et al., 2021; higgins et al., 2018). these drinks, available in carbonated or non-carbonated forms and with or without sugar, are distinct from traditional beverages like coffee, tea, sodas, and sports drinks, even though they may seem similar. a notable difference is in their caffeine content, with energy drinks potentially containing between 40 to 250 milligrams per 8 fluid ounces, as per the u.s. food and drugs administration (fda, 2018). this range is significantly higher compared to the caffeine content in an 8-ounce cup of coffee, which usually contains 80 to 100 milligrams. studies also indicate that energy drinks have an average taurine concentration of approximately 750 milligrams per 8-ounce serving (ahuja et al., 2021; caine & geracioti, 2016). the rise in the consumption of energy drinks among adolescents can be attributed to a myriad of factors. targeted advertising, the promise of increased alertness, combating fatigue, aspirations for improved academic and athletic performance, and the trend of mixing these drinks with alcohol are some of the driving forces behind their popularity (quigley et al., 2019; reissig et al., 2009). however, this increasing consumption has been linked with several adverse health effects, including elevated blood pressure and psychological issues such as anxiety (lisko et al., 2017). furthermore, due to the addictive properties of caffeine and other similar components in energy drinks, there have been increased reports of anxiety, stress, and depression among consumers (linden-carmichael & lau-barraco, 2017; richard & smith, 2016). given these associated risks, some countries have instituted restrictions on the sale of energy drinks, with others contemplating similar regulatory measures (winston et al., 2005). therefore, this scoping review aimed to examine the use of energy drinks in adolescents and young adults to provide a synthesized summary of the evidence and identify gaps in our knowledge. the research question is: have there been observable trends in the consumption of energy drinks among adolescents and young adults (aged 12-25) in the past decade, with particular emphasis on identifying influencing factors and associated health and behavioral risks? this scoping review aimed to identify empirical studies that have explored the use of energy drink consumption among adolescents and young adults. method: a scoping review search was conducted in the following five databases: pubmed, embase, lilacs, scopus, and psycnet. some inclusion criteria, such as being published in the last 10 years, and exclusion criteria, such as article type, animal-model usage, and age, were used to select the studies, and 11 were analyzed independently. results: the results showed that adolescents use energy drinks for many factors, such as connection with peers and family, propaganda, and taste. some studies have been developed in australia and the united states of america, and some have explored other variables associated with energy drinks and alcohol use. conclusion: it is essential to understand how energy drink consumption and behaviors are related to health or risky behavior and its associations with other drugs. more research is needed to explore the long-term health impacts of energy drink consumption during the critical developmental periods of childhood and adolescence, as well as its association with alcohol and other substances. the findings underline the importance of stringent regulations, public health policies, and educational initiatives to mitigate the risks associated with energy drink consumption among adolescents. future research is essential to understand the long-term implications and develop effective preventive strategies to safeguard adolescent health and well-being. keywords: energy drinks, adolescents, health, consumption filipe reis teodoro andrade1,2, gabriel thalheimer1,2, santiago david vásquez hidalgo2,3, & rosa maria martins de almeida1,2,3 1department of developmental and personality psychology, universidade federal of rio grande do sul, 2psychology institute, universidade federal of rio grande do sul, 3basic health sciences institute, universidade federal of rio grande do sul 31 energy drink consumption among adolescents and young adults with energy drinks gaining popularity due to aggressive marketing strategies, it is imperative to scrutinize the associated risks, thereby laying the groundwork for the development and implementation of prevention programs targeting both the youth and their guardians (ahuja et al., 2021; brache & stockwell, 2011; zandvliet et al., 2005). methods a literature review followed the premises proposed by prisma (page et al., 2021a; page et al., 2021b). the scoping review was carried out according to the following steps: (1) formulation of the research question; (2) production and registration of the investigation protocol; (3) definition of inclusion and exclusion criteria; (4) developing of the research strategy and conducting the reference search; (5) screening of studies based on inclusion and exclusion criteria; (6) evaluation of the quality of studies; (7) data extraction (8) data synthesis and evaluation of the quality of the studies (donato & donato, 2019). the approach for conducting systematic scoping reviews by levac et al. (2010) guided the review based on the five-stage methodological framework that arksey and o’malley (2005) developed. stage 1: identifying the research question. the central question guiding this scoping review was: "have there been observable trends in the consumption of energy drinks among adolescents and young adults (aged 12-25) in the past decade, with particular emphasis on identifying influencing factors and associated health and/or behavioral risks?" stage 2: identifying relevant studies after the initial search in embase and pubmed, five electronic databases were searched: embase, pubmed, psycnet, scopus, and web of science, with the last searches performed on august 03, 2022. date limits were set for 10 years, and the search strategy included using descriptors: energy drinks and (teenagers) and (addiction), with necessary adaptations to the specifications of each database (table 1). in searches between june 07, 2022, and august 03, 2022, 143 materials were identified. stage 3: study selection quantitative and qualitative peer-reviewed, original, full-length research papers were included. the reviewers were previously trained for the task according to the following exclusion criteria: (a) reviews and meta-analyses; (b) theses, dissertations, abstracts, and publications in congresses; (c) studies that are not in english; (d) animal model research; (e) sample with subjects under 12 or over 25 years old. participants this review focused on adolescents and young adults aged between 12 and 25 years. the population may have been studied in schools, universities, or through surveys. concept during the review, the focus was on energy drink consumption by adolescents, specifically on health and relational factors. studies that solely focused on addiction to sugar were not considered. the pico strategy was used based on eligibility criteria, with p (population) being adolescents, i (intervention) lower levels of use, c (comparison) being patterns of use in adolescents, and o (outcome) being energy drink consumption during adolescence. search strategy when performing the search strategy in the five different databases, a total of 143 records were identified. these records were exported to rayyan software (ouzzani et al., 2016). duplicate records were then removed, resulting in 139 records for screening the title and abstract. the screening was performed by two authors (frta and gt), who independently compared the titles and abstracts of each record with the inclusion criteria. frta and gt finally agreed to include 11 records as relevant studies for full-text screening. the records considered eligible for full-text screening were then distributed among one other author, rmma, in addition to frta and gt. they independently screened the full-text studies to assess eligibility for inclusion in the review. the research tool rayyan software was used to combine all materials, remove duplicates (n=143), and for the independent reviewers (frta and gt) to screen the 139 unique titles and abstracts simultaneously (ouzzani et al., 2016). frta and gt had a concordance rate of 96.8%, and a third reviewer (rmma) assessed divergences. with those steps complete, 13 articles were selected for the second round of assessments, this time analyzing full text according to the same criteria previously stated. based on the analysis of the complete texts, 13 articles were selected for the data extraction phase. after this second exclusion phase, data extraction began, con32 andrade et al. girls. in contrast, ludden & wolfson (2010) found that girls were likelier than boys to report expectations around appetite suppression. patterns of use according to age were less clear-cut, with some studies showing that consumption levels increased with age and others demonstrating that the converse was true. martz et al. (2015) showed that cross-racial and ethnic patterns were also identified; black students were less likely to consume energy drinks than their white counterparts or latins. other studies have suggested that consumption levels are highest among aboriginal, hispanic, and/or black students (martz et al., 2015; visram et al., 2016; xu et al., 2020). higher consumption levels were positively associated with being underweight or obese, being from a single-parent family, receiving complimentary school meals, having special educational needs, and having higher spending (reid et al., 2015; scalese et al., 2017). young people with higher scholastic averages, a higher sense of coherence, higher levels of parental monitoring, and more educated parents were less likely to consume and consistently associated with energy drink consumption was the use of alcohol and/or binge drinking, smoking, or susceptibility to smoking and other substance energy drinks (miller, 2008). one survey of australian college students observed that premixed alcohol-mixed energy drinks (ameds) included the ability to drink more, sensations of being more awake or in control, the symbolic attractiveness of ameds, and the ease of obtaining and concealing the beverages for underage drinkers. the survey also identified several negative aspects of ameds, including difficulty speaking, hangovers, and increased aggression (jones et al., 2012). a study on the appropriateness of caffeinated drinks for children found that high caffeine intakes (>5 mg/kg body weight per day) were associated with an increased risk of apprehension (anxiety) and withdrawal symptoms. nevertheless, evidence from young adult studies and expert discussions was used to suggest that relatively small quantities of caffeine may benefit cognitive function and sports performance, as well as contribute to daily liquid intake (jones et al., 2012; kemps et al., 2019; sanchis-gomar et al., 2015). views regarding the consumption of energy drinks our analysis of mixed method studies and relevant survey results revealed two significant themes: sidering as inclusion criteria in the study: (a) articles that had energy drinks in their title; (b) studies that evaluated the effect of energy drinks on adolescents; (c) research that made comparisons between groups or intragroup; at this stage, two articles were excluded (see figure 1). stage 4: charting the data three authors (frta, gt, and rmma) analyzed energy drink use in adolescence, including three main phases: preparation, organizing, and writing. one author (frta) extracted study characteristics, which were also reviewed by gt and included in an agreement between rmma. as this was a review, study quality (e.g., risks of bias, study strength) was considered, but not for a meta-analysis. tables 1 and 2 show the systematization and categorization of relevant topics from the results of the studies included in this review, reflecting the review questions. stage 5: collating, summarizing, and reporting the results the main characteristics of the eleven included studies are presented in table 2. the studies were grouped by year of publication. studies published in the same year were grouped alphabetically by first authors’ surnames. the extracted data were: (1) citation; (2) country; (3) study design; (4) outcome measures; (5) sample; (6) main findings. findings the f indings of the review are presented according to the review questions. table 2 reports the general information and significant f indings of the reviewed publications. results concerning the overall number of articles, there were 119.796 participants from different countries, most of them from china, the united states of america, and italy, aged 12 to 19 years, who completed various surveys. the average is 11.979,6 adolescents. the most predominant type of test was the socio-demographic questionnaire, covering 50% of the total articles. several studies indicated that boys were more likely to report consumption than girls and in a more significant amount (choi et al., 2016; koivusilta et al., 2016; magnezi et al., 2015). in this scoping review, cross-sectional survey data suggested that the use of energy drinks is patterned by gender. larson et al. (2014) found a significant connection between regular consumption and lower breakfast frequency for 33 energy drink consumption among adolescents and young adults ergy drinks by children and young people is associated with several adverse outcomes and health-damaging behaviors. 139 studies were located, with 11 meeting our inclusion criteria. a total of 99.740 participants were included in the 11 articles. in which we have obtained the gender data of 28.326 participants (28.4%), amongst 47.2% were males and 52.7% were females. three randomized controlled trials demonstrated that pre-exercise ingestion of an energy drink positively impacted some aspects of sports performance (o’dea, 2003; pennay & lubman, 2012; sanchis-gomar et al., 2015). nevertheless, the referred studies involved small numbers of athletes, and the results should thus be treated with some vigilance. several cross-sectional studies indicated that energy drink consumption by adolescents was strongly and positively associated with higher rates of impulsivity, risk behavior, smoking, alcohol, and other substance use, as well as being linked to physical health manifestations such as headaches, loss of vigor, stomach aches, insomnia, fatigue, and hyperactivity (azagba et al., 2014; o’dea, 2003). two studies provided evidence of a dose-response effect, although none of the investigations could define the reason (jones et al., 2012; pennay & lubman, 2012). typically, boys consume more energy drinks than girls. usage was found to be patterned by gender and age, although there was some variance between studies on the direction of the association. the highest consumption levels have been observed in sedentary and physically active people, suggesting a link between sports and screen-based relaxation activities. an exciting finding among the analyzed studies is in a hungarian study by toth et al. (2020) where he examined 631 high school students and their relationships with energy drinks that corroborate the hypothesis of this review. the social environment of respondents and the amount of time they spend with friends were also factors influencing ed use. parents supporting or forbidding education use have a significant influence on their children. those with a weaker sense of coherence and a tendency toward depression were much more likely to become addicted, those who were active in sports were significantly less likely to report symptoms of depression, and their sense of coherence was also more potent than young people who did not engage in sporting activities at the same time, ed consumption was widespread among young people who were active in sports (tóth et al., 2020). motivations for usage and convincing on usage. motivations for use many individuals, particularly boys involved in sports, consume energy drinks to enhance their athletic performance. others may opt for energy drinks as an occasional substitute for soft drinks, but only when they have extra funds available, as they tend to be pricier (abian-vicen et al., 2014; costa et al., 2014; gallo-salazar et al., 2015). participants in studies have commonly reported that energy drinks "wake you up, make you feel alert, and taste good," "make me hyper," and "keep me energized for soccer matches" (abian-vicen et al., 2014; o'dea, 2003). a research study conducted by jones explored the perceptions of alcohol-energy drinks (aeds) among 12-17-year-olds and found that young people enjoyed them because they increased the fun at parties and acted as a pick-me-up (jones, 2011). convincing on use the use of energy drinks among young people is influenced by advertising and brand loyalty, according to a study that involved participants from three different age groups (16-21, 22-28, and 29-35 years). the study found that energy drinks were advertised on various platforms such as tv, the internet, games promotions, sports sponsorship, and shops. industry marketing targeted specific drinks to men or women using sexualized imagery, humor, and social media (bunting et al., 2013). the younger age group seemed more aware of their projected social image and more influenced by their peers when making purchasing decisions. social situations, particularly spending time with friends, were identified as familiar contexts for energy drink consumption. parents also played a significant role in influencing their children's use of energy drinks. they either discouraged or prohibited the consumption of energy drinks or encouraged and endorsed their use. the study found that energy drinks were easily accessible from convenience stores or supermarkets, provided by parents, shared by siblings or friends, or obtained free at sponsored events. (bunting et al., 2013: costa et al., 2014). discussion this review set out to examine evidence of any associations between adolescents and young adults’ health and consumption of energy drinks. it also sought to explore consumer experiences and attitudes toward these drinks. the evidence demonstrates that the use of en34 andrade et al. group at risk. that said, an experimental study developed in canada provided evidence that current warnings in caffeinated energy drinks (ceds) could be enhanced to increase the salience of messages, with a more significant impact from clear, descriptive, front-of-package ‘high source of caffeine’ labels, eliciting lower product appeal and perceived safety ratings in young adults aged 12–24 years (reid et al., 2015). as caffeine is the primary psychoactive ingredient in energy drinks and is responsible for the vast majority of toxicity, energy drink labels that present high levels of caffeine associated with 'danger' could reduce the number of poisonings through indiscriminate use (zandvliet et al., 2005). advertisements for energy drinks are often targeted towards adolescents through popular tv shows and websites, which could potentially encourage them to consume such drinks (harris et al., 2015). it is important to note that while the average amount of caffeine consumed by teenagers has decreased over the past 20 years, there has been a significant increase in energy drink consumption among adolescents over the past decade (tran et al., 2016). this is a cause for concern due to the numerous reported adverse effects of excessive caffeine, ranging from minor sleep disturbances to mortality. high consumption of energy drinks among young people in recent years is a worrying trend (mesirow et al., 2015). the need to understand adolescents' consumption of energy drinks is justified primarily by a range of immediate risk behaviors that are associated. regarding future health, recent reviews have pointed out that standards adopted during this period have a potentially lasting influence and can extend into adulthood, with repercussions on physical and psychological health (rice & klein, 2019). different behaviors of children and adolescents can negatively affect health and well-being, with short or long-term impacts. regarding energy drinks, there is evidence that the age at first use predicts future risks. a longitudinal study with young american military officers pointed to the age range between 13 and 16 years as critical, suggesting that adolescents who begin consumption during this period become more likely to consume larger quantities of the product in isolated episodes than those who started consumption after the 20 years (sather et al., 2016). furthermore, new associations have been found between frequent ed consumption with alcohol by adolescents and a greater risk of developing alcohol dependence in adulthood (arria et al., 2011). ed does not present therapeutic benefits, contains the studies mentioned above have reported perceived beneficial effects on young people’s bodies and sports performance, with slight mention of any adverse effects and limited knowledge of energy drink ingredients among participants (franklin et al., 2013; pennay & lubman, 2012; sampasa-kunyinga et al., 2020; visram et al., 2016). other literature findings show that energy drinks can significantly increase the likelihood of negative mental health conditions, such as stress, anxiety, and depression. these adverse outcomes are particularly prevalent in adolescents and young consumers (richards et al., 2016). although energy drinks may positively impact mood in the short term, long-term consumption is more likely to harm mental health (trapp et al., 2014). however, there is a lack of comprehensive data regarding the potential link between energy drink consumption and mental health issues in young people (kaur et al., 2020). consequently, it is plausible that the components of energy drinks could contribute to the development or aggravation of mental health problems (babu et al., 2008). as for the appeal of energy drinks among the young, taste and energy-seeking were identified as critical drivers for consumption. advertising and brand loyalty have been highlighted as significant influences on young people’s attitudes toward energy drinks, and peers, family, and friends also played an important role. a few studies found that more than half of young energy drink consumers (53%) reported using energy drinks to continue partying and drinking alcohol over a more extended period and may experience adverse effects ranging from difficulty sleeping to addiction to alcohol (franklin et al., 2013; park et al., 2012; wiggers et al., 2020). a study by leal and jackson (2019) used samples for monitoring students between 2010 and 2016 and found that energy drink consumers are significantly more likely to intend to initiate marijuana use. youth who heavily use energy drinks have substantially higher odds of having the intention to use marijuana (snipes & benotsch, 2013). other studies in table 2 show that adolescents may have associations with depressive symptoms when they ingest energy drinks with alcoholic beverages (cotter et al., 2013; tóth et al., 2020; xu et al., 2020). aggressive marketing campaigns by manufacturers toward adolescents and young adults put this 35 energy drink consumption among adolescents and young adults tor, in combination with the gendered marketing and perceived links to sports performance. more research is required to explore the longer-term health impacts, given that childhood and adolescence are critical yet understudied periods in developing health-related behaviors and use of energy drinks associated with alcohol or types of consumption. the potential effects of heavy and long-term energy drink consumption on child development, behavior, and educational outcomes also warrant further study. furthermore, the findings have important practical implications for public health policies and laws governing the sale of energy drinks to minors on a prevention level. the results highlight the significance of imposing more stringent regulations and education efforts to block adolescents' access to these drinks, promoting healthy habits. dealing with the problem of children and teens consuming energy drinks requires acknowledging the complexity of their choices. while educating them about health may have little impact, healthcare professionals and others should provide clear information about the safety of consuming energy drinks. they may need guidance from organizations like the food and drug administration (fdau.s.a), the brazilian health regulatory agency (anvisa), and the european medicines agency (ema). it's essential to conduct further research to explore the long-term health impacts, particularly during childhood and adolescence, which are critical yet understudied periods in developing health-related behaviors. strengths and limitations three authors thoroughly and systematically screened titles and abstracts, followed by full-text studies and reference lists. discussions were held to ensure that no appropriate studies were lost. we attempted to use various search terms such as "stimulant drink," "energy strip," "energy shot," and "energy mint," as well as "youth," "young adults," and "teen" for the population. however, these terms yielded little results in the research bases. this was a limitation of our study. additionally, we only included studies in the english language, which may have caused us to miss some relevant papers. we searched five databases, but this is a partial number. however, we followed the recommendations of experienced academics to cast as wide a net as possible regarding the context, concept, and population. understudied ingredients, is not fully regulated, and has no safe consumption levels yet established for children and adolescents (curran & marczinski, 2017; howland & rohsenow, 2013; seifert et al., 2011). the context is one of uncertainty regarding the acute and chronic safety of these products. thus, it is necessary to understand the patterns of ed consumption by adolescents in our reality, the motivations that have led them to consume, and the factors that may be associated, both protective factors against consumption and risk factors, due to eventual or regular use. special attention to this stage of development, characterized by lower assessment and self-protection capabilities, can prevent global health and well-being issues, with consequences in different areas of adult life. conclusion the data collected covered several significant biases to be considered; however, regarding the use of energy drinks for adolescents, it is essential to have more studies to understand that energy drink consumption might increase risk behaviors associated with alcohol, which can be seen through competition, or impulsive risk, and depression (table 2). adolescence is a phase of significant biological and social changes. it is crucial to be aware of these aspects, primarily regarding social support, for a greater possibility of dealing with new situations. this review contributes to the growing body of evidence regarding the health effects of consuming energy drinks. for young people, the negative implications may outweigh the positive ones. despite this, factors like the brand, relationships with energy drink users, taste, and perceived benefits increase their popularity among young consumers. the advertising for these products worldwide often features ideas of power, strength, energy, and explosion, using images and product names that allude to these concepts. it is crucial to explore the effects of high levels of ingredients like caffeine, taurine, and sugar in energy drinks on young people's bodies. more education is needed about energy drink patterns for this demographic. however, addressing this issue through policies and interventions is complex due to the choices adolescents and young people make. while individual health education is unlikely to have a significant impact, healthcare and other professionals can play a role in promoting safe consumption habits. young men were identified as an essential fac36 andrade et al. emerging adolescent health risk: caffeinated energy drink consumption patterns among high school students. preventive medicine, 62, 54-59. https://doi.org/10.1016/j.ypmed.2014.01.019 babu, k. m., church, r. j., & lewander, w. (2008). energy drinks: the new eye‐opener for adolescents. clinical pediatric emergency medicine, 9(1), 35–42. https://doi.org/10.1016/j. cpem.2007.12.002 bonar, e. e., cunningham, r. m., polshkova, s., chermack, s. t., blow, f. c., & walton, m. a. (2015). alcohol and energy drink use among adolescents seeking emergency department care. addictive behaviors, 43, 11–17. https://doi.org/10.1016/j. addbeh.2014.11.023 brache, k., & stockwell, t. (2011). drinking patterns and risk behaviors associated with combined alcohol and energy drink consumption in college drinkers. addictive behaviors, 36(12), 1133-1140. https://doi.org/10.1016/j.addbeh.2011.07.003 bryant ludden, a., & wolfson, a. r. (2010). understanding adolescent caffeine use: connecting use patterns with expectancies, reasons, and sleep. health education & behavior, 37(3), 330-342. https://doi.org/10.1177/1090198109341783 bunting, h., baggett, a., & grigor, j. (2013). adolescent and young adult perceptions of caffeinated energy drinks. a qualitative approach. appetite, 65, 132-138. https://doi.org/10.1016/j. appet.2013.02.011 caine, j. j., & geracioti, t. d. (2016). taurine, energy drinks, and neuroendocrine effects. cleveland clinic journal of medicine, 83(12), 895–904. https://doi.org/10.3949/ccjm.83a.15050 costa, b. m., hayley, a., & miller, p. (2014). young adolescents’ perceptions, patterns, and contexts of energy drink use. a focus group study. appetite, 80, 183-189. https://doi.org/10.1016/j.appet.2014.05.013 choi, h. j., wolford-clevenger, c., brem, m. j., elmquist, j., stuart, g. l., pasch, k. e., & temple, j. r. (2016). the temporal association between energy drink and alcohol use among adolescents: a short communication. drug and alcohol dependence, 158, 164-166. https://doi.org/10.1016/j. drugalcdep.2015.11.009 cotter, b. v., jackson, d. a., merchant, r. c., babu, k. m., baird, j. r., nirenberg, t., & linakis, j. recommendations for further research the findings have considerable and varied implications in the context of this research. this study reveals the increasing concern over adolescent energy drink intake and its potential connection to other drugs, especially alcohol. theoretically, our findings add to the field by verifying and deepening our knowledge of the dangers that alcoholic drinks pose to adolescents. our research indicates that further long-term studies are required to track adolescents and better understand how their behavior may be affected as they approach adulthood through energy drinks. additionally, this study highlights the need for more investigation into the development and effectiveness of preventive and educational programs targeting adolescents. this includes researching school-based interventions, public awareness campaigns, and collaborating with mental health professionals to combat the psychological risks of consuming energy drinks and other substances. ultimately, this study establishes a strong foundation for future research to safeguard adolescent health and well-being while identifying key areas where significant contributions can be made to address the dangers of energy drink consumption in this age group. references abian-vicen, j., puente, c., salinero, j. j., gonzálezmillán, c., areces, f., muñoz, g., ... & del coso, j. 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(2019). adolescent health. https://www.who.int/health-topics/adolescent-health#tab=tab_1 wiggers, d., reid, j. l., & hammond, d. (2020). efficacy of canadian health warning statements on caffeinated energy drinks: an experimental study among young canadians. health education research, 35(6), 618–626. https://doi.org/10.1093/ her/cyaa040 winston, a., hardwick, e., & jaberi, n. (2005). neuropsychiatric effects of caffeine. advances in psychiatric treatment, 11(6), 432-439. https://doi. org/10.1192/apt.11.6.432 xu, h., guo, j., wan, y., zhang, s., yang, r., xu, h., ding, p., & tao, f. (2020). association between screen time, fast foods, sugar-sweetened beverages and depressive symptoms in chinese adolescents. frontiers in psychiatry, 11, 458. https:// doi.org/10.3389/fpsyt.2020.00458 zandvliet, a. s., huitema, a. d., de jonge, m. e., den hoed, r., sparidans, r. w., hendriks, v. m., van den brink, w., van ree, j. m., & beijnen, j. h. (2005). population pharmacokinetics of caffeine and its metabolites theobromine, paraxanthine and theophylline after inhalation in combination with diacetylmorphine. basic & clinical pharmacology & toxicology, 96(1), 71-79. https://doi. org/10.1111/j.1742-7843.2005.pto960111.x 41 energy drink consumption among adolescents and young adults table 1 search strategies used for embase, psychnet, pubmed, scopus, and web of science 42 andrade et al. table 2 summary of the information and characteristics of each study (n =11) 43 energy drink consumption among adolescents and young adults 44 andrade et al. 45 energy drink consumption among adolescents and young adults 46 andrade et al. note. some of the studies utilized abbreviation words. st: screen time, ffs; fast foods; ssbs: sugar-sweetened beverages; ed: energy drink; eds: energy drinks; mtf: monitoring the future; arcs: alcohol-related consequences; amed: alcohol mixed with energy drink. 47 energy drink consumption among adolescents and young adults figure 1 flow chart of steps performed during a scoping review 19 graduate student journal of psychology fall 2024 vol. 23 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university exploring the relationship between gendered racism, identity centrality, and binge-eating symptoms among black women gendered racism refers to discrimination based on gender and racial identity, which is a common experience for many black women. to cope with gendered racism, black women may utilize behaviors that are associated with adverse mental health outcomes known as maladaptive coping. examples of maladaptive coping include disordered eating, like binge eating and emotional eating (brown, 2022). binge eating is marked by eating a large amount of food within a relatively short period; it is often accompanied by feelings of distress and a loss of control when eating (american psychiatric association, 2013). binge eating disorder (bed) occurs when this behavior happens at least once a week for at least three months (american psychiatric association, 2013). emotional eating is when an individual is in a negative emotional state and consumes food often high in fat or sugar as a coping response to stress (arnow et al., 1995; volpe et al.,2024). the literature has reported varying rates of binge eating in black women as percentages have ranged from 1.5%-36% (goode et al., 2020; scott et al., 2018). for binge eating, research has primarily focused on white women and often has regarded it as a disorder that was more prominent in this racial group (marques et al., 2011; watson et al., 2019). yet, other research has shown that binge eating rates are higher for black women compared to their white counterparts (goode et al., 2018). binge eating is an imperative maladaptive disorder to focus on in black women due to its high prevalence rates in this community, which are not matched with equally as high diagnosis and treatment rates. the researchers chose to focus on binge eating for this study due to its high prevalence among black women. black women have some of the lowest rates of receiving care and treatment for disordered eating despite their high prevalence rates of binge eating (goode et al., 2020). so much so that less than 8% of black women with binge eating disorder seek treatment in comparison to the 20% of white women with bed who seek treatment, showcasing that black women have some of the lowest rates of access to eating disorder care (goode et al., 2022; wilfley et al., 2001). even for the black women who do access treatment, their retention is low (thompson-brenner et al., 2013). the health disparities that exist for black women plagued by binge eating suggest that the current eating disorder treatment and interventions are not the best fit for black women in a way that is understanding of their lived experiences, culture, and gendered racial identity (goode et al., 2020; marques et al., 2011). gendered racism, the intersection of racism and sexism, can be used to explain the intersectional, discriminatory lived experiences that black women often encounter (behrendt-mihalski, 2017; thomas et al., 2008). encounters of gendered racism occur throughout black women’s lifetimes, so it is crucial black women often experience gendered racism, the intersection of racism and sexism. they adopt coping mechanisms in response, such as avoidance, spirituality, and disordered eating behaviors. the researchers focused on binge eating, defined as eating a large amount of food within a relatively short period; it is often accompanied by feelings of distress and a loss of control when eating. the high prevalence of binge eating among black women led the researchers to explore the psychosocial risk factors that contribute to binge eating among black women. they employed the intersectionality theory to investigate the relationship between gendered racism, identity centrality, and binge eating. the current study sought to understand the relationship between gendered racism and binge eating as moderated by gendered racial identity centrality, the degree to which black women view their race and gender as integral to their identity. participants were 281 black women from 18-35 who completed an online survey via qualtrics. the moderation results indicated that participants with low or medium levels of identity centrality and more experiences with gendered racism were associated with higher levels of binge eating. conversely, when participants’ identity centrality was high, there was a non-significant influence on the relationship between gendered racism and binge eating behaviors. to implement effective interventions for black women, healthcare providers must gain a better understanding of their unique lived experiences, such as the influence of gendered racism and black women’s barriers to receiving proper diagnosis and treatment for disordered eating. keywords: loneliness, isolation, mental health, alcohol use, traumatic stress rachael o. holly & danielle dickens department of psychology, spelman college, atlanta, georgia 20 holly & dickens to examine the ways that such encounters negatively impact the way that they interact with the world (jackson et al., 2010; volpe et al., 2024). the purpose of this current study was to examine the relationship between gendered racism, gendered racial identity centrality, and binge eating behaviors in black women. binge eating in black women as defined by the american psychiatric association (2013), binge eating occurs when an individual’s eating patterns are of a higher quantity than what would typically be eaten in a discrete period, in addition to the feeling of losing control when eating. past research has examined black women’s binge eating symptoms, but more research is required to understand the factors that influence black women’s binge eating. while past researchers have found that binge eating is almost twice as prevalent in black women, 5%, as it is in white women, 2.5%, significant disparities exist in black women’s access to treatment for this disorder (goode et al., 2022; striegel-moore et al., 2000). the loss of control when eating, characterized by binge eating, is associated with feelings of psychological distress, in addition to and is exacerbated by the discrimination that black women face from gendered racism (brown et al., 2022; tanofsky-kraff et al., 2012). such findings highlight the racial disparities often seen in both research and healthcare treatment for black women as they are frequently overlooked in the discussion of care for maladaptive eating behaviors. black women have such high prevalence rates for binge eating, but little research exists to identify the psychosocial factors contributing to these rates. in understanding the lived experience of black women, it is critical to know the different avenues through which discrimination and oppression can maladaptively be seen in black women’s health behaviors, which influences poorer health outcomes. black women’s experiences with gendered racism and eating behaviors experiences with gendered racism, the intersection of sexism and racism, can serve as a chronic stressor for black women and are linked to increased psychological distress, lowered well-being, and maladaptive coping strategies (lewis, 2023; lewis et al., 2017). these encounters can also be seen via gendered racist microaggressions, which are more subtle, everyday experiences with gendered racism that contribute to the perpetuation of this form of discrimination in black women’s everyday lives (lewis & neville, 2015). gendered racism can cause black women to become hyper-cognizant of their racial and gender identities, as these discriminatory experiences make them hyperaware of the negative stereotypes often attributed to them (williams & lewis, 2021). past research has examined the relationship between experiences of gendered racism and emotional eating as mediated by the superwoman schema. they found that there was a significant relationship between gendered racial microaggressions and emotional eating. in addition to the superwoman schema and self-compassion, which mediated the relationship between gendered racial microaggressions and emotional eating (volpe et al., 2024). according to these researchers, high alignment with the superwoman schema and lower levels of self-compassion mediated the relation between gendered racial microaggressions and emotional eating. this finding suggests the vital role that such factors play in maladaptive eating behaviors in black women. while the literature has examined the relationship between gendered racism and emotional eating through the context of stereotypes, research has not yet examined how one’s alignment with one's identity as a black woman can impact maladaptive eating as a response to gendered racism. gendered racism also highlights the need for research to incorporate an intersectional lens to understand black women’s encounters with discrimination, as they cannot be defined solely by their race or gender. as a response to experiences with gendered racism, research shows that black women will turn to emotional eating, which can help to understand further the maladaptive health behaviors that black women adopt in response to the stress created by gendered and racial discrimination (diggins et al., 2015; volpe et al., 2024). though it is showcased in the literature that black women often adopt emotional eating, the current research primarily focuses on this behavior as solely a response to racism or examines racism and sexism separately (pickett et al., 2020; volpe et al., 2024). there is a lack of understanding of the intersectional impact that gendered racism has on emotional eating and other disordered eating behaviors, such as binge eating, among black women. buffering effects of gendered racial centrality while past literature has noted that stronger identification with racial identity can serve as a buffer for 21 binge eating & identity centrality in black women women’s identities should be understood in interaction with each other (collins, 2015). intersectionality theory is a framework that encompasses how a black woman’s experiences of oppression must be understood through interlocking systems of oppression. their multiple marginalized identities, such as race, gender, and class, cannot be seen as separate from each other and instead need to be understood as interlocked (crenshaw, 1989). considering the multiple forms of discrimination that black women encounter is crucial to recognizing factors that exacerbate the high prevalence of their binge eating. to understand how gendered racism contributes to black women’s adverse health outcomes, an intersectional approach to aspects of this group’s identity was utilized (collins, 2015). given the limited research on black women in the eating disorder literature, often intersectionality theory is not used to recognize how discrimination faced at the intersection of race and gender can influence one’s disordered eating (gwira, 2024). intersectionality theory (crenshaw, 1989) is a necessary framework to examine the influence of black women’s intersectional experiences of oppression on binge eating symptoms. utilizing intersectionality theory (crenshaw, 1989) can help to understand how holding multiple marginalized identities, such as being a woman and black, puts black women at greater risk for experiencing discrimination, which is associated with greater negative health outcomes (burke et al., 2020; rouhani, 2014). the intersectionality framework can support the knowledge of black women’s eating disorders, as past literature has noted how psychological distress related to their identity is linked to maladaptive coping and disordered eating behaviors (brown et al., 2022; watson et al., 2019). to best understand the multiple avenues in which discrimination negatively impacts black women’s lived experience and, in turn, their disordered eating behavior, an intersectional lens must be utilized. the literature has started to integrate intersectionality theory more in eating disorder research by considering how the intersection of black women’s identities can contribute to the recognition and treatment of binge eating (dickens et al., 2024; gwira, 2024). the researchers utilized intersectionality theory to help identify why such significant health disparities exist with black women’s disordered eating. the present study research on black women’s disordered eating beracial discrimination, much less is known about how gendered racial identity centrality can impact the experiences and impacts of discrimination on black women (sellers & shelton, 2003; syzmanski & lewis, 2016). gendered racial identity centrality entails the extent to which black women integrally define themselves by their gender and race and the degree to which these aspects of their identity are significant to their self-concept (thomas et al., 2011; thomas, 2004). moreover, past research has also found that black women who have higher levels of gendered racial identity centrality are more likely to engage in avoidance or denial of a stressor, otherwise known as disengagement coping, when experiences of gendered racism are high (szymanski & lewis, 2016). also, black women with more positive perceptions of their identities were associated with lower levels of distress (sellers & shelton, 2003; williams & lewis, 2019). few studies have explored the relationship between gendered racial identity centrality, discrimination, and mental health in black women. thus, more research needs to be conducted to examine whether gendered racial centrality can have a buffering influence on the relationship between gendered racism and adverse behaviors like binge eating. currently, little research exists to fully understand the extent to which gendered racial identity buffers against prevalent adverse mental health outcomes faced by black women, such as disordered eating. past research has examined the moderating role that gendered racial centrality has on the relationship between gendered racism and black women's psychological distress. also, the literature has explored how gendered racial identity centrality is linked to increased psychological distress in black women. dickens et al. (2023) found that gendered racial identity centrality did not moderate or decrease the relationship between gendered racism and identity shifting. similarly, behrendt-mihalski (2017) found that gendered racial identity centrality did not moderate the relationship between gendered racism and depressive symptoms in black women. to enhance disordered eating interventions for black women, it must be understood how they perceive the aspects of their identity, such as race and gender, as they relate to their lived experience and the intersections of their gendered racial identities. intersectionality theory the overarching framework for this study was intersectionality theory, which illustrates how black 22 holly & dickens health behaviors among participants between the ages of 18-35 (jones et al., 2021). this study's sample consisted of 281 women in the united states. their ages ranged from 18-35 (m = 27.29, sd = 5.78). the majority of the participants self-identified as either black or of african descent, 81.5% (n = 242), heterosexual, 81.5% (n = 242), christian, 71.0% (n = 211). for educational attainment, the highest percentage of participants had received a high school diploma/ ged, 20.9% (n = 62). the median household income for the participants was $15,000–30,000. see table 1 for more detailed demographic information. the researchers received irb approval from spelman college and chicago state university to conduct this study. a survey was administered via the web platform qualtrics, where participants completed questionnaires about their experiences with discrimination and stereotypes, coping mechanisms, and their influences on health behaviors and well-being. the qualtrics survey was distributed through online community boards for black women, social media sites, professional listservs (e.g., apa’s section 1: division 35 – black women psychologists), student organizations, and personal and professional connections (e.g., recruitment emails to personal connections, professional colleagues). the researchers also used qualtrics to further recruit a larger sample of black women. the participants not recruited via qualtrics were entered into a raffle where they could win one out of four $25 gift cards. while the participants recruited via qualtrics received $5 in compensation (an amount qualtrics established given the survey length). measures gendered racism the scheduled sexist events (sse; klonoff & landrine, 1995) was used to examine the participant's experiences with gendered racism. the scale was revised to be specific to black women’s experiences with discrimination based on their gendered racial identities. it assessed the frequency with which a woman has experienced recent racist and sexist discrimination. the scale consisted of 20 items that utilized questions related to experiences of racism and sexism from the participant’s childhood to the present. the scale had four dimensions: “(a) sexist degradation, (b) sexism in distant relationships, (c) sexism in close relationships, and (d) sexist discrimination in the workplace” (jones et al., 2021). sample items from this scale include “how havior often focuses on singular aspects of their identity, such as solely their race or their gender. however, much less is understood about how the intersections of their identities contribute to how they respond to and cope with experiences with gendered racism. thus, the researchers used intersectionality theory to guide their study on how black women’s racial and gender identities, along with the discrimination they face due to these identities, contribute to their maladaptive eating behaviors. the influence of gendered racial identity centrality on binge eating behaviors in black women and the link between experiences with gendered racism and disordered eating are imperative areas of study. it is essential to explore this topic among black women to understand why disordered eating, like binge eating, is seen at such high rates in black women. due to this, the current study aimed to examine how encounters with gendered racism are related to binge eating behaviors in black women. along with to what degree black women’s gendered-racial identity centrality moderated this relationship. the researchers hypothesized that experiences with gendered racism will positively influence the binge eating behaviors of black women (hypothesis 1). also, the researchers hypothesized that gendered racial identity centrality would moderate the relationship between gendered racism and binge eating behaviors in black women (hypothesis 2). so, higher levels of gendered racial identity centrality would buffer against the positive relationship between gendered racism and binge eating behaviors. the researchers hypothesized that lower levels of gendered racial identity centrality would be associated with a stronger influence on the relationship between gendered racism and binge eating. so, lower levels of gendered racial identity centrality would strengthen the positive relationship between gendered racism and binge eating behaviors in black women. method participants and procedure participants were recruited via social media and emails to professional and personal contacts from various areas across the united states. the eligibility criteria for this study were that participants had to identify as black/african american women and be in the 18-35 age range. the current study was part of a larger study that examined black women’s experiences with stereotypes and discrimination and their 23 binge eating & identity centrality in black women i experience strong urges to eat which i seem unable to control, but at other times i can control my eating urges,” “d. i feel incapable of controlling urges to eat. i have a fear of not being able to stop eating voluntarily.”. the average scores were taken; higher scores indicated more severe binge eating behaviors, while lower scores indicated fewer binge eating behaviors. the internal reliability score for the original bes was 0.87, while croncbach’s α for the current study was 0.91. data analysis the data from the qualtrics survey was exported to statistical package for social sciences (spss) version 24 (ibm corporation, 2016). descriptive statistics were calculated for the demographic variables, which included the percentage and frequency. preliminary correlation analyses were conducted to examine the correlations between the variables. multiple regression was performed via process macro model 1(hayes, 2017), with the bootstrapping method based on 5000 resamples to analyze the variables that influenced binge eating behaviors in black women, including gendered racism and gendered racial identity centrality. results preliminary analysis h1 proposed that gendered racism will be positively related to binge eating behaviors in black women. gendered racism was positively associated with binge eating behaviors in black women, r = .14, p < .01. therefore, h1 was supported. correlations were run to explore the relationship between all the study’s variables. the results indicated a significantly positive relationship between gendered racism and gendered racial identity centrality, r (241) = .14, p = .03. the relationship between gendered racism and binge eating was significantly positively correlated, r (241) = .28, p < .001. there was no significant correlation between gendered racial identity centrality and binge eating, r (241) = -.06, p = .32. on average, the participants rated their experiences with gendered racism as lower (m = 2.55, sd = 1.07). the mean scores indicated that with experiences with gendered racism, participants, on average, answered either “once in a while” or “sometimes” as their responses for the gendered racism items. participants reported higher than average ratings for their gendered racial identity centrality (m = 5.05, sd = 1.20). most participants rated “slightly agree” for their responses to the gendered racial identity centralimany times were you denied a raise, a promotion, tenure, a good assistant, a job, or other such things, at work that you deserved because you are a black woman?” and “how many times have you been treated unfairly by strangers because you are a black woman?”. the sse was rated on a six -point likert scale where participant's responses to the items ranged between one (never) and six (all the time). the scores of each item were averaged, and higher scores indicated that participants experienced more encounters with gendered racism and lower scores suggested that participants had fewer experiences with gendered racism. for past studies, the reliability scores for the original sse-lifetime sample by klonoff & landrine (1995) scored 0.92, and the revised scale had a reliability score of 0.93 (thomas et al., 2008). the croncbach’s α for the current study was 0.95. gendered racial identity centrality the researchers assessed gendered racial identity centrality using the multidimensional inventory of black identity centrality subscale (mibicentrality; sellers et al., 1997), modified to measure gendered racial identity centrality. the scale contained ten items on a seven-point likert scale where responses ranged from one (strongly disagree) to seven (strongly agree). sample items were “i have a strong sense of belonging to black women” and “being a black woman is an important reflection of who i am”. average scores were taken where higher scores indicated greater feelings that one’s gender and race were central to their overall identity and lower scores denoted participants who felt that their gender and race were less central to their overall identity. jones et al. (2021) reported the scores from the mibi-centrality scale and had internal consistency scores of 0.76, while croncbach’s α for the current study was 0.77. binge eating symptoms the binge eating scale (bes; gormally et al., 1982) was utilized to examine binge eating behaviors in the participants. the bes consists of 16 items that examine eating behaviors, such as the quantity of food consumed and feelings after eating. participants were given three or four selections and were asked to choose whichever best fit their eating behaviors with varying severities. a sample item reads, “a. i usually am able to stop eating when i want to. i know when “enough is enough,” “b. every so often, i experience a compulsion to eat which i can’t seem to control,” “c. frequently, 24 holly & dickens behaviors. biases among healthcare providers prevent them from accurately inquiring about, detecting, or understanding eating disorders in black women (goode et al., 2022; marques et al., 2011). the lack of proper diagnosis, treatment, and care for this marginalized group highlights the need for an intersectional approach to the examination of black women’s experiences with disordered eating. past research has examined how race or gender impacts black women’s maladaptive behaviors (mccoy & major, 2003; syzmanski & lewis, 2016). however, such factors were examined separately from each other rather than looking at the intersection of racism and sexism. the purpose of the present study was to investigate the relationship between gendered racism and binge eating behaviors in black women, as well as to analyze the moderating influence that gendered racial identity centrality has on this relationship. the current study, along with previous research, highlights a need to understand the factors that impact black women’s maladaptive eating behaviors to understand better the risk factors that lead them to engage in binge eating (pickett et al., 2020; volpe et al., 2024). past research has examined how racism or sexism separately influence the eating behaviors of black women as a coping mechanism but seldom have researchers analyzed how gendered racism can influence the relationship between gendered racism and binge eating in black women. the researchers adopted an intersectional framework in their methodology to highlight the interrelated nature of black women’s experiences of oppression. we examined how the interaction of race and gender identities, in addition to the prejudice they face, can serve as either a protective or risk factor for black women’s binge eating. gendered racism and binge eating consistent with hypothesis 1, there was a significant positive relationship between gendered racism and binge eating. such that participants who had more experiences with gendered racism were associated with higher binge eating behaviors. intersectionality theory exemplifies the need to understand the factors that contribute to and influence black women’s disordered eating behaviors. to understand the factors that influence how black women respond to discriminatory experiences, their multiple marginalized identities must be examined as they relate to and interact with each other. this finding is consistent with previous ty items. for binge eating behaviors, participants rated lower levels (m = 1.07, sd = .55). on average, participants answered the items about binge eating with responses that correlated with low binge eating behaviors. moderators of binge eating behaviors the hypothesized moderated model was tested using moderation analysis via process macro model 1. h2 stated that the influence of gendered racism on binge eating behaviors for black women would be moderated by gender-racial identity centrality. before the analyses, variables were mean-centered to lessen multicollinearity (aiken & west, 1991). predictor variables accounted for a significant amount of variance in binge eating, r2 = .10, f (3, 237) = 9.05, p < .001. then, we examined whether the relationship between gendered racism and binge eating in black women was moderated by gendered-race identity centrality (see figure 1). the interaction term was significant, b = -.05, p < 0.05. therefore, h2 was partially supported. next, we conducted simple slope analyses and probed interactions. when gendered racial identity centrality was low (b = .20, p < 0.001) and medium (b = .14, p < 0.001), gendered racism was associated with higher levels of binge eating in black women. however, when gendered racial centrality was high, this relationship was nonsignificant (b = 07, p = .15). therefore, lower levels of gendered racial centrality amplify the influence of gendered racism on binge eating behaviors in black women. h2 was partially supported. the researchers hypothesized that lower levels of gendered racial identity centrality would moderate the relationship between gendered racism and binge eating. their hypothesis was supported at low levels for gendered racial identity centrality. the researchers hypothesized that high levels of gendered racial identity centrality would have a buffering influence on the positive relationship between gendered racism and binge eating in black women. instead, the relationship was not significant. discussion the literature has yet to examine how black women’s experiences with their gendered racial identity and gendered racism influence their maladaptive eating, such as binge eating. the current study adds to the dearth of research that exists on disordered eating in black women. disparities exist for healthcare interventions on black women’s disordered eating 25 binge eating & identity centrality in black women the intersection of racial and gender discrimination influenced black women’s binge eating as well as how their identity centrality related to this connection. gendered racial identity centrality black women’s use of disordered eating has seldom been researched via the influence of their gendered racial identity. gendered racial identity centrality has been linked to research that suggests it can be a buffer or amplifier of the negative impact of discrimination (jones et al., 2021; thomas et al., 2011). consistent with the hypothesis, gendered-racial identity centrality moderated the relationship between gendered racism and binge eating. while gendered-racial identity centrality was a moderator, the influence was not in the direction that the researchers hypothesized. only for participants who reported low or medium gendered-racial identity centrality, gendered racism was associated with higher levels of binge eating in black women. however, participants with high levels of gendered racial identity centrality produced a non-significant moderating influence between gendered racism and binge eating. thus, hypothesis 2 was supported in the opposite direction than they hypothesized. the researchers speculated that higher levels of gendered racial identity centrality would buffer the relationship. it may be that lower levels of gendered racial identity centrality have a much more significant impact because it makes individuals vulnerable to more discriminatory experiences. still, this is consistent with the overarching framework of the intersectionality theory. the researchers believed that black women with lower gendered racial centrality are more prone to the adverse effects of gendered racism, which can lead to binge eating. the current findings about high gendered racial identity centrality are inconsistent with previous research, as the researchers found a nonsignificant moderating relationship between gendered racism and binge eating behaviors. symanski & lewis (2016) examined the moderating effect that identity centrality had on detachment coping and the psychological distress formed in response to gendered racism. they found that when identity centrality was high, gendered racism predicted psychological distress. the researchers hypothesized that a higher gendered racial identity centrality would serve as a buffer against the positive relationship between gendered racism and binge eating. the literature on black women’s gendered racial identity centrality found it to be a research, which found that higher levels of discrimination based on one’s gendered racial identity led to greater utilization of disordered eating behaviors, such as emotional eating, as a maladaptive coping response (diggins et al., 2015; hoggard et al., 2019; volpe et al., 2024). in alignment with the intersectionality theory (crenshaw, 1989) and given the negative impacts of the intersections of oppression, such as gendered racism, black women’s experiences with discrimination based on race and gender and their interactions exacerbate their issues with health and well-being. since the researchers focused on gendered racism, it allowed them to see this relationship at the intersection of racism and sexism and binge eating behaviors in black women. binge eating in black women has been associated with worsened physical health and a higher risk of being overweight or obese, as more than 30% of black women with obesity also report binge eating (goode et al., 2020; wilson et al., 2012). binge eating disorder has also been found to be comorbid with several somatic and psychiatric disorders, such as mood disorders and substance use disorders, along with obesity (goode et al., 2020; hudson et al., 2010). thus, furthering the understanding of the factors, such as gendered racism, that contribute to black women’s binge eating behaviors is imperative for adequately tackling the health care issues that they face. research has been conducted to identify aspects of maladaptive eating treatment that can be beneficial for black women. such treatments are based on culturally competent care that recognizes black women as a population that has unique factors that influence their binge eating behaviors. past research has found that interventions conducted in a group using cognitive-behavioral therapy can be effective. these interventions address the dysfunctional cognitions and maladaptive behaviors associated with binge eating to create an impactful intervention for bed in black women (goode et al., 2020;2022; q da luz et al., 2021). along with this, interventions that tackle the physical health of black women have been supported by researchers to be effective interventions. these approaches educate black women to be aware of their eating behaviors and increase their physical activity (goode et al., 2018;2022). intersectionality theory was integral for the researchers of this study as it allowed them to investigate the relationship between gendered racism and binge eating among black women. the theory illuminated how 26 holly & dickens major life events, can put older women at increased risk for disordered eating (koumoutzis & cichy, 2020). thus, the relationship between gendered racism and binge eating, as well as the moderating influence of identity centrality, could be higher if the participants of the study were older. such research highlights the need to understand the factors that contribute to the increase in depressive symptoms from middle age to older age. also, participants had lower levels of binge eating overall, so the results might differ in individuals who, on average, have higher levels of binge eating behaviors. for older black women with higher levels of binge eating behaviors, identity centrality could have an even more significant moderating influence. identity centrality in older populations possibly would lessen the strength of the relationship between gendered racism and binge eating. moreover, the researchers recognize further limitations of this study due to their use of a survey, which could lead to social desirability bias when answering questions about binge eating. participants may have felt less comfortable being truthful about their binge eating behaviors due to stigma towards eating disorders and maladaptive eating behaviors. stigmatization related to engaging in binge eating behaviors may have led participants to report lower scores that are less representative of their behavior. this may lessen the significance of the data on the relationship between gendered racism, identity centrality, and binge eating in black women. future directions these findings are imperative for understanding how to make culturally relevant disordered eating interventions for black women. as many healthcare professionals do not have the proper knowledge of how maladaptive eating behaviors manifest for black women, they often overlook black women who could benefit from disordered eating treatment and care (goode et al., 2022; marques et al., 2011). the current study and previous research are critical for equipping healthcare providers with the knowledge to best approach and care for their black women patients. providers must approach their black women patients with an understanding of how disordered eating can manifest for them. such an understanding is necessary for providing black women with the proper diagnosis, care, and treatment they need for their maladaptive eating behaviors. an understanding of how black women center their gendered racial significant moderator in the relationship between factors related to gendered racism and coping. yet, the findings are mixed regarding whether it serves as a buffer (lewis et al., 2017; williams & lewis, 2019). past research has found that lower levels of gendered racial identity centrality are linked to higher usage of disengagement coping and poor mental and physical health outcomes, which is consistent with this study’s results (williams & lewis, 2019; lewis et al., 2017). the finding that high gendered racial identity centrality did not serve as a moderator is inconsistent with past research that has found it to be associated with lower levels of distress (sellers & shelton, 2003; williams & lewis, 2019). based on the literature, there are mixed findings on the influence of gendered racial centrality as a buffer or harmful factor with experiences of discrimination among black women (jones et al., 2021; symanski & lewis, 2016). also, given that the sample of participants had a moderate level of gendered racial centrality, such that being a black woman was somewhat important to their overall sense of self, this might have influenced the effect of the relationship between gendered racism and binge eating behaviors. more research needs to be done on the moderating influences of identity centrality on black women to understand this relationship better. such contrasts in the study of high identity centrality demonstrate the need for a further examination of the influence that high identity centrality has on black women’s experiences with distress. limitations while the researchers were able to find significant results from this study regarding black women’s binge eating behaviors as it relates to their identity, there were some limitations. the majority of the participants were younger, identified as christian, and with more than half having an associate’s degree or higher. thus, the participants of this study may be less representative of the population. the age of the participants was relatively younger than that of the broader population; thus, it is less generalizable to the greater public. much like black women, older populations are much less regarded in eating disorder research. hence, a lack of understanding exists about the age-related factors that can influence the maladaptive eating behaviors of older people. in the literature, researchers have found that psychosocial stressors, as well as stressors associated with 27 binge eating & identity centrality in black women group from receiving eating disorder treatment. such barriers for black women include a lack of recognition of their engagement in disordered eating behaviors. these women may not have adequate knowledge of disordered eating to detect their use of maladaptive behaviors, considering the stereotype that eating disorders primarily impact white women (good et al., 2022; scott et al., 2023). as shown by past research, the high rates of eating disorders, such as binge eating, in black women warrant a need to create approaches that allow them to receive proper diagnosis, care, and treatment for their disordered eating behaviors. references arnow, b., kenardy, j., & agras, w. s. 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(2024). black young adult superwomen in the face of gendered racial microaggressions: contextualizing challenges with acceptance and avoidance and emotional eating. annals of behavioral medicine, 58(5), 305-313. https://doi. org/10.1093/abm/kaae017 wilfley, d. e., pike, k. m., dohm, f. a., striegel-moore, r. h., & fairburn, c. g. (2001). bias in binge eating disorder: how representative are recruited clinic samples?. journal of consulting and clinical psychology, 69(3), 383. https://doi. org/10.1037/0022006x.69.3.383 watson, l. b., lewis, j. a., & moody, a. t. (2019). a sociocultural examination of body image among black women. body image, 31, 280–287. 30 holly & dickens https://doi.org/10.1016/j.bodyim.2019.03.008 williams, m. g., & lewis, j. a. (2021). developing a conceptual framework of black women’s gendered racial identity development. psychology of women quarterly, 45(2), 212-228. https://doi. org/10.1177/0361684320988602 williams, m. g., & lewis, j. a. (2019). gendered racial microaggressions and depressive symptoms among black women: a moderated mediation model. psychology of women quarterly, 43(3), 368-380. https://doi.org/10.1177/0361684319832511 31 binge eating & identity centrality in black women table 1 sociodemographic characteristics of participants note. n (%), m, and sd represent the number of participants, mean, and standard deviation, respectively. 32 holly & dickens figure. 1 this figure illustrates the relationships between low (-1 sd), medium (average), and high (+1 sd) levels of gendered racism and binge eating symptoms at low (-1 sd), medium (average), and high (+1 sd) levels of gendered racial identity centrality. statistically significant values (p < .001) were denoted with **. figure 1. interaction between gendered racism and binge eating symptoms in black women questionnaires can be made available upon request. 59 graduate student journal of psychology fall 2024 vol. 23 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university effects of absorption training on positive activity experiences for individuals with anhedonia: a single case series angelica tong & ed watkins department of psychology, university of exeter, exeter, united kingdom ‘a good life is characterised by complete absorption of what one does’ (nakamura & csikszentmihalyi, 2009, p.195). studies have suggested that being fully absorbed in activities is crucial to well-being and happiness (csikszentmihalyi, 1990; nakamura & csikszentmihalyi, 2009; tse et al., 2020). specifically, the inability to be absorbed in pleasurable activities seems to prevent people from enjoying the associated benefits such as improving one’s positive mood (killingsworth & gilbert, 2010; lambert & csikszentmihalyi, 2020; watkins, 2016). for instance, killingsworth and gilbert (2010) found that individuals reported being less happy when their minds wandered regardless of how enjoyable the activities were. furthermore, previous studies also raised the possibility that increased absorption in activities may counter rumination (hvenegaard et al., 2019; watkins et al., 2011; watkins et al., 2012) which may interfere with an individual’s ability to experience pleasure and rewards from positive activities (watkins, 2016). this study sets out to explore the effects of absorption training (at), a component of rumination-focused cognitive behavioural therapy (rfcbt), which aims to increase absorption, in improving the experiences of positive activities in terms of positive affect and rumination among individuals with anhedonia, as suggested by the literature. absorption and positive affect one potential benefit of increased absorption is improving positive affect (pa) gained from activities (asakawa, 2004; collin et al., 2008; fullagar & kelloway, 2009; rogatko, 2007; tse et al., 2020). absorption is conceptualised as a flow experience that is associated with positive experiences and affect (norsworthy et al., 2021). flow, introduced by csikszentmihalyi (1975), refers to a state of deep absorption in an activity (csikszentmihalyi, 1999). this absorbing state is characterised by nine components such as simultaneous feelings of action-awareness merging, time transformation, complete concentration, a sense of control, a loss of self-consciousness, and an intrinsically rewarding experience (csikszentmihalyi, 1990; nakamura & csikszentmihalyi, 2009). furthermore, individuals possessing traits like curiosity and persistence may have higher tendencies to experience flow (csikszentmihalyi, 1990; nakamura & csikszentmihalyi, 2009). according to csikszentmihalyi (1990), through repeated experiences of flow from positive activities providing potential for growth such as sports or work, people’s happiness and life satisfaction would increase (csikszentmihalyi, 1999). this association between flow and pa is supported by empirical studies (asakawa, 2004; collin et al., 2008; fullagar & kelloway, 2009; rogatko, 2007; tse et al., 2020). in asakawa’s (2004) experience-sampling study (ess) of japanese undergraduates’ experiences of daily activities, participants’ levels of pa, such as enjoyment, were the highest in the flow condition compared to feeling relaxed or apathetic. similarly, more intense daily flow experiences were associated with higher daily pa in a diary study of us adults (collins et al., 2008). however, it is worth noting that the causal relationship between flow and pa is not strongly established since most studies on the two are correlational (asakawa, 2004; collin et al., 2008; tse et al., 2020). existing literature has suggested an association between being absorbed in activities and improved experience in activities in terms of better mood gain and reducing rumination. this single-case series aimed to collect methodological information and preliminary data for future trials regarding the effects of absorption training; a rumination-focused cbt component, on improving positive activity experiences among individuals with anhedonia using a multiple baseline design (n=16). there were no significant effects of absorption training found regarding the level of absorption, positive affect, and rumination during the positive activities which might be due to high baselines, limiting the effects of intervention. the effect sizes indicated that absorption training might have larger effects on improving absorption and reducing rumination than increasing positive affect during activities. in terms of suggestions for methodology, future clinical trials should target participants with higher levels of anhedonia using a larger and homogenous sample and provide higher-intensity training. it is also worth exploring whether absorption training has larger effects on specific types of populations such as clinically depressed individuals. keywords: absorption training, rumination-focused cbt, absorption, positive activities, rumination 60 nevertheless, there is some indirect evidence regarding the causal relationship between flow and pa (fullagar & kelloway, 2009; rogatko, 2007). for instance, the experimental study by rogatko (2007) found that participants’ levels of pa were higher after conducting high-flow than low-flow-inducing activities, yet, since flow and pa were measured simultaneously after the activities, the study could not conclude their temporal relationship. an ess on architectural students doing studio work also found a positive association between the two and importantly, its time-lag analysis suggested flow preceded the changes in affect (fullagar & kelloway, 2009). though more direct evidence regarding the causal relationship is required, these studies provide support that interventions that can increase absorption in positive activities may increase pa gain. absorption and rumination in addition to increasing pa, increased absorption may also reduce maladaptive rumination (watkins et al., 2011; watkins et al., 2012; watkins, 2016). rumination has been suggested as both a state response (martin & tesser, 1996) and a trait-like tendency (nolenhoeksema, 1991) while maladaptive state rumination (msr) is defined as the momentary thoughts of focusing on implications and causes of one’s distress (marchetti et al., 2018; nolen-hoeksema et al., 2008). through repeated occurrences of goal discrepancies, msr may develop into a habitual tendency of depressive rumination (watkins & nolen-hoeksema, 2014) which is suggested as a transdiagnostic process of multiple mental disorders (ehring & watkins, 2008; nolen-hoeksema, 2000; nolen-hoeksema et al., 2008; nolen-hoeksema & watkins, 2011; watkins, 2008). furthermore, maladaptive rumination may interfere with the ability to experience rewards from positive activities and contribute to anhedonia (watkins, 2016), the reduced ability to experience pleasure in normally pleasurable activities (american psychiatric association, 2013). these hypothesised effects are supported by existing findings where the negative perception of feedback on one’s performance might reduce flow level and its associated benefits such as better performance (lambert & csikszentmihalyi, 2020). similarly, negative mind-wandering was associated with reduced pleasure while doing pleasurable activities (killingsworth & gilbert, 2010). encouragingly, increased absorption in activities is suggested to counter maladaptive rumination based on several theoretical principles (watkins, 2016). first, it may shift the abstract processing style characteristic of depressive rumination to a more process-focused and concrete mindset (dykman, 1998; watkins, 2008, 2016; watkins & roberts, 2020). additionally, being more immersed and connected in positive activities may counter rumination such as running commentaries that evaluate one’s performance in mind and enhance individuals’ ability to experience pleasure and rewards from the activities (watkins, 2016). these theories support the hypothesis that interventions that increase absorption may reduce rumination during activities. however, it is important to note that these proposed effects have not yet been examined. absorption training absorption training, a component of rfcbt, was developed based on the theoretical and empirical evidence in the literature regarding the association between increased absorption on improving pa and reducing maladaptive rumination. rfcbt is a treatment for residual depression by targeting depressive rumination in which absorption is conceptualised as a flow experience (watkins, 2016). specifically, at involves a mental imagery exercise of using a memory of being absorbed in activities to help individuals recapture the experience of being in an absorbed state of mind. through daily practice, it aims to help participants activate the absorbed mindset more easily during positive activities (watkins, 2016). it is suggested that by doing more positive activities with an absorbed state of mind, the training can reduce rumination by facilitating a shift to a more helpful absorbed mindset and counter the running commentary that evaluates one’s performance during activities (watkins, 2016). moreover, it may also help individuals improve their pa by better connecting them with the experiences and rewards of positive activities (watkins, 2016) based on the suggested association between flow and pa in existing research. nevertheless, these proposed effects of at on absorption, pa, and rumination are yet to be examined. there is indirect evidence of its effects on rumination where previous trials demonstrated that rfcbt has been effective in reducing depressive rumination (hvenegaard et al., 2019; watkins et al., 2011; watkins et al., 2012). yet, these trials did not examine at as an isolated component (hvenegaard et al., 2019; watkins et al., 2011) and its effects on improving individuals’ tong & watkins 61 absorption training, positive activities days (tanious & onghena, 2019). the changes in the three variables after the introduction of at will then be examined. as a preliminary study with resource constraints, a single-case experimental design (sced) allows detailed and individualised data to be collected with fewer resources, such as not requiring a control group. (morley et al., 2015; tanious & onghena, 2019). furthermore, by evaluating the intervention effects across multiple participants concurrently within the same general period with the intervention being introduced at various time points, the mbd can increase the likelihood that the changes in the three variables are due to the effects of at instead of factors such as history, cohort effect, and regression to mean (morley et al., 2015; onghena, 2020). additionally, participants’ tendencies to experience pleasure, flow, and maladaptive rumination will be measured. method participants forty-one individuals were recruited through the university of exeter research platform, sona, (n=16), and snowball sampling on the messaging platform – whatsapp (n=25). inclusion criteria included individuals aged 18 or above in the uk with access to electronic devices and reporting at least mild levels of anhedonia by scoring 1 or above on the snaith-hamilton pleasure scale (snaith et al., 1995). twenty-five individuals were found eligible after screening and four were unvailable during the study, yielding a final sample of twenty-one participants. five participants were excluded from the data analysis since four were unable to carry out the planned activities three times per week and one reported having issues with at, discontining practice. the remaining 16 participants were included in the analysis. see table 1 for participants’ demographic details. all participants provided written informed consent and received reimbursement of £30 amazon voucher upon completing the study. the study was approved by the university of exeter psychology research ethics committee. design the single case series aimed to explore the effects of absorption training on the experiences of positive activities in terms of absorption, positive affect, and maladaptive state rumination for individuals with anhedonia. a multiple baseline design was employed with participants randomly assigned by an experiences of positive activities have not been tested. previous studies have found that concrete mental imageries of positive memories may increase positive mood (werner-seidler & moulds, 2012), and cognitive training using positive mental imageries may reduce anhedonia in daily activities among depressed individuals (blackwell et al., 2015). it is yet to be examined whether mental imagery of an absorbing memory can induce an absorbed mindset in positive activities in the present and thus improve the experiences. hence, studies examining at as an isolated component are needed to better understand such effects (hvenegaard et al., 2019; watkins et al., 2011). additionally, experimental methodological information is required for examining at’s effects in future clinical trials. current study the study will explore the effects of absorption training. its first aim is to use a single case series (scs) to explore the effects of absorption training in improving individuals’ experiences of positive activities based on their levels of absorption (flow), positive affect, and maladaptive state rumination. specifically, this study targets individuals with anhedonia and examines at’s effects on their experiences of positive activities. the second aim is to collect methodological information for designing future clinical trials. the hypotheses are as follows: participants’ level of absorption while completing their selected activities will be higher after the introduction of at compared to baseline (h1). based on the association between increased absorption on pa and rumination (asakawa, 2004; csikszentmihalyi, 1990; watkins, 2016), it is also hypothesised that while conducting at, participants will gain more pa from doing their selected activities (h2) and their levels of msr in selected activities will decrease (h3). to explore these, this scs will adopt a multiple baseline design (mbd) to evaluate at’s effects on each participant individually. mbd involves using a baseline period as a control for each individual and introducing intervention at varying baseline lengths. the intervention effects are then explored within the individual and across the participants (morley et al., 2015). specifically, this study will take repeated daily measurements of participants’ levels of absorption, pa, and msr in positive activities during the baseline and at phases and introduce at to the participants at varying lengths of baseline from seven to fourteen 62 tong & watkins algorithm using their assigned anonymized participant identifier to varying baseline lengths ranging from 1 to 2 weeks before conducting the at which lasted for 7 to 14 days. the baseline lengths allowed sufficient time for obtaining a stable baseline which can minimize the effects of confounds such as maturation (carr, 2005), and sufficient data to explore intervention effects where participants conducted their chosen activities for a minimum of three times in both the baseline and intervention periods. materials and measures screening and dispositional measures individuals who were interested in joining the study completed the screening measure in the online survey during recruitment. the dispositional measures (dispositional flow scale – 2 and ruminative response scale – short form) were sent to eligible individuals via email. participants were required to complete the dispositional measures either before or during the first meeting with the researchers. snaith-hamilton pleasure scale (shaps; snaith et al., 1995). the shaps is a 14-item self-report measure of the ability to experience pleasure (e.g., i would find pleasure in my hobbies and pastimes) using a 4-point scale (0 disagree to 3 strongly agree). higher total scores indicate lower tendencies to experience pleasure (range 0 to 14). the scale has shown good criterion validity and satisfactory internal reliability, yielding a kuder-richardson score of 0.857 (snaith et al., 1995). it was used as a screening measure to include individuals reporting elevated levels of anhedonia (scored 1 or above). dispositional flow scale – 2 short form (dfs-2 sf; jackson et al., 2008). the dfs-2 sf is a 9-item self-report instrument that assesses the tendency of experiencing flow in a target activity (e.g., i am completely focused on the task at hand) using a likert scale from 1(never) to 5 (always). the scale has shown acceptable internal consistency (α=.77) and good construct and divergent validities (jackson et al., 2008). its instruction was modified in this study to target frequencies of flow experiences in ‘all daily activities’ instead of in a specific activity. ruminative response scale – short form (rrs-sf; treynor et al., 2003). the rrs-sf is a 10item, 4-point likert scale (1 almost never to 4 almost always) self-report measure of ruminative tendencies in response to sad and depressive moods. higher total scores suggest higher tendencies to ruminate (range 10 to 40). it has two subscales – brooding and reflection with brooding suggested as the most pathological rumination (treynor et al., 2003). hence, five items from the brooding subscale which has shown satisfactory internal consistency (α=.77) (treynor et al., 2003) were administered at the start of the study (e.g., when you feel sad, down, or depressed, how often do you think “why can’t i handle things better?”) to assess participants’ maladaptive ruminative tendency. daily survey throughout the 21-day study, participants were prompted to complete a daily survey once via email or text messages at their preferred time before midnight with questions assessing their levels of absorption, pa, and msr in positive activities stemming from the validated scales below. flow state scale. the 36-item, 5-point likert scale (1 strongly disagree to 5 -strongly agree), flow state scale (fss; jackson & marsh, 1996) is a self-report instrument that assesses the situational-specific experience of flow with a satisfactory internal consistency reported (α =.83) ( jackson & marsh, 1996). six items from the fss (e.g., ‘when doing the activity, time seemed to alter ‘either slowed down or speeded up’) measuring absorption-related dimensions complete concentration, time distortion, loss of self-consciousness, action-awareness merging, autotelic experience (norsworthy et al., 2021) were included in the daily survey to assess at’s effects on participants’ levels of absorption in activities. positive affect. the impacts of at on participants’ pa in activities were assessed by the item ‘doing this activity improved my positive mood’ using a likert scale from 1 (strongly disagree) to 5 (strongly agree). brief state rumination inventory. the brief state rumination inventory (bsri; marchetti et al., 2018) is an eight-item self-report measure of msr in response to negative mood using a visual analogue scale from 0 (completely disagree) to 100 (completely agree). higher total scores represent higher degrees of msr (range from 0 to 800). it has shown high internal consistency (α=.91) and good construct and criterion validities (marchetti et al., 2018). five items that correlate positively with the rrs brooding subscale (treynor et al., 2003) were included in the daily survey (e.g., ‘when doing the activity, it is hard for me to shut off negative thoughts about myself ’) to assess whether 63 at can reduce participants’ level of msr in activities. activities planning during the first meeting, participants were guided to select a positive activity to undertake during the study. specifically, they were first guided to consider a few suitable positive activities. the selection criteria are any activities (1) that they found positive, (2) they could get absorbed in doing, (3) they enjoy doing the activities and would like to do more of them and (4) they could get distracted sometimes and found it hard to engage in the activities. they then selected one planned activity they would like to undertake three times per week and scheduled the time to do it during the study. absorption training the at was tailored to the participants’ planned activities with a training session followed by daily practices. first, a training session guided by the at manual was conducted where participants were first guided to identify a memory of being absorbed in the planned activity according to the flow criteria (csikszentmihalyi, 1990). participants were then prompted to imagine themselves in the memory and describe their sensory-perceptual experiences, such as body sensations, smell, and sounds. next, a mental imagery exercise was conducted to help participants recreate that absorbing experience with the researcher prompting them to recapture the sensory-perceptual experience using the participants’ descriptions of the experience. the exercise was recorded while being conducted. after the exercise, the researcher checked whether the participants had a positive experience by asking about their feelings or levels of energy. participants were then instructed to conduct and schedule the daily practice. following the session, participants received the audio recordings of the exercise via email or text messages and practiced activating the absorbed mindset by listening to the audio recordings daily. procedure the study targeted individuals who wanted to improve their engagement and performance in activities that they enjoy by advertising on sona or whatsapp. individuals interested in participating clicked on the sona or whatsapp link, directing them to an online survey. in the survey, participants first read an information sheet about the study and were told it would investigate whether a mental strategy can improve their moods and performance in pleasurable activities. those who gave their informed consent to participate could continue with the survey. they then completed the screening measure and were instructed to create their anonymized identifier at the end of the survey. individuals eligible for the study were later contacted within 48 hours via email or text messages with the link to the baseline measures and arranged a meeting with the researchers. individuals not eligible were notified and received a debriefing form via email. the participant identifiers of the eligible individuals were sent to the research supervisor via email and were allocated to various baseline lengths using an algorithm by the research supervisor. the researchers were then notified of the randomization results via email. during the 21-day study, participants completed three meetings with the researchers via video conferencing to encourage participation throughout the study and allow the researchers to make adjustments promptly if participants raised any concerns regarding conducting the planned activities and at during subsequent meetings. in the first meeting, participants first completed the baseline measures on dispositional flow, trait rumination, and demographic questions followed by an explanation of the study’s requirements by researchers and activity planning. following the meeting, participants conducted the planned activities a few times per week and recorded their experiences over the 21 days by completing a daily survey as instructed. participants received the link to the survey once on the online survey tool, qualtrics, via email or text messages daily at their preferred times and completed it before midnight. following the baseline period ranging from 1 to 2 weeks, a second meeting was arranged where at was introduced. afterward, participants practiced at daily alongside doing the planned activities and the daily survey until the third meeting. at the end of the study, a third meeting was conducted to review the effects of at and debrief the participants. lastly, participants received the reimbursement (£30 vouchers) via email. data analysis visual analysis of participants’ data on graphical plots (morley, 2015) and statistical analyses using the rcmdrplugin.scda plug-in package for r software (bulté & onghena, 2013) was performed. to determine the statistical significance of the results, a non-parametric significance test – randomization test (rt), which requires arrangements of intervention being randomized, was used since repeated absorption training, positive activities 64 tong & watkins measurements of each participant in sced might result in autocorrelation and violate parametric assumptions (heyvaert & onghena, 2014; tanious & onghena, 2019). rt was performed for each participant to obtain the individual p-value for at’s effects on absorption, pa, and msr. the combined p-values were computed from the meta-analyses of individual p-values using pearson's method (1934) (bulté & onghena, 2013). regarding effect sizes calculation, the non-parametric effect size index – percentage of data exceeding the median (pem) which calculates the proportion of data points during the at phase that exceeds the median of baseline data (ma, 2006) was used for computing individual effect sizes for the three variables. pem smaller than 0.7, between 0.7 and 0.89, and between 0.9 and 1, represent questionable, moderate, and high effectiveness (ma, 2006). the overall effect sizes were computed by taking the average of all individual effect sizes. data of participants who did not complete the planned activities and surveys at least three times in both the baseline and intervention periods and did not conduct at during the intervention period at least three times were excluded from the data analysis. results statistical analysis: randomization test and effect size calculations a non-parametric significance test – rt (tanious & onghena, 2019) was used to examine whether at can increase participants’ levels of absorption and pa and reduce their level of msr in the planned activities. the effect sizes regarding the three outcomes were calculated using the index – pem (ma, 2006). the results showed that there were mean increases in absorption (0.38 points) and pa (0.35 points) and decreases in msr (-30.29 points) after the introduction of at among the participants. medium effect sizes were found for the changes in absorption (79.70%) and msr (77.06%) and a small effect size was found for pa (49.75%) (table 2). however, the rt indicated that the changes were not significant (p > 0.05). regarding the effects of at on non-planned activities, only three participants conducted the nonplanned activities at least twice in both baseline and at phases. the amount of data collected was limited for conducting a significant statistical analysis. visual analysis the impacts of at on participants’ experiences of positive activities in this scs was also examined by visual inspection of the multiple-baseline data in graphical plots concerning the changes in level and trend (morley, 2015) of absorption, pa, and msr while doing positive activities across the baseline and at phases. data representing the daily scores reported by each participant regarding the three variables during the planned and non-planned activities are presented in figures 1, 2, and 3 respectively. regarding the change in absorption, the daily scores reported for most of the baseline periods were stable. seven participants showed an increase in absorption after the introduction of at and four exhibited a slight upward trend continuously. however, the scores of nine participants reflected no change during the at phase. regarding the change in pa, most baseline periods were stable while one participant showed a pattern of decrease. three participants showed an increase in pa gained after the introduction of at while one continued to show an upward trend; the level of pa remained stable for the other two participants during the at phase. five participants showed no change and conclusions could not be drawn for seven participants due to unstable scores across both phases. one participant’s level of pa decreased contrary to the hypothesis. regarding the change in msr, most of the baseline scores were stable or decreasing. after the introduction of at, three participants exhibited decreases in msr levels compared to baseline. ten participants showed no obvious change during the at phase. conclusions cannot be drawn for three participants due to unstable scores across both phases. the visual inspection results were consistent with the rt results for each individual, indicating that there were no significant effects of at on the three variables shown. dispositional tendencies participants reported tendencies to experience flow, pleasure, and rumination. participants reported moderate tendencies to experience flow (mean: 2.84, sd: 0.58). the tendencies to experience pleasure (scores ranging from 1 to 14) and rumination (scores ranging from 8 to 20) varied across participants (table 3). discussion to our knowledge, this single case series is the first to explore the effects of absorption training on 65 improving the experiences of positive activities among individuals with mild levels of anhedonia. this preliminary study also aimed to collect methodology information for future clinical trials. it is hypothesized that at can improve absorption and positive affect and reduce maladaptive state rumination experienced during the planned positive activities. although there were expected increases in absorption and pa and a decrease in msr shown after at was introduced, the results indicated that the effects of at were not significant. absorption analyses did not show a strong effect of at on increasing participants’ absorption levels during planned activities. this contrasts with the proposed effects of at where by practicing getting into the absorbed state daily using a mental imagery exercise of an absorbing memory, individuals will be more likely to activate an absorbed mindset during activities (watkins, 2016). methodological issues could have contributed to the results, such as participants reporting fairly positive experiences in the planned activities and varied levels of anhedonia at baseline, and the effectiveness of training sessions and daily practice were not monitored. methodological issues will be discussed further in later sections. moreover, the medium effect size found for changes in absorption could mean that a larger effect may be found in larger samples. positive affect questionable effects of at on improving pa gained from doing the planned activities were also indicated by the results. another proposed effect of at is that by better connecting individuals with the experiences and rewards of positive activities and improving their abilities to experience pleasure with increased absorption, there will be improved positive mood gain (watkins, 2016). the proposed effect is supported by previous findings demonstrating individuals’ pa increased during flow despite their causal relationship not being strongly established (asakawa, 2004; collin et al., 2008; fullagar & kelloway, 2009; rogatko, 2007; tse et al., 2020). the study’s results could be due to the negligible increase in absorption among participants after the introduction of at being insufficient to improve participants’ pa. furthermore, only a small effect size was found which may be explained by only one item being used to measure the changes in pa. single-item measures could be more prone to random error and are less able to capture different facets of pa (sarstedt & wilczynski., 2009). moreover, nine participants reported a median of four on the item’s 5-point scale at baseline meaning only reporting the highest point of the survey during the at phase would pass the thresholds for effect size calculations. to address these issues, future studies could use multiple-item measurements such as the positive and negative affect schedule scale (watson et al., 1988) which measures different types of pa and has shown high sensitivity to momentary fluctuations of mood (watson et al., 1988). maladaptive state rumination similarly, no particular effects of at on reducing the msr experienced by participants during the planned activities were shown. existing literature suggested at may reduce rumination by getting individuals immersed in the process of the activities instead of evaluating their performances and inducing the concrete absorbed mindset to counter the ruminative thinking style (watkins, 2016). likewise, the result could be due to the increase in absorption in this study following at being insufficient to counter rumination. previous findings demonstrated that rfcbt, with at as a component, was effective in reducing depressive rumination (hvenegaard et al., 2019; watkins et al., 2011; watkins et al., 2012). however, it is important to note that previous rcts had higher intensities of treatment with multiple therapy sessions. nevertheless, the medium effect size found suggested that future studies with improved design may detect a stronger effect. methodological limitations and suggestions this study has identified methodological information that may be valuable for future large-scale trials. first, the effects of at shown might be limited by high levels of absorption and pa and low levels of msr reported at baselines. as this study targeted activities that participants found enjoyable and potentially absorbing, participants might have high activity-specific tendencies to experience flow and pa in these activities despite exhibiting generally mild levels of anhedonia. as previous findings indicated, the results of dispositional measures are not the same as aggregated assessments of momentary trait-relevant behaviour (augustine & larsen, 2012). targeting dispositional tendencies within a particular context such as participants’ tendencies to experience flow in a specific activity may better predict participants’ experiences than a general dispositional measure (jackson et al., 2008). thus, to obtain the desired baseline absorption training, positive activities 66 tong & watkins levels of the three variables to better examine at’s effects, future studies could use measures assessing participants’ activities-specific flow propensity such as the dfs-sf (jackson et al., 2008) during activities selection to select relatively low-flow inducing activities. second, the participants reported varied levels of anhedonia (ranging from 1 to 14). it could be possible that the intensity of at in this study was insufficient to improve the experiences of positive activities for individuals with high levels of anhedonia. to better explore at’s effects in a population with anhedonia and target individuals with less positive experiences in activities, future studies could include a larger and more homogenous sample of individuals with higher levels of anhedonia; those scoring 3 or above, the cut-off score for anhedonia, in shap (snaith et al., 1995). it may also be useful to explore at’s effects in specific types of population such as those with higher ruminative tendencies. third, the study did not monitor the effectiveness of the training session which may impact the intervention outcomes. mental imagery research has found that higher levels of imagery vividness reported in the training session led to greater reductions in depression symptoms (blackwell et al., 2015). although researchers had checked participants’ moods or levels of energy after the training session, participants’ responses might have been subject to demand characteristics where they overstated the training’s effects (nichols & maner, 2008). to limit the impacts of demand characteristics and assess the effects of the training session, future studies should administer validated scales such as the fss (jackson & marsh, 1996) to assess participants’ level of state flow during the training session. fourth, the adherence rates of daily practice were low and only three participants completed the daily practice. though the impacts of the frequency of daily practice on at’s effects are uncertain due to the small sample size, large effect sizes were found for some changes in absorption, pa, and msr among participants who completed the at daily suggesting the impacts of frequency daily practice may be worth exploring. moreover, there was no measurement of active engagement during the daily practice such as how absorbed participants were. previous evidence suggested more active engagements with the intervention had led to better treatment outcomes in mental imagery intervention (blackwell et al., 2015). to examine whether at could have larger effects, future studies should require higher completion rates (80%) of daily practice and include measures to monitor the effectiveness of daily practice such as participants’ levels of absorption. fifth, the study only lasted for a short period with a single training session and a daily practice period of 7 to 14 days. a study examining rfcbt reported latency of treatment effects where the effects only showed within two to six weeks after initiation of treatment (watkins, 2007). subsequent rct also indicated significant treatment effects on reducing depressive rumination resulting from 12 to 16 sessions of rfcbt (hvenegaard et al., 2019; watkins et al., 2011; watkins et al., 2012). despite this study being conducted in a non-clinical context, a longer period allows potential latency effects to be shown and more data collection. moreover, multiple sessions may be required to provide more training according to the participants’ progress (blackwell et al., 2015). to improve the training’s quality, a longer study period with more than two weeks of daily practice and multiple training sessions may be beneficial. sixth, the duration of activities conducted by participants, which might affect their level of absorption, was not recorded. previous research has suggested that a sufficiently long period may be required to enter into flow (copperstone, 2004; rogatko, 2007). for instance, rogatko (2007) found a positive association between pa and high-flow-inducing activities that were conducted for one hour. in contrast, copperstone (2004) found no significant improvements for flow components such as time distortion, loss of self-consciousness, and action-awareness merging among counselors in a 10-minute psychotherapy session after receiving flow training. however, it is important to note that the flow training was different from at and the study by copperstone (2004) targeted psychotherapy sessions instead of pleasurable activities. nevertheless, future studies can require participants to conduct the activities for longer periods such as 30 minutes, and examine whether at’s effects would increase. lastly, without a control group, this study’s results can be attributed to other factors such as history, cohort effect, or regression to mean instead of at (morley et al., 2015; onghena, 2020). although the mbd could arguably reduce the possibility that the results were influenced by these factors (morley et al., 2015; onghena, 2020), future group studies should include control groups to better examine the effects of at. 67 absorption training, positive activities implications and future directions this study indicated that at warrants further studies with refined methodology. in terms of practice implications, the study raised the possibility that it may benefit individuals who want to improve their experiences in positive activities. however, this assumption requires caution since no strong evidence regarding the effects of at was found. nevertheless, nearly all participants reported expected changes in absorption, pa, and msr, and the medium effect sizes for absorption and rumination were found. this suggested that stronger effects of at may be found particularly regarding the absorption and rumination in studies with larger sample sizes and refined methodology. apart from methodological issues, there are several issues future studies should address. first, it is crucial to explore whether dispositional tendencies to experience rumination, flow or pleasure may influence at’s effects. stratification of intervention recipients is crucial in examining interventions’ effects, which enables early prediction of recipients’ response patterns and allows interventions to be tailored to the individual (fu et al., 2013). furthermore, at’s effects on depressed individuals are also worth exploring. previous evidence found that concrete mental imagery of positive memories can improve mood in depressed individuals (werner-seidler & moulds, 2012). similarly, at, a mental imagery exercise recapturing the sensory-perceptual experiences in absorbing memory, may induce an absorbed mindset in positive activities (watkins, 2016). however, depressed patients were found to have reduced vividness when generating mental imagery of positive memories (werner-seidler & moulds, 2011) and were more prone to compare their current states with the positive memories (holmes et al., 2016; rimes & watkins, 2005; treynor et al., 2003; watkins, 2008). these findings indicate that evidence of at in a non-clinically diagnosed population may not be directly transferable to depressed individuals and a higher intensity of at interventions may be needed for the clinical population. conclusion in conclusion, this preliminary study is the first to examine the effects of absorption training of rumination-focused cbt in improving experiences of positive activities for individuals with anhedonia, which could be a new application of mental imagery exercises apart from those evidenced in the existing literature. the effect sizes indicated that absorption training might have stronger effects on improving absorption and reducing rumination than increasing positive affect in activities. future studies can further explore whether it can benefit individuals to improve their experiences in positive activities for both clinical and non-clinical populations. additionally, several methodological issues merit consideration in designing future trials, such as high benchmark levels of absorption, rumination, and positive activities in activities at baseline, varied levels of anhedonia reported, and uncertain effectiveness of training components. to refine the methodology and better conclude the effects of absorption training, future studies should target larger and homogenous samples with higher levels of anhedonia and their experiences of low flow-inducing activities. future studies should also provide higher-intensity training such as having multiple training sessions, requiring more frequent daily practice, and monitoring participants’ training progress. as for stratification of intervention recipients to better understand which group will benefit the most from absorption training, exploring whether the effects of absorption training would vary among individuals with different dispositional tendencies such as those with high rumination tendencies and depressed individuals could be beneficial for future 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(2012). mood repair and processing mode in depression. emotion, 12(3), 470–478. https://doi.org/10.1037/ a0025984 72 table 1 demographic data for participants tong & watkins 73 absorption training, positive activities table 2 scores at baseline and during absorption training for 16 participants note. pem, the percentage of data points exceeding the median atest statistics used in randomization test: mean difference of change in scores from at to baseline phases (at-baseline) of all participants bcombined p-values computed by meta-analysis of individual p-values with the multiplicative approach using pearson’s method (1934) in rcmdrplugin.scda plug-in (bulté & onghena, 2013) caverage effect size for all participants. pem: <70% reflects questionable effectiveness. 70% to 89% reflects moderate effectiveness. 90% or above suggests large effects (ma, 2006) daverage scores from daily survey questions – baseline phase: questions 4-9e; questions 15f; questions 10-14g; absorption training phase: questions 5-10e; questions 16f; questions 11-15g 74 tong & watkins table 3 participants’ dispositional tendencies to experience rumination, flow, and pleasure note. rrs-sf, ruminative response scale – sf; dfs-2 sf, dispositional flow scale – 2 short form; shaps, snaith-hamilton pleasure scale. 75 absorption training, positive activities figure 1 sixteen participants’ levels of absorption during positive activities in a 21-day period participant 1 baseline absorption training participant 2 days a bs or pt io n baseline absorption training a bs or pt io n days participant 3 baseline absorption training a bs or pt io n days note. the vertical dotted line is the point of transition from baseline to introduction of absorption training. 76 tong & watkins figure 1 (cont.) participant 4 baseline absorption training a bs or pt io n days participant 5 baseline absorption training a bs or pt io n days participant 6 baseline absorption training a bs or pt io n days 77 absorption training, positive activities figure 1 (cont.) participant 7 baseline absorption training a bs or pt io n days participant 8 baseline absorption training a bs or pt io n days participant 9 baseline absorption training a bs or pt io n days 78 tong & watkins figure 1 (cont.) participant 10 baseline absorption training a bs or pt io n days participant 11 baseline absorption training a bs or pt io n days participant 12 baseline absorption training a bs or pt io n days 79 absorption training, positive activities figure 1 (cont.) participant 13 baseline absorption training participant 14 baseline absorption training days a bs or pt io n a bs or pt io n days participant 15 baseline absorption training a bs or pt io n days 80 tong & watkins figure 1 (cont.) participant 16 baseline absorption training a bs or pt io n days : planned activity without absorption training : planned activity with absorption training : non-planned activity without absorption training : non-planned activity with absorption training 81 absorption training, positive activities figure 2 sixteen participants’ levels of positive affect during positive activities in a 21-day period. participant 1 baseline absorption training days po sit iv e a ffe ct participant 2 baseline absorption training po sit iv e a ffe ct days participant 3 baseline absorption training po sit iv e a ffe ct days note. the vertical dotted line is the point of transition from baseline to introduction of absorption training. 82 tong & watkins figure 2 (cont.) participant 4 baseline absorption training po sit iv e a ffe ct days participant 5 baseline absorption training po sit iv e a ffe ct days participant 6 baseline absorption training po sit iv e a ffe ct days 83 absorption training, positive activities figure 2 (cont.) participant 7 baseline absorption training po sit iv e a ffe ct days participant 8 baseline absorption training po sit iv e a ffe ct days participant 9 baseline absorption training po sit iv e a ffe ct days 84 tong & watkins figure 2 (cont.) participant 10 baseline absorption training po sit iv e a ffe ct days participant 11 baseline absorption training po sit iv e a ffe ct days participant 12 baseline absorption training po sit iv e a ffe ct days 85 absorption training, positive activities figure 2 (cont.) participant 13 baseline absorption training po sit iv e a ffe ct days participant 14 baseline absorption training po sit iv e a ffe ct days participant 15 baseline absorption training po sit iv e a ffe ct days 86 tong & watkins figure 2 (cont.) participant 16 baseline absorption training po sit iv e a ffe ct days : planned activity without absorption training : planned activity with absorption training : non-planned activity without absorption training : non-planned activity with absorption training 87 absorption training, positive activities figure 3 sixteen participants’ levels of maladaptive state rumination during positive activities in a 21-day period. participant 1 baseline absorption training r um in at io n days participant 2 baseline absorption training r um in at io n days note. the vertical dotted line is the point of transition from baseline to introduction of absorption training. 88 tong & watkins figure 3 (cont.) participant 3 baseline absorption training r um in at io n days participant 4 baseline absorption training r um in at io n days participant 5 baseline absorption training r um in at io n days 89 absorption training, positive activities figure 3 (cont.) participant 6 baseline absorption training r um in at io n days participant 7 baseline absorption training r um in at io n days participant 8 baseline absorption training r um in at io n days 90 tong & watkins figure 3 (cont.) participant 9 baseline absorption training r um in at io n days participant 10 baseline absorption training r um in at io n days participant 11 baseline absorption training r um in at io n days 91 absorption training, positive activities figure 3 (cont.) participant 12 baseline absorption training r um in at io n days participant 13 baseline absorption training r um in at io n days participant 14 baseline absorption training r um in at io n days 92 tong & watkins figure 3 (cont.) participant 15 baseline absorption training r um in at io n days participant 16 baseline absorption training r um in at io n days : planned activity without absorption training : planned activity with absorption training : non-planned activity without absorption training : non-planned activity with absorption training 64 adverse childhood experiences and familial factors in adolescent suicidality byoungwook d. park1, pauline goger 2, & christine b. cha3, 4, 5 1icahn school of medicine at mount sinai, mount sinai behavioral health center, new york, ny 2department of psychological and brain sciences, fairfield university, fairfield, ct 3center for brain and mind health, yale school of medicine, new haven, ct 4child study center, yale school of medicine, new haven, ct 5department of counseling & clinical psychology, teachers college, columbia university, new york, ny suicide is a major public health concern across the lifespan (centers for disease control and prevention [cdc], 2023). in particular, adolescents between the ages of 10 and 19 are especially vulnerable, with suicide ranking as the second leading cause of death in this age group in the united states (american academy of child and adolescent psychiatry [aacap], 2019). in this developmental stage, parents or primary caregivers have a unique psychosocial influence, as children are legally, emotionally, and developmentally dependent on them (armsden & greenberg, 1987; delgado et al., 2022; moretti & peled, 2004). for this reason, when examining adolescent suicidal thoughts and behaviors (stbs; e.g., suicide attempts, suicidal ideation, and suicide plan), familial factors are often considered (cha et al., 2018; shain et al., 2016; wang et al., 2022). furthermore, efforts are often made to include parents and families in treating depressed and suicidal youth, and parents can play a key role in connecting youth with mental healthcare services (adrian et al., 2023; curry, 2001; diamond et al., 2003; sander & mccarty, 2005). suicide is a multifaceted phenomenon shaped by the interplay of diverse risk and protective factors (de berardis et al., 2018). among various risk and protective factors, the current study focuses on the following: suicidal ideation (si), adverse childhood experiences (aces), family functioning (ff), and perceived parental criticism (ppc). suicidal ideation suicidal ideation (si) refers to the contemplation of suicide with or without the intent, or hope for death by self-inflicted means (de leo et al., 2021). individuals experiencing si may have varying degrees of intensity and frequency in these thoughts, ranging from fleeting wishes to die without the intention of engaging in corresponding behaviors (i.e., passive si) to current, persistent, suicidal thoughts with detailed plans (i.e., active si; harmer et al., 2024). this construct is a well-established risk factor for suicide and is prevalent among youth (buitron et al., 2016; chu et al., 2015; saffer et al., 2015). specifically, approximately 22% of female and 12% of male high school students in the united states have contemplated suicide (kann et al., 2018). while some research suggests that si alone (i.e., si without specific plans, intent, actual preparatory behaviors, or access to lethal means) may not indicate high suicide risk (joiner et al., 2003), it remains a significant risk factor as individuals who have expressed thoughts of killing oneself has a higher risk of completing suicide than people who had not (hubers et al., 2018). thus, the severity of si plays a crucial role in risk formulation for both adolescents and adults. adverse childhood experiences adverse childhood experiences (aces) refer to potentially traumatic and stressful life events or circumstances purpose: adverse childhood experiences (aces) are risk factors for adolescent suicidal ideation (si), but the influence of immediate family factors on this association remains understudied. this study examines how family functioning (ff) and perceived parental criticism (ppc) moderate the relationship between aces and si. methods: 46 community-based adolescents between the ages of 15 and 19 (mage = 17.43 years, 69.57% female) participated in a study examining cognitive risk factors for si. several self-report measures were administered: the suicidal ideation questionnaire to assess si severity, the adverse childhood experiences questionnaire to measure aces, the mcmaster family assessment device – general functioning scale to evaluate ff, and the perceived criticism measure to determine ppc. results: neither the presence (ß = .26, p = .09) nor the count of aces (ß = .24, p = .12) significantly predicted si severity. si severity was significantly associated with specific aces such as emotional abuse, emotional neglect, and mental illness or suicide attempts in the household (ß = .39-.65, p = .00-.04), but not with others (ß = -.21-.40, p = .08-.99). furthermore, ff (ß = .28, p < .01) and ppc (ß = .19, p =.04) independently moderated the association between aces and si severity, while their combined interaction was not significant (ß = -.03, p = .74). conclusion: specific aces predicted si severity. moreover, lower ff and higher ppc independently amplified the impact of aces on si severity in adolescents, highlighting the need for interventions that enhance ff and address ppc to mitigate adolescent suicide risk. keywords: suicide, adolescent, adverse childhood experiences, family functioning, perceived parental criticism graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 65 that occur during childhood or adolescence, which can have lasting negative effects on an individual's well-being (sahle et al., 2022). these adverse experiences typically encompass various events that can be classified into three categories: abuse (i.e., physical, emotional, or sexual), neglect (i.e., physical or emotional), and household dysfunction (i.e., substance abuse or mental health issues in the family, domestic violence, incarceration, or parental separation; sahle et al., 2022). the association between aces and the severity of si and suicide attempts has been consistently demonstrated in both community and high-risk adolescent samples (dunn et al., 2013; miller et al., 2013; sahle et al., 2017). in a nationally representative sample of 10,914 participants, the cumulative lifetime counts of aces influenced the prevalence of si and suicide attempts in adulthood (thompson & kingree, 2022). specifically, one ace increased the odds of endorsing active si by 1.5 times, two aces increased the odds of si by 2 times and a suicide attempt by 3 times, and three aces increased the odds of si by 3 times and a suicide attempt by 5 times. notably, interventions such as parenting education, mental health counseling, social service referrals, and social support are shown to effectively reduce behavioral and mental health problems in children who have experienced such potentially traumatic events (marie-mitchell & kostolansky, 2019). family functioning various family-related variables have been recognized as both protective and risk factors in adolescent suicidality (wang et al., 2022). family cohesion and the adolescent-parent connection were identified as protective factors against the current si turning into later suicide attempts (shain et al., 2016; sun et al., 2020). in a study involving 852 chinese outpatient adolescents and adults, parental emotional warmth and less punitive mothers were recognized to be protective against the development of stbs (wang et al., 2022). on the contrary, negative family functioning (ff), impaired parent-child relationships, family breakdown, low paternal attachment, apathetic and severe child-rearing style, adolescents not talking to family adults about concerns, domestic violence, arguing at home, low familial adaptability and cohesion, and low parental care have been identified as significant risk factors (ohtaki et al., 2019; saffer et al., 2015; shain et al., 2016; sheftall et al., 2013; wang et al., 2022;; weissinger et al., 2023). among 5,557 adolescents in hong kong aged 11 to 18, lower levels of family functioning and parent–adolescent communication were significantly associated with depression and suicidal ideation (kwok & shek, 2011). notably, the improvement of interpersonal relationships with family members has been identified as a helpful recovery factor following si (grimmond et al., 2019). perceived parental criticism perceived parental criticism (ppc) is a construct in expressed emotion literature (i.e., critical or hostile attitudes expressed by family members or caregivers toward a person with a psychiatric disorder) that has a crucial role in family relationships (hooley & miklowitz, 2017). in adolescents, ppc captures how much parental criticism is perceived, internalized, and affects the individual. it is hypothesized that ppc has an impact on si and suicide attempts through its connection to constructs in the interpersonal theory of suicide (chu et al., 2017), such as thwarted belongingness or perceived burdensomeness (hagan & joiner, 2017). adolescence, a developmental stage from ages 10 to 19, is characterized by the emergence of independence, the development of sexuality, the formation of new meaningful relationships, and accompanying vulnerabilities (berenbaum et al., 2015; remschmidt, 1994; world health organization [who], 2025). during this crucial and delicate period, adolescents’ sensitivity to parental criticism may intensify their feelings of loneliness or distort their perception of their worth to others. for instance, when parental criticism is interpreted as rejection or disapproval of their inherent value, it can undermine their sense of belonging within the family. moreover, if adolescents begin to view themselves as a burden as a result of ppc, this perception may reinforce feelings of burdensomeness, increasing the risk of suicidal ideation or self-destructive behaviors. thus, the importance of protective social networks and trusted adults during this period has been highlighted by many (pringle et al., 2018). however, there are conflicting findings on the association between ppc and suicidality. some studies report ppc as a significant indicator of depression, si, and suicide attempt (hagan & joiner, 2017; muyan & chang, 2015; rapp et al., 2021; wang et al., 2017), while others suggest that ppc only has an indirect effect on non-suicidal self-injury (nssi) through self-criticism (baetens et al., 2015), or find no significant association between nssi and ppc altogether (daly & willoughby, 2019). further investigation is warranted to clarify the association between ppc and adolescent suicidality. aims and hypotheses previous research has established that si, aces, ff, and ppc individually contribute to adolescent suicidality. although the predictive relationship between aces and si is well established, the moderating influence of ff and ppc on this association remains largely unexplored. by delving into the moderating effects of ff and ppc, we aim to identify park, goger, & cha 6666 adverse experiences, family, and adolescent suicidality participation in the study were used as grounds for exclusion. out of 176 community-based adolescents who enrolled in the study, 46 completed the adverse childhood experience questionnaire (ace-q). relatively few adolescents completed the ace-q because its administration was discontinued mid-study in an effort to shorten the baseline protocol. thus, only this subgroup of adolescents (n = 46) between the ages of 15 and 19 (mage = 17.43 years, 69.6% female; table 1) was analyzed. the participants were racially diverse, with 45.7% identifying as white, 23.9% identifying as black or african american, 21.7% identifying as asian, and 4.3% identifying as multiracial or other. additionally, 17.4% of the adolescents identified as hispanic. the majority (67.4%) of the adolescents reported heterosexual sexual orientation, followed by bisexual (19.6%), homosexual (8.7%), questioning (2.2%), and other (2.2%). measures suicidal ideation questionnaire (siq) the severity of both passive and active suicidal ideation in adolescents over the past month was assessed using the siq (reynolds, 1987), a 30-item self-report measure rated on a seven-point likert scale (0 = “i never had this thought,” 6 = “almost every day”). an elevated score on the siq suggests a frequent and pervasive presence of si (boege et al., 2014). the siq is scored by summing responses to each question, and a score of 41 or higher is considered clinically significant. the siq was validated among 226 adolescents aged 13 to 18 years, with a cronbach’s α = .98 (pinto et al., 1997). adverse childhood experiences questionnaire (ace-q) the ace-q (felitti et al., 1998) was administered to assess and quantify adverse or traumatic experiences encountered throughout the participants’ lifetime. the ace-q consists of 10 yes-no items and addresses the following domains: emotional, physical, and sexual abuse, emotional and physical neglect, parental separation, domestic violence, household substance abuse, mental illness or suicide attempts in the household, and incarceration of family members. moreover, scores of four or higher (i.e., the presence of four or more distinct aces) are deemed clinically significant. a high ace-q score has been associated with an increased risk for depression, suicide attempts, smoking, drug abuse, adolescent pregnancy, and impaired work performance in adulthood (anda et al., 2004; dube et al., 2003; edwards et al., 2007; felitti et al., 1998; hillis et al., 2004). this questionnaire has been validated among 79 adolescents, with intraclass correlation coefficient values exceeding or being equal to .65 (i.e., good to excellent agreement) across all 10 items (pinto et al., 2014). nuanced pathways through which aces may or may not translate into si later in adolescence. since the family environment plays a pivotal role in adolescents’ emotional and psychological development, investigating these interactions can offer insights into how familial factors exacerbate or mitigate the risk of adolescent suicidality in the presence of aces. thus, the current study examines how aces predict the severity of si in adolescents, and to what extent this association is moderated by ff and ppc. understanding this intricate relationship may offer valuable insights into protective and risk factors of adolescent suicidality, contributing to the design of targeted interventions and support systems for at-risk youth. first, this study will investigate the association between aces and the severity of si in adolescents, positing the following hypotheses: hypothesis 1a: adolescents with at least one ace will endorse a higher severity of si than those without aces. hypothesis 1b: subcategories of aces will correspond with si severity in adolescents, such that those adolescents with a history of each type of ace report more severe si than their respective nonace comparison group. hypothesis 1c: a higher count of aces will predict a higher severity of si in adolescents. second, the moderating effects of ff and ppc on the association between aces and the severity of si in adolescents will be examined. the following hypotheses are posited: hypothesis 2a: aces will be more strongly associated with si severity among adolescents with lower ff. hypothesis 2b: aces will be more strongly associated with si among adolescents with higher ppc. hypothesis 2c: aces will be more strongly associated with si among adolescents with higher ppc and lower ff. methods sample participants were recruited from the urban community in the greater new york metropolitan area via in-person (e.g., street fairs and flyers) and online (e.g., social media advertisement and researchmatch) recruitment efforts for a study examining cognitive risk factors associated with si. post-baccalaureateand masters-level research assistants conducted screenings via phone to determine eligibility. eligibility was determined based on the presence of stbs in adolescence, while (1) challenges in the adolescent’s and parent/guardian’s understanding of informed consent and study procedure, (2) self-disclosure of immediate suicidal intent, (3) the occurrence of violent and agitated behaviors, (4) limited proficiency in the english language, and (5) psychiatric symptoms of adolescents which would hinder consent or 67 park, goger, & cha mcmaster family assessment device – general functioning scale (fad-gf) the mcmaster family assessment device (fad; epstein et al., 1983) is a 60-item self-report questionnaire that assesses an individual’s perception of their family across domains of problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. each item is scored on a four-point likert scale ranging from “strongly agree” to “strongly disagree.” in the current study, only 12 questions from the general functioning domain were utilized to gauge adolescents' perceptions of how their families work together on essential tasks (byles et al., 1988). lower scores on the fad-gf indicate better general ff, and it has been validated for standalone use in 1,869 families with children between 4 to 16 years of age (cronbach’s α = .86; byles et al., 1988). perceived criticism measure (pcm) two items from the perceived criticism measure (pcm; hooley & teasdale et al., 1989) were employed to assess adolescent’s ppc (i.e., “how critical do you think your parent or guardian is of you?” and “when your parent or guardian criticizes you, how upset do you get?”). each item is scored on a 10-point likert scale ranging from “not at all critical” to “very critical.” responses to these two items were summed to derive the total pcm score for analysis. the pcm has robust test-retest reliability (r = .75) over a five-month period (hooley & teasdale et al., 1989). some argue that the construct and assessment of the pcm merely reflect negatively biased perceptions influenced by individuals’ moods. however, it was observed that the pcm scores did not change significantly after successful positive and negative mood inductions in 150 undergraduate students (r = -.12 and r = -.09, respectively; gerlsma et al., 2014). procedure adolescents and their families who met the eligibility criteria participated in assessments during an initial laboratory visit and subsequent follow-up evaluations conducted online via email at 3 and 6 months. compensation included a $35 gift card for baseline assessments, with opportunities to win $50 and $100 gift cards in raffles for completing the 3and 6-month follow-ups, respectively. notably, the final 18.75% of the total 176 participants (n = 33) completed baseline visits virtually due to the impact of the covid-19 pandemic. furthermore, suicidal participants who were recruited during the pandemic indicated elevated levels of si severity when contrasted to suicidal participants recruited before the onset of the pandemic (r2 = .04; p = .04). however, data collection for the 46 participants under examination in this study occurred before the pandemic, with the last participant completing the baseline visit on december 8th, 2018. thus, this difference in the severity of si in suicidal adolescents did not impact current analyses. all study procedures were approved by the institutional review board at teachers college, columbia university. statistical analyses all analyses were conducted with statistical package for the social sciences (spss; version 29; ibm spss inc., chicago, illinois). linear regression to examine whether adolescents with at least one ace will endorse a higher severity of si than those without aces (hypothesis 1a), linear regression was utilized. given the slightly right-skewed distribution of both si and aces, linear regression was chosen for analysis due to its robustness against mild violations of assumptions (ernst & albers, 2017). adolescents with a score of one or more on the ace-q were assigned to the aces group, while those with a score of zero on the ace-q were assigned to the non-aces group. subsequently, the analysis was completed while examining this dichotomous classification of aces as an independent variable and the severity of si as a dependent variable. furthermore, linear regression was employed to examine whether subcategories of aces corresponded with si severity in adolescents, such that adolescents with a history of each type of ace reported more severe si than their respective non-ace comparison group (hypothesis 1b). 10 discrete linear regressions were conducted between individual items in ace-q and the severity of si. linear regression was employed once more to assess whether a higher count of aces predicted a higher severity of si in adolescents (hypothesis 1c). this potential predictive relationship was assessed by examining the total score of ace-q as an independent variable and the total score of siq as a dependent variable. moderation analysis process macro version 4.2 (hayes, 2022) was used to conduct moderation analysis while examining aces as an independent variable, severity of si as a dependent variable, and ff and ppc as discrete and composite moderators. process is an observed variable, ordinary least squares (ols), and logistic regression path analysis modeling tool, often used in the fields of social, business, and health sciences. it supports both mediation and moderation analyses by generating 5000 bootstrapped samples, automatically mean-centering continuous variables, establishing product terms, and presenting confidence intervals. 68 results demographic characteristics participants with at least one ace accounted for approximately 67% (n = 31) of the sample. furthermore, around 13% (n = 6) of the sample indicated experiencing four or more aces (i.e., clinically significant levels) in their lifetime. in terms of aces, this sample was representative of the population as approximately 64% of u.s adults report having at least one ace, and 17% report having four or more aces (swedo et al., 2023). hypothesis 1a: adolescents with at least one ace will endorse a higher severity of si than those without aces. there was no significant association between the history of ace (i.e., presence of at least one ace vs. no ace) and si severity (ß = 0.26, p = .09). hypothesis 1b: subcategories of aces will correspond with si severity in adolescents, such that those adolescents with a history of each type of ace report more severe si than their respective non-ace comparison group. out of 10 subcategories of aces measured by ace-q, a significant regression was found in emotional abuse (ß = 0.49, p = .01; table 2), emotional neglect (ß = 0.65, p < .001), and mental illness or suicide attempt in the household (ß = 0.39, p = .04) with severity of si. for emotional abuse, r2 = 0.24, indicating that emotional abuse explained approximately 24% of the variance in si severity. in the case of emotional neglect, r2 = 0.43, signifying that approximately 43% of the variability in si severity can be accounted for by emotional neglect. for mental illness or suicide attempt in the household, r2 = 0.15, indicating that being in a household with a family member who has a mental illness or who has made a suicide attempt explained 15% of the variance in si severity. on the contrary, no significant regression was observed for physical abuse (ß = 0.37, p = .08), sexual abuse (ß = 0.40, p = .09), physical neglect (ß = 0.22, p = .40), parental separation (ß = -0.02, p > .99), witnessing domestic violence (ß = 0.29, p = .20), household substance and alcohol abuse (ß = -0.21, p = .40), and incarceration of household members (ß = 0.39, p = .10). hypothesis 1c: a higher count of aces will predict a higher severity of si in adolescents. there was no significant association between the count of aces and the severity of si in adolescents (ß = 0.24, p = .12). hypothesis 2a: aces will be more strongly associated with si severity among adolescents with lower ff. the moderation analysis revealed that approximately 68% of the variability in si severity in adolescents was predicted by aces and ff (r2 = 0.68, f(3, 20) = 13.90, p < .001; table 3). additionally, the results indicated that aces (ß = 0.21, p = .04) had a significant positive effect on si severity. while ff did not have significant effects on si severity independently (ß = 0.19, p = .12), it was revealed that there was a significant interaction between aces and ff (ß = 0.28, p < .01). this significant interaction indicated that ff moderated the effect of aces on si severity. this moderating effect is displayed in figure 1. the graph demonstrates that the association between aces and si severity is stronger for adolescents with lower ff (ß = 0.49, p < .01; table 4), and weaker for adolescents who have moderate ff (ß = 0.20, p = .04). furthermore, the graph suggested that aces had a negative impact on the severity of si for adolescents with high ff. specifically, adolescents in the high aces group within the high ff category endorsed lower si than those in the low aces group. however, this decline in si within the high ff group was not found to be statistically significant upon further investigation (ß = -0.08, p = .46). in interpreting this result, it should be noted that a significant correlation was found between aces and ff (r(25) = .48, p = .02). upon further investigation, it was revealed that only one subcategory of aces was correlated to ff (i.e., emotional abuse; r(23) = .55, p < .01). to address the potential issues of multicollinearity both aces and ff were mean-centered. this pre-processing step aimed to reduce the correlation between aces and ff, enhancing the precision of the results and contributing to a more reliable examination of their relationship (iacobucci et al., 2017). hypothesis 2b: aces will be more strongly associated with si among adolescents with higher ppc. approximately 47% of the variability in si severity in adolescents was predicted by aces and ppc (r2 = 0.47, f(3, 22) = 6.42, p < .01; table 3). the results indicated that both aces (ß = 0.48, p < 001) and ppc (ß = 0.29, p = .02) had a significant positive effect on si severity. furthermore, there was a significant interaction between aces and ppc (ß = 0.19, p = .04), indicating that ppc moderated the effect of aces on the severity of si. figure 2 visualizes this interaction. the prevalence of aces exhibited a significant positive impact on the severity of si within all three groups of ppc, with the most pronounced association observed among adolescents with high ppc (ß = 0.67, p < .01; table 5). a less pronounced association was observed for adolescents with moderate levels of ppc (ß = 0.47, p < .001), followed by adolescents with low ppc (ß = 0.28, p = .01). a significant correlation between aces and ppc was not observed (r(23) = -0.29, p = .15). hypothesis 2c: aces will be more strongly associated with si among adolescents with higher ppc and lower ff. adverse experiences, family, and adolescent suicidality 69 park, goger, & cha this model explained approximately 72% of the variability in si severity (r2 = 0.72, f(4, 19) = 5.89, p < .01; table 3). the analysis revealed that aces (ß = 0.18, p = .38), ppc (ß = 0.12, p = .29), and ff (ß = 0.17, p = .41) did not have a significant independent effect on the severity of si. interactions between aces x ppc (ß = -0.11, p = .41), ppc x ff (ß = 0.06, p = .64), and aces x ppc x ff (ß = -0.03, p = .77) were also not found to be significant. nonetheless, the interaction between aces and ff remained significant (ß = 0.32, p = .02). the interactions are visualized in figure 3. the figure showed that aces had a negative impact on the severity of si for adolescents with high ff, irrespective of varying levels of ppc. however, upon further investigation, these interactions were not significant (i.e., high ff x low ppc (ß = -0.06, p = .72; table 6), high ff x moderate ppc (ß = -0.15, p = .60), high ff x high ppc (ß = -0.23, p = .58). lastly, out of nine slopes visualized in figure 3, two showed significant associations: low ppc x low ff (ß = 0.64, p = .01; table 6) and moderate ppc x low ff (ß = 0.50, p = .01). discussion the current study examined how aces predict the severity of si in adolescents, and to what extent this relationship was moderated by familial factors such as ff and ppc. the results indicated that low ff and high ppc independently exacerbated the impact of childhood adversity on the severity of adolescent si. this moderating effect, however, was not observed when examining ff and ppc compositely. furthermore, specific forms of aces were significantly associated with the severity of si in adolescents. nonetheless, the presence and counts of aces were not significantly associated with the severity of si. moderating role of ff and ppc as hypothesized, aces were more strongly associated with si among adolescents who had lower ff. this finding suggests that the combined impact of aces and lower ff exacerbates the risk of si in adolescents. visualizing the moderating effects of ff revealed intriguing patterns (figure 1). prior to conducting post hoc analysis, positive associations between the count of aces and severity of si were expected for all three groups of ff (i.e., low, moderate, and high). indeed, this pattern was observed among adolescents in both lowand moderate-ff groups. although the impact was more pronounced in the low ff group than the moderate ff group, this finding indicated that adolescents with moderate ff face comparable risks to those with low ff. given that not talking to family adults about concerns or lacking a trusted adult in one’s life has been linked to an elevated risk of teen suicidality (weissinger et al., 2023), it is plausible that adolescents from families with low and moderate functioning may not perceive their parents or guardians as trusted adults with whom they can discuss concerns when experiencing potentially traumatic life events. this inability to openly share the experiences of adverse events could exacerbate si among adolescents and prevent them from receiving timely and appropriate help. in contrast, the opposite trend was observed in the high ff group; the severity of si decreased as the count of aces increased. this unanticipated trajectory can be attributed to several plausible explanations. in families with high ff, children may generally perceive their parents or guardians as trusted adults and be more inclined to seek help from them when faced with potentially traumatic events. additionally, families characterized by high general ff may be better equipped to provide appropriate assistance when adolescents experience crises and reach out for help. adolescents’ willingness to seek help, coupled with the family’s competency in providing necessary support, may act as a buffer against the exacerbation of si associated with childhood adverse events. furthermore, the increased severity of si observed in adolescents with fewer aces within the high ff group could be attributed to these adolescents perceiving their few aces as not substantial enough to justify seeking help, despite the less apparent but surely debilitating negative consequences of aces. as the count of aces rises, adolescents may feel more justified and validated in seeking support from their families, which can diminish the detrimental effects of aces. however, the downward trend observed in the high ff group should be interpreted with caution, as the slopes are not statistically significant (table 4). as predicted, aces were more strongly associated with si among adolescents with higher ppc. this finding suggests that the risk of si is exacerbated when aces are conjoined with a higher level of adolescents’ perception of parental criticism. as visualized in figure 2, across all varying levels of ppc, the severity of si increased as aces experienced by adolescents increased. the most prominent association was observed in the high ppc group, followed by the moderate, and then the low ppc groups. there may be several reasons why higher levels of ppc intensify the association between adverse events in childhood and si in adolescence. parental criticism is associated with the development of internalizing symptoms (i.e., sadness, anxiety, and loneliness) in children (ahmadzadeh et al., 2022; ehrenreich & underwood, 2016). in a longitudinal study conducted by piqueras and colleagues (2019), inter70 nalizing symptoms (e.g., symptoms of depression) had a significant association with current suicidal behaviors in 239 adolescents. given this body of research, it can be speculated that persistent parental criticisms may significantly shape adolescents' self-perception. the internalization of critical messages from a caregiver may lead to the cultivation of a more pessimistic self-view. this curtailed self-esteem in youth may intensify feelings of thwarted belongingness and perceived burdensomeness (eades et al., 2019). thus, adolescents may experience heightened feelings of isolation and a diminished sense of emotional support from their parents. consequently, both thwarted belongingness and perceived burdensomeness can compound emotional distress, amplifying the impact of aces and further elevating the risk of adolescent stbs (ogrodniczuk et al., 2023; roeder & cole, 2019). given that ppc is a construct designed to gauge adolescents' perception of parental criticism, there is ambiguity regarding its direct correlation with the frequency or actual intensity of criticism received. it is conceivable that ppc does not solely reflect the objective frequency or severity of parental reproach, but rather encompasses a subjective element influenced by individual interpretations. this suggests that certain adolescents may be more prone to interpreting their parents' feedback as highly critical, irrespective of the actual tone or intention of such expressions. likewise, it is plausible that certain adolescents exhibit greater resilience in the face of potentially unwarranted and harsh parental criticism. while ppc captures external factors (i.e., how critical the parents are), it also encompasses the subjective filters through which adolescents interpret and process parental behaviors. finally, there was insufficient evidence to conclude that ff and ppc compositely moderate the association between aces and adolescent si. thus, we could not conclude that aces are more strongly associated with si among adolescents with both lower ff and higher ppc. since ff and ppc independently moderated the association between aces and adolescent si, the absence of a significant result in evaluating ff and ppc as composite moderators raises questions. potentially, the interplay between ff, ppc, aces, and si may have been more complex than initially hypothesized. it is also possible that other variables or interactions that were not accounted for in the study design could have contributed to the observed outcomes. in this composite model, while all other interactions were not significant, the interaction between aces and ff remained significant, once again validating the finding in hypothesis 2a. this finding becomes clearer when inspecting figure 3. among the nine interactions depicted in the figure, statistical significance was exclusively observed in the interactions involving the low ff group (i.e., low ff x low ppc and low ff x moderate ppc). this illustrates the pivotal role of ff as a moderating variable in the complex interplay between adverse events in childhood and si in adolescence. moreover, the intriguing pattern depicted in figure 1 reemerged in figure 3. the figure displayed that aces had a negative impact on the severity of si for adolescents with high ff, irrespective of varying levels of ppc. once again, this suggested that adolescents in the high aces group with high ff endorsed lower si than those in the lower aces group. while these interactions were not significant (table 6), this recurring trend warrants further investigation. association between aces and si select forms of childhood adversity were associated with the severity of si in adolescents. these include emotional abuse, emotional neglect, and mental illness or suicide attempts in the household. in contrast, physical abuse, sexual abuse, physical neglect, parental separation, witnessing domestic violence, household substance and alcohol abuse, and incarceration of household members did not correspond to si severity in adolescents. this finding is partially aligned with the current literature and the hypothesis. most studies examining the association between aces and si report that the majority, if not all, subcategories of aces predict later suicidality (wang et al., 2019). while there is conflicting evidence regarding the consistent prediction of suicidality by household challenges, such as parental separation or incarceration of a family member (sahle et al., 2022), a more robust body of research consistently associates emotional, physical, and sexual abuse, as well as emotional and physical neglect during childhood with later stbs (miller et al., 2013; pournaghash-tehrano et al., 2021; wang et al., 2022). given this evidence, it is worth noting that only three out of 10 subcategories of aces were significantly associated with si severity in the current study. the nonsignificant results across seven subcategories of aces should be interpreted with caution, as significant outcomes were identified solely within the three most prevalent categories of aces in the sample, with parental separation being the only exception (i.e., parental separation was prevalent, but the interaction was not significant; table 2). hence, the lack of significant results in the remaining seven ace categories associated with si severity may be due to insufficient representation of adolescents who experienced those specific adversities in the sample. moreover, subcategories of aces that are consistently associated with si severity, such as physical and sexual abuse, exhibited potential significance. while adverse experiences, family, and adolescent suicidality 71 park, goger, & cha not significant at p = .05, both physical abuse (β = 0.37, p = .08; table 2) and sexual abuse (β = 0.40, p = .09) were significant at p = .10. the detection of some significance despite the small sample size may suggest a moderate association between the adolescent si severity and specific ace types. contrary to the hypothesis, the result did not suggest that adolescents with at least one ace endorse a higher severity of si than those without aces. this finding is not aligned with the existing literature and should be interpreted with caution for several reasons. scoring one on the ace-q may not definitively indicate the presence of adverse events in childhood. for instance, question six on the ace-q evaluates parental separation or divorce, which is generally associated with various negative mental health outcomes in children (çaksen, 2022). however, the impact of divorce depends on factors such as the intensity and duration of the separation process, as well as the availability of familial or non-familial support (spremo, 2020). since the ace-q lacks detailed assessments of these nuanced aspects, it is difficult to determine whether an affirmative response to question six or other questions signifies an adverse event experienced in childhood. moreover, spremo (2020) suggests that family dynamics typically stabilize two to four years after divorce. without knowing the timing of parental divorce relative to the date of assessment, we lack the temporal context to accurately gauge how the presence of at least one ace, especially parental separation, predicts adolescent si. lastly, it is plausible that the negative impact of aces may not fully manifest itself when assessed in close proximity to the occurrence of the adverse event. however, this explanation appears less likely as a large body of research suggests that aces are generally associated with an increased risk of si and suicide attempts across community, clinical, and high-risk samples of adolescents (miller et al. 2013). once again, contrary to the hypothesis, no significant association was observed between the count of aces and the severity of si. this finding should also be interpreted with caution, considering a body of research that suggests an alternative perspective. for instance, a study with a sample of 989 chinese college students concluded that a cumulative effect was observed between aces and si, indicating that a higher count of aces corresponded to an increased likelihood of endorsing si (wang et al., 2019). while chinese society has increasingly integrated elements of individualism through western influence, it remains more collectivistic than the u.s., particularly in its emphasis on family interdependence (kolstad & gjesvik, 2014). cultural factors like these may influence how individuals perceive and respond to adversity within the family context (oyserman & lee, 2008). however, cultural explanations alone appear insufficient to account for the discrepancy between the current findings and those from studies conducted in collectivistic contexts. notably, similar associations between the cumulative negative impact of aces on si have been observed in a sample of 1,532 u.s.based adolescents (meeker et al., 2021). it is possible that the absence of a significant association in the current study is attributable, at least in part, to the limited sample size. limitations and future directions there are several limitations to consider in interpreting the findings. although the current sample was ethnically diverse, the small sample size may impact the generalizability of the findings. several negative findings did not align with the existing literature (i.e., nonsignificant association between the presence of one ace, counts of aces, and selected forms of aces with si severity). the analyses should be replicated in a larger sample for more precise and representative findings. . furthermore, although not statistically significant, the recurring pattern of negative association between counts of aces and severity of si in high ff warrants future investigation in a larger sample. if replicating this analysis in a larger sample reveals a statistically significant decrease in si for adolescents from families with high ff, it would suggest that not only are the negative effects of aces on adolescent suicidality potentially more pronounced in those with lower ff, but also that higher ff could serve as a protective factor. lastly, ff and ppc should be evaluated as composite moderators in a larger sample, as the current study may have lacked the statistical power in the analysis to detect a significant interaction effect. additionally, the study did not include measures of psychiatric disorders (e.g., major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder), which are known to be closely associated with both ace exposure (daníelsdóttir et al., 2024) and si (gilmour, 2016; panagioti et al., 2015; rihmer & rihmer, 2019). due to limitations in available data, key demographic variables such as household income, single-parent status, and parental education level were not included in the analyses either. the absence of these variables limits the ability to assess potential confounding effects or to better contextualize the observed association. the cross-sectional design of the study also limits our ability to explore the dynamic changes in adolescent experiences with aces over time. future research could benefit from longitudinal investigations which capture the evolving impact of aces throughout adolescents’ lives. additionally, the use of self-report measures intro72 adverse experiences, family, and adolescent suicidality duces potential biases. recall bias, along with individual differences in how adolescents define events as adverse, may impact the accuracy of reported aces. relatedly, ff and ppc assessments may have been influenced by transient factors such as recent adolescent-parent conflicts (e.g., arguing with parents right before the assessments). the utilization of the ecological momentary assessment (ema) has the potential to address both concerns. with the use of appropriate questions, the ema methodology may enable the capture of real-time fluctuations in family interactions. this includes assessing the frequency, intensity, and content of parental criticism, as well as adolescents' corresponding stbs. finally, despite both variables being mean-centered to improve the interpretability of the regression model, the multicollinearity between aces and ff should be noted in interpreting results. clinical implications given that ff and ppc are found to independently amplify and attenuate the effects of aces in adolescent suicidality, strategies focused on enhancing ff while simultaneously mitigating ppc should be considered. clinically, targeted interventions can be developed to achieve the desired goal. when treating youth with suicidal thoughts, clinicians can assess for aces, ff, and ppc to identify atrisk individuals and provide appropriate early prevention support within the family context (e.g., implementing targeted family therapy, providing specific parenting support, or designing programs that address ff and ppc). evidence-based treatment targeting family cohesion can also be employed (e.g., attachment-based family therapy; abft; diamond et al., 2010; diamond et al., 2003). fostering an environment that promotes open communication and supportive family relationships becomes crucial at home. encouraging positive interactions, active listening, and constructive dialogue can enhance ff and mitigate potential ppc issues. implementing structured family activities such as shared meals may further strengthen familial bonds (utter et al., 2013). additionally, educational initiatives can be extended to parents and caregivers to raise awareness about the impact of aces and the role of ff and ppc in adolescent mental health. providing resources and guidance on effective parenting strategies and communication skills can empower families to create a nurturing and resilient environment. while it is ideal for parents or guardians to be involved in treating adolescents for their stbs, there are situations in which this is not feasible (e.g., intense family conflict, abuse, neglect, or when caregivers are unavailable or unwilling to participate). cultural stigma or differing beliefs about mental health treatment may also limit caregiver involvement. in such cases, treatment can focus on building adolescents’ skills (e.g., emotion regulation, distress tolerance) to help them manage their well-being independently. this approach may still be effective, as both ff and ppc reflect not only the objective reality of familial dynamics but also adolescents’ subjective perceptions of them. conclusion the present study found that family functioning (ff) and perceived parental criticism (ppc) independently moderated the relationship between adverse childhood experiences (aces) and suicidal ideation (si) in an ethnically diverse adolescent sample. this novel contribution to the literature highlights how specific family dynamics may either buffer or exacerbate the impact of early adversity on youth suicidal thoughts. several unexpected null findings also emerged: (1) only certain forms of aces were significantly associated with adolescent si; (2) the presence of at least one ace and the total number of aces were not significantly associated with si; and (3) the moderation model was nonsignificant when ff and ppc were assessed as a composite variable. these findings should be interpreted with caution, particularly considering the study’s limitations, as they diverge from previous research. to gain a more nuanced understanding of the critical role of family in adolescent development in the context of aces and suicidality, future studies should replicate this research in a larger sample and collect more detailed information on adolescents’ perceptions and reports of aces, ff, and ppc. references american academy of child and adolescent psychiatry. 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(2019). suicidality among young adults: unique and cumulative roles of 14 different adverse childhood experiences. child abuse & neglect, 98, 104183. https://doi. org/10.1016/j.chiabu.2019.104183 weissinger, g., myhre, k., ruan-iu, l., van fossen, c., & diamond, g. (2023). adolescent suicide risk, firearm access, and family functioning: screening in primary care. families, systems & health, 41(1), 16–25. https://doi.org/10.1037/ fsh0000680 world health organization (2025). adolescent health. https://www.who.int/health-topics/adolescent-health#tab=tab_1 78 adverse experiences, family, and adolescent suicidality table 1 demographic characteristics of the participants note. n = 46 79 park, goger, & cha table 2 linear regression analyses: severity of suicidal ideation (si) and subcategories of adverse childhood experiences (aces) note. se = standard error; ll = lower limit; ul = upper limit; sa = suicide attempts. *p < .05 80 adverse experiences, family, and adolescent suicidality table 3 summary of moderated regression analyses predicting suicidal ideation (si) severity in adolescents note. aces = adverse childhood experiences; ff = family functioning; ppc = perceived parental criticism; se = standard error; ll = lower limit; ul = upper limit. aaces will be more strongly associated with si among adolescents who have lower family functioning; n = 24, r2 = .68. baces will be more strongly associated with si among adolescents who have higher perceived parental criticism; n = 26, r2 = .47. caces will be more strongly associated with si among adolescents who have higher perceived parental criticism and lower family functioning; n = 24, r2 = .72. *p < .05 81 park, goger, & cha table 4 conditional effects of adverse childhood experiences (aces) at values of family functioning (ff) note. sd = standard deviation; se = standard error; ll = lower limit; ul = upper limit; fad-gf = the mcmaster family assessment device – general functioning. ahigher score in fad-gf indicates worse ff. this table based on the results of fad-gf. *p < .05 82 adverse experiences, family, and adolescent suicidality table 5 conditional effects of adverse childhood experiences (aces) at values of perceived parental criticism (ppc) note. sd = standard deviation; se = standard error; ll = lower limit; ul = upper limit. *p < .05 83 park, goger, & cha table 6 conditional effects of adverse childhood experiences (aces) at values of family functioning (ff) and perceived parental criticism (ppc) note. sd = standard deviation; se = standard error; ll = lower limit; ul = upper limit. *p < .05 84 adverse experiences, family, and adolescent suicidality figure 1 moderating effects of family functioning (ff) on the association between adverse childhood experiences (aces) and adolescent suicidal ideation (si) note: the interactions between variables are statistically significant (p < .05) for low ff and mid ff. however, the downward trend observed in high ff was not significant. additional details are available in table 4. 85 park, goger, & cha figure 2 moderating effects of perceived parental criticism (ppc) on the association between adverse childhood experiences (aces) and adolescent suicidal ideation (si) note: the interactions between variables are statistically significant (p < .05) for all categories of ppc. additional details are available in table 5. 86 adverse experiences, family, and adolescent suicidality figure 3 moderating effects of family functioning (ff) on the association between adverse childhood experiences (aces) and adolescent suicidal ideation (si) note: among the nine slopes depicted in the figure, only low ppc x low ff and moderate ppc x low ff were statistically significant at p < .05. additional details are available in table 6. 52 effects of anxiety on attention-based tasks in a college population jacob desoto1,2 & jessica gaby2 1department of psychology, western carolina university 2department of psychology, middle tennessee state university the current study examines the potential relationship between anxiety as measured by the statetrait anxiety inventory (stai) and performance on the navon and stroop tasks, reflecting different aspects of attention that are crucial for academic success. these cognitive tasks measure different aspects of attention, including visual global and local processing, and executive inhibition (miyake et al., 2000; navon, 1977; stroop, 1935). we measured two types of anxiety: trait anxiety and state anxiety. trait anxiety can be defined as the general level of anxiety a person feels on an everyday basis, whereas state anxiety is the level of anxiety they feel in the current moment (shilton et al., 2019; spielberger et al., 1983). we aimed to examine how anxiety may impact a person’s attention, executive functioning, and visual processing. if there is indeed a difference in performance based on anxiety, this could affect future treatment considerations for college students with anxiety diagnoses. we hypothesized that individuals with high levels of trait anxiety would have a local processing bias in the navon task, specifically demonstrated by slower reaction times on global processing than participants with low trait anxiety for the navon task. additionally, we hypothesized that participants with high trait anxiety would have faster reaction times on local processing than participants with low trait anxiety. for the stroop task, we hypothesized that individuals high in state anxiety, those high in trait anxiety, and those who score high in both types of anxiety would have slower reaction times on the incongruent trials of the stroop task than those low in both types of anxiety. this study further explores the relationship that may exist between anxiety and interference in each of these tasks, leading to a better understanding of how state and trait anxiety impact performance on attention-based tasks in a college population. anxiety in college students college can be an emotional experience for students, with the potential for many first-time, unfamiliar experiences. while many of these experiences may be enjoyable and eye-opening, some aspects of college, such as academic expectations or financial concerns, may lead individuals to experience high stress and anxiety levels. in one study, 40% of undergraduate university students displayed anxiety symptoms (beiter et al., 2015). asher blackdeer et al. (2021) collected a sample of 117,430 students from over 100 college institutions and found that 9.2% of the overall sample displayed symptoms of anxiety. these studies demonstrate how prevalent anxiety can be in college students across the united states and suggest that pressures regarding academic performance may be a contributing factor (e.g., asher blackdeer et al., 2021; beiter et al., 2015). research frequently suggests an impact of state-level anxiety on performance in specific contexts, such as test anxiety or statistics anxiety (e.g., cassady & johnson, 2002; chew & dillon, 2014; hoegler & nelson, 2018). more broadly, literature on trait anxiety suggests an inconsistent impact on academic performance. for example, vitasari et al. (2010) found that in university engineering students, there was a small previous literature suggests that trait anxiety may lead to diminished global processing, and therefore, a local processing bias (basso et al., 1996), which may contribute to a narrowed scope of attention and impaired cognitive flexibility. additionally, there is conflicting data on how anxiety interacts with performance on the stroop task (e.g., ursache & cybele raver, 2014). to understand this relationship, the authors used the state-trait anxiety inventory (stai) to divide participants into groups based on their levels of anxiety. specifically, the researchers explored the effects of state and trait anxiety on college students’ attention using the navon task and the stroop task. the navon task was used to compare the performance of people with high and low trait anxiety, utilizing two t-tests to analyze local and global processing. four groups were created for the stroop task: high trait/low state, low state/high trait, high trait/high state, and low state/low trait, which were compared through an anova. no statistically significant differences were found in performance on the stroop and navon tasks based on state or trait anxiety. this may be due to the age range of participants and the lack of clinical elevation of these factors. the findings suggest that moderate levels of anxiety may not impact attention drastically in a college population. keywords: anxiety, attention, college, stroop task, navon task graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 53 desoto & gaby but significant correlation between high anxiety as measured by the stai and low academic performance. another study found a significant indirect correlation between low academic performance and trait anxiety in middle school students (owens et al., 2012). however, chaplin (1989) suggests that it may not be the anxiety itself but rather how an individual reacts to anxiety that determines the impact on academic achievement. anxiety and attention attention may have an important impact on academic achievement. in addition to academic achievement, anxiety appears to impact attention (najmi et al., 2012; pacheco-unguetti et al., 2010). the executive control network, or executive attention, consists of problem-solving, working memory, and managing conflicts. executive attention is a part of the broader category of executive functioning and can be investigated using the stroop task, which requires executive control when managing conflicting information. the scope of attention involves the ability to expand or narrow one’s visual focus relative to the size of an individual’s visual environment (kosslyn et al., 1999; najmi et al., 2012). one study suggests that undergraduate students with high levels of trait anxiety had an impairment in expanding the scope of their attention compared to students with low levels of anxiety. the authors of this study suggest the scope of visual attention may be related to global and local processing (najmi et al., 2012). global and local processing when someone looks at a painting, do they start by recognizing the entire picture or by focusing on the detail within the painting? this question concerns the global and local elements found within the painting. regarding visual perception, local processing focuses on the individual elements that make up a scene (nayar et al., 2015). global processing involves seeing all the individual elements that create the scene and using this information to create a comprehensive global image (navon, 1977; nayar et al., 2015). the theory of global precedence states that visual perception tends to start from seeing the big picture (the forest) first and then noticing the finer details (the trees) (navon, 1977). research indicates that young children may rely mainly on local-level strategies and develop global-level strategies similar to the average adult between the ages of 7 and 10 (nayar et al., 2015). this demonstrates that humans may naturally adapt global processing strategies as their brains develop. this may be because a child’s prefrontal cortex is still developing (tsujimoto, 2008). as humans develop, there are instances where these global-level strategies may be beneficial. for example, woltin et al. (2012) found that participants from a college sample correctly understood the communicative intent of a written message (sincere or sarcastic) more frequently when they were globally primed than when they were locally primed. anxiety and global/local processing high trait anxiety may impact an individual’s scope of attention on global/local tasks, leading to a local-level processing bias (basso et al., 1996; becker et al., 2017; najmi et al., 2012; shilton et al., 2019). shilton et al. (2019) found that participants with high trait anxiety were biased toward processing local-level visual stimuli in a global-local visual processing task, with less of a preference towards global-level processing. in contrast, their high state anxiety group displayed greater interference (slower reaction times) from global stimuli when attempting to process the local-level stimuli compared to their low state anxiety group. this would indicate that, unlike trait anxiety, no local processing preference appears to result from state anxiety (shilton et al., 2019). on the other hand, basso et al. (1996) found that male participants exhibiting symptoms of depression or anxiety displayed a bias towards local processing, suggesting that these pathologies diminish global processing. becker et al. (2017) used a navon task to demonstrate that trait-level anxiety may lead to a local processing bias. according to tyler and tucker (1982), individuals with trait anxiety may rely more on their left hemisphere in visual perception, such as performing the navon task. if this is true, this may explain some of the local processing bias. this detail-focused (local-level) perceptual bias may indirectly lead to maladaptive behaviors, such as an eating disorder (becker et al., 2017). stroop task and executive attention if a student were to shout out an answer without raising their hand during a lecture, that would be an example of failing to inhibit a response. the ability to restrain one’s unwanted responses is known as response inhibition (albert et al., 2013). in this study, one task we used to measure attention was the stroop task. in this task, participants are shown multiple trials of the color names in various colors of ink (e.g., the word blue in the ink color red) (stroop, 1935). the 54 anxiety effects on attention-based tasks primary component measured in the stroop task is managing the conflict of incongruency between color and word meaning through inhibition (miyake et al., 2000; stroop, 1935). the primary area of the brain involved in the stroop task appears to be the dorsolateral prefrontal cortex (dlpfc), which may have a role in executive functioning (milham et al., 2003). anxiety and stroop task some evidence suggests that state anxiety does not negatively affect but may actually improve performance on the stroop task (see ursache & cybele raver, 2014). however, there is mixed evidence. rosa-alcázar et al. (2021) found that higher scores on a generalized anxiety disorder (gad) screening survey were associated with worse performance on the stroop color-word test. another study found that participants who met the criteria for gad performed worse than the “healthy” control group (hallion et al., 2017). the authors suggested that the presence of gad predicted deficits in performance on the stroop task. this study’s results could indicate how participants with high trait anxiety may perform on the stroop task. data suggests that trait anxiety may impair the dlpfc’s role in attentional control while processing conflicting information (bishop, 2009). furthermore, heller et al. (1997) found that individuals with high levels of trait anxiety (anxious apprehension) seem to have asymmetry in the frontal lobes. these findings could be seen in decreased activity in the right frontal lobe, which may lead to possible deficits in executive functioning tasks (heller et al.,1997; milham et al., 2003). finally, one study found a positive correlation between academic achievement and activation of brain areas responsible for strong performance on the stroop task (veroude et al., 2013), suggesting that if anxiety harms an individual’s performance on the stroop task, it may also adversely affect their academic performance (hallion et al., 2017; saviola et al., 2020; veroude et al., 2013). methods participants one hundred and seventeen undergraduate and graduate students from a large university in the southeast united states completed our study. participants were recruited through sona, word of mouth, email, and social media (e.g., facebook, instagram, and reddit). golden and freshwater (2002) suggest a shift in stroop scores after the age of 25, so all participants were between 18-25. we also only included participants who completed every item of the anxiety scale and both attention tasks. this study was approved by middle tennessee state university’s institutional review board, and all participants provided informed consent. of our 117 participants, 24 identified as male, 81 identified as female, 10 identified as non-binary or a third gender, and two preferred not to say. in the sample, 92 participants identified as white, 13 participants as hispanic or latino, 13 participants as black or african american, four participants as asian, one participant as native hawaiian or pacific islander, eight participants as mixed ethnicity, and four as other ethnicity. participants also reported previous anxiety diagnoses. there were 27 gad diagnoses, 13 unspecified anxiety diagnoses, seven social anxiety disorder diagnoses, six panic disorder diagnoses, two preferred not to say, and one agoraphobia diagnosis reported. additionally, 35 participants reported being prescribed medication for anxiety or attention-deficit/ hyperactivity disorder, and one preferred not to say. 65 participants reported that they currently were or had previously received psychotherapy for anxiety or depression. fifty-one participants reported having never received psychotherapy, and one preferred not to say. lastly, 33 participants reported that they were currently taking prescribed or non-prescribed psychotropic medications, 18 participants reported a history of severe head injury (e.g., concussion, tbi), and 20 participants reported using recreational substances. measures all data was collected using psytoolkit, a browser-based data collection tool with a large collection of psychological tests. the program allows researchers to assemble these individual tasks, along with demographic questions, and distribute them virtually for cloud-based data collection (stoet, 2010, 2017). traditionally, reaction time data is collected via in-person testing methods; the gold standard for collecting this type of data is a program called e-prime 3.0, which does not have browser-based capabilities. kim et al. (2019) found a high degree of replicability in reaction time measurement between e-prime and psytoolkit. no significant differences were observed in the response time results between the two, indicating that psytoolkit is comparable to e-prime 3.0 for measuring reaction times (kim et 55 desoto & gaby al., 2019). using psytoolkit allowed participants to complete the study without any in-person interaction, minimizing any chance of spreading covid-19 and allowing us to distribute the study more widely. psytoolkit meets the standards of data protection laws in europe and is supported by sona. there is currently no available reliability and validity on the navon and stroop task as measured through psytoolkit. however, other studies have used psytoolkit to measure reaction times and inhibitory control (e.g., invernizzi et al., 2022; utamatanin & pariwatcharakul, 2022). other theses and dissertations have utilized psytoolkit in studies measuring the stroop task (e.g., ackerman, 2022; anjomshoae, 2022; bertleff, 2022). while there is limited data on these tasks as measured on psytoolkit, psytoolkit was the best option for collecting the data needed, considering our available resources. the state-trait anxiety inventory (stai) form y was used to measure state anxiety (in the present moment) and trait anxiety (general sense of anxiety). the stai is a 4-point likert scale ranging from “not at all” to “very much so” (spielberger et al., 1983). stai-s is the state anxiety subscale, consisting of 20 items about “how you feel right now, at this moment,” and stai-t is the trait anxiety subscale also consisting of 20 items about “how you generally feel.” in a sample of undergraduate students, the internal consistency reliability for males on the stai-s was α = 0.91, and on the stai-t, α = 0.90. for females, stai-s was α = 0.93, and for stai-t, α = 0.91 (spielberger, 1983). in a meta-analysis, barnes et al. (2002) reported an average internal consistency for stai form y of α = .92. in a sample of undergraduate students, creamer et al. (1995) found moderate test-retest correlation coefficients between the stai-t and the beck anxiety inventory (r = .57 and .68), as well as the stai-s with the beck anxiety inventory (r = .56 and .64). the navon task measures participants’ global and local processing. it was chosen because it has been used in previous literature on anxiety and global/local processing (becker et al., 2017; shilton et al., 2019). the navon task measures response times and errors in processing global and local visual elements (navon, 1977; nayar et al., 2015). this task presents the participant with a global stimulus (i.e., a large letter). this global stimulus shape comprises many local stimuli (i.e., small letters). participants are asked to decide if they see the target letters (h or o) on either the global level or the local level of the stimuli (stoet, 2010, 2017; navon, 1977). the psytoolkit version of the task consists of 50 trials: 12-13 global congruent trials, 12-13 local congruent trials, and 24-26 trials that have neither h nor o in either the global or local elements and consist of only other letters. each global-level figure is seven local-element letters tall and five letters wide. for the navon task, one study on undergraduate students had an average test-retest reliability using pearson correlation coefficients r = .66 for global-level processing and r = .73 for local-level processing, which suggests acceptable reliability (dale & arnell, 2013). first, participants viewed a screen with instructions and examples of congruent and incongruent trials, with no practice trials. upon clicking through the instructions, the task began. during each trial, participants viewed a large letter composed of small letters. participants had to indicate whether the figure contained the letters h or o by pressing a key. participants pressed the “b” key if either of these letters were present, and the “n” key if neither letter was included in the figure. participants had 4000 milliseconds to respond. a green smiling face would flash on the screen to alert participants if they correctly identified an h or o appearing on either the global or local level of the figure, and a red frowning face would appear if the participant incorrectly identified an h or o appearing. if participants exceeded the time limit without a response, the word “slow” would appear on the screen, leading to the next trial. the stroop task was chosen for this study because it is widely used to measure executive skills and functioning (rueda et al., 2016). the stroop color-word task provided by psytoolkit measures inhibition in executive control through response times. for this study, we exclusively used the color-word trials where the participant was asked to only respond to the color of the ink the word is in while ignoring its meaning. participants were expected to ignore the word’s meaning in this task and respond only to its color. there were congruent (e.g., the word blue in the ink color blue) and incongruent trials (e.g., the word red in the ink color blue). the psytoolkit version of the stroop color-word task consists of 40 trials of the color-word stroop task while ignoring the word’s meaning, with 11-12 congruent trials and 28-29 incongruent trials. the task began with 56 anxiety effects on attention-based tasks instructions and examples of congruent and incongruent trials, but there were no practice trials. upon clicking through the instructions, the task began. a fixation cross flashed on the screen for 250 milliseconds in these trials to direct the participant’s attention. this was followed by the name of a color (blue, red, yellow, or green) in blue, red, yellow, or green ink flashing on the screen for 2000 milliseconds, during which the participants had to identify the color of the ink with a key press. the participant had to press the key on their keyboard that matched the corresponding color: b for blue, r for red, y for yellow, and g for green. in each trial, the participant had to respond within 2000 milliseconds. if they chose the incorrect key or exceeded the time limit, the word “wrong” would appear on the screen, leading to the next trial. if they chose the correct key, the word “correct” would appear. one study using undergraduate students found retest reliability for the standard stroop color-word task’s congruent color-word α = .71 (p < .001) and an incongruent color-word of α = .79 (p < .001) (strauss et al., 2005). procedures to begin, the participants visited the url and read the informed consent. after agreeing to participate, participants completed the state anxiety index of the stai. participants then completed both the navon and stroop tasks. we chose to put the state anxiety subscale before the two tasks to get as accurate a measurement of their current state as possible. we also chose to put the trait subscale after the tasks in an attempt to avoid inducing any additional anxiety in the participant. the study was counterbalanced so that equal numbers of participants started with the navon or the stroop task. there were no breaks between the two tasks, with the next task following the completion of the first task. upon completion of both tasks, the participants then completed the trait anxiety index of the stai. this was followed by the collection of demographic information. lastly, a debriefing statement appeared on screen thanking the participants for their participation and ending the experiment. results analysis summary all the data was analyzed using jamovi (version 2.4.1). participants were split into low and high anxiety groups by their mean scores on the stai-s and stai-t subscales for each task. in the navon task, we divided participants into a low trait anxiety group and a high trait anxiety group using a mean split of the stai-t scores. we conducted a t-test to compare median response times on global congruent trials between participants with high and low trait-anxiety. we used the same method to compare the two groups’ response times for local congruent trials. for the stroop task, we divided participants into four groups based on state and trait anxiety. we conducted an anova to compare response times on incongruent trials across the four groups. state-trait anxiety inventory we calculated each participant’s state anxiety scores (stai-s) and trait anxiety scores (stai-t). scores were calculated by summing the likert responses (valued one to four) on each 20-item subscale, with some items being reverse-coded per the stai manual (spielberger et al., 1983). for each subscale (stai-t, stai-s), scores can range from 20 to 80. in the original normative data, their college sample was split into male and female groups. the male group’s average score on the state subscale was (m = 36.47, sd = 10.52), and the female group’s average score on the state subscale was (m = 38.76, sd = 11.07). the average male score on the trait subscale was (m = 38.30, sd = 8.88), and the average female score on the trait subscale was (m = 40.40, sd =9.31) (spielberger et al., 1983). in our study, participants’ scores on each subscale of the stai were used to create a mean split to divide participants into high and low trait anxiety and high and low state anxiety groups as indicated. participants’ state anxiety subscale scores (n = 117, m = 45.56, sd = 11.78) were normally distributed, slightly skewed right with a .20 skewness, and platykurtic with kurtosis of -.73. trait anxiety (n = 117, m = 51.74, sd = 11.91) was normally distributed, slightly skewed left with a -.21 skewness, and platykurtic with kurtosis of -.42. navon task reaction times in each trial were measured in milliseconds, with a notation of whether the trial was a local or global congruent task. we calculated the median reaction time for each participant for global and local trials. we then divided participants into hightrait and low-trait anxiety groups using a mean split on their stai-t scores. we calculated a mean global and local reaction time based on the median scores for each group and compared them using one-tailed t-tests. we conducted a t-test on median global pro57 desoto & gaby cessing response times in milliseconds, comparing low and high trait anxiety groups to address our first hypothesis. we hypothesized that participants with high trait anxiety would have slower reaction times on global processing than those with low trait anxiety. equality of variance was assumed f(1,115) = 0.979. we did not find a statistically significant difference, t(115) = -0.09, p = .464, d = -0.02 between our low trait anxiety (n = 58, m = 828.67, sd = 171.97) and high trait anxiety (n = 59, m = 831.60, sd = 180.98) groups in reaction times on global trials. we also conducted a t-test on median local processing response times in milliseconds, comparing low trait and high trait anxiety groups to address our second hypothesis. we hypothesized that participants with high trait anxiety would have faster reaction times on local processing than low trait anxiety participants. equality of variance was assumed, f(1,115) = .660. we did not find a statistically significant difference, t(115) = -1.15, p = .127, d = -0.21 between our low trait anxiety (n =58, m = 815.78, sd = 179.60) and our high trait anxiety (n = 59, m = 861.09, sd = 242.95) groups in reaction times on local trials. stroop task lastly, we conducted a one-way anova between the low state/low trait group (ll) (n = 43, m = 927.70, sd = 180.87), high state/low trait (hl) (n = 15, m = 1021.40, sd =225.63), low state/ high trait (lh) (n = 22, m = 923.91, sd =177.71), and high state high trait group (hh) (n = 37, m = 942.38, sd = 162.84) on median stroop incongruent trials. we did not find a statistically significant difference between groups, f (3, 113) = 1.12, p = .344. this addressed our last hypothesis, that the three groups of anxiety (hl, lh, and hh) would have slower reaction times on the incongruent trials of the stroop task when compared to the control group (ll). discussion this study explored the possible interactions between state and trait anxiety and attention in college students through performance on versions of the navon and stroop tasks available on psytoolkit (stoet, 2010, 2017). we measured the relationship of trait anxiety with global and local processing using the navon task. we also measured the relationship between state anxiety and trait anxiety on cognitive inhibition of executive control through the stroop task. we did not find statistically significant results to support our three hypotheses: there was no association found between anxiety and performance on either task in this study. anxiety and global/local processing we hypothesized that participants with high trait anxiety would have slower reaction times on global processing trials than those with low trait anxiety. additionally, based on previous findings, we hypothesized that participants with high trait anxiety would have faster reaction times on local processing trials than low-anxiety participants. however, our results showed no significant differences between groups on either task. some evidence suggests the lack of a finding in our global processing t-test is not surprising (shilton et al., 2019). there is considerable evidence from previous literature for our local processing hypothesis (basso et al., 1996; becker et al., 2017; derryberry & reed, 1998; shilton et al., 2019). interestingly, although not statistically significant, our results went in the opposite direction of what was hypothesized for local processing: on average, for global trials, low trait anxiety participants (m = 828.67) had slightly faster reaction times than high trait anxiety participants (m = 831.60). for local trials, the high trait anxiety participants (m = 861.09) had slightly slower reaction times than those with low trait anxiety (m = 815.78). our high trait anxiety participants did not display a local processing bias. variations between our design and previous studies may explain our findings (e.g., online study or having specific target letters). some of the previous literature used different global and local processing paradigms (basso et al., 1996; shilton et al., 2019). other variables could also explain the observed results, including variability due to uncontrolled testing environments, as participants completed the study online with no restrictions about the type of location where they completed the tasks. there is a need to further investigate global and local processing in college samples. in a sample of undergraduate students, tan et al. (2017) found evidence that their participants were more willing to take academic risks when globally primed than participants who were locally primed. this willingness to take more significant risks in an educational setting could lead to greater academic achievement. to our knowledge, the literature on global and local processing and academic success is sparse. one study used a global and 5858 anxiety effects on attention-based tasks local processing paradigm to predict academic achievement. however, this study focuses on meta-motivation, and it was unclear how global and local processing affect academic achievement (nguyen et al., 2023). another study found that in children with attention-deficit/hyperactivity disorder, the ability to shift between global and local stimuli was predictive of academic achievement. (sjöwall & thorell, 2014). in that same study, inhibition was also predictive of academic achievement (sjöwall & thorell, 2014). additionally, the ability to efficiently process one’s visual environment on the global level appears to be beneficial in understanding written communication (woltin et al., 2012). this may translate to the ability to understand the information in a textbook while studying, suggesting that if anxiety does decrease global processing, high trait anxiety could impair reading ability while studying (basso et al., 1996). anxiety and stroop task we hypothesized that the hl group (m = 1021.40), lh group (m = 923.91), and the hh group (m = 942.38) would have slower reaction times on the incongruent trials of the stroop task when compared to the ll group (m = 927.70). we found no significant impact of anxiety on response inhibition. our groups’ distributions may have contributed to our observed results (see limitations for a more in-depth discussion). it is important to continue investigating how various factors influence executive attention. studies have found a correlation between executive functioning and academic achievement from early childhood through college (baars et al., 2015; best et al., 2011). limitations this study had several limitations, one of which was group dispersion. for our anova, we would have preferred to have roughly 25 participants in each of our four groups. instead, we had 43 participants in our ll group, 15 participants in our hl group, 22 participants in our lh group, and 37 participants in our hh group. this lack of dispersion may have prevented our groups from varying enough to observe any notable differences. collectively, our average stai scores were roughly a standard deviation above the original normative sample (spielberger et al., 1983). this may have contributed to a lack of lower levels of anxiety. another limitation is the fact that we measured state anxiety without any stress induction or any way to control it. this caused us to rely on participants already being in an anxious state when creating our groups. the average age of participants in our study was only 19.85. previous studies had participants ranging in age from 17 to 71. many previous studies used participants with a wider range of ages; it is possible that age may contribute to the discrepancies between those studies and our results (hallion et al., 2017; pacheco-unguetti et al., 2010; rosa-alcázar et al., 2021). our study may better represent anxiety’s effect on predominantly white college students between the ages of 18-25, but it may not be generalizable to other demographics or the general population. preferably, we would have recruited more participants to allow us to exclude additional factors that may have affected their performance, such as the use of psychotropic medication, psychotherapy, and past head injury (e.g., traumatic brain injury, concussion). as previously mentioned, the study was conducted entirely online, which limits our control of participants’ machines and testing environments. additionally, psytoolkit versions of both tasks required the use of key inputs. this motor input might have unintentionally activated areas of the brain (cramer et al., 1999), which would ultimately add additional variability. despite this, hallion et al. (2017) also used a computer-adapted version of the stroop task and found evidence suggesting that the presence of gad predicted stroop task results. previous studies that used the traditional stroop color word test design with word trials and color trials may also contribute to the observed differences (hallion et al., 2017; rosa-alcázar et al., 2021). the psytoolkit version of the stroop task required four different keystrokes, which might have made the task more confusing and possibly measured more than response inhibition. additionally, we eliminated timed-out and incorrect trials, where the traditional stroop color word test asks the test taker to retry the item as the timer goes down. our method requires the test taker to inhibit their response to every trial correctly. differences between versions of the task may influence observed performance. we also used versions of these tasks that do not have normative data. finally, we had more women in our high anxiety group than our low anxiety group, which could possibly impact scores. additionally, having a higher percentage of males in our low anxiety groups may have had an impact on the observed results. males and females are known to desoto & gaby have neural structural differences (ingalhalikar et al., 2013). specifically, findings in other visual perception tasks that target the right parietal lobe show a difference in performance between males and females (kalichman, 1988; linn & petersen, 1985). given this, our findings on global processing, which targets the right parietal lobe, may be affected by gender differences between groups (kimchi & merhav, 1991). future directions in the future, studies should examine other areas we did not address, such as socioeconomic status, culture, or gender-related differences that may contribute to individual differences on these tasks. future studies examining how emotions, mood, and anxiety may contribute to deficits in attention should consider a more general and comprehensive battery, such as tasks designed to measure the other two neural networks of attention, proposed by posner and petersen (1990) (alerting and orienting). in this study, only one aspect of executive attention was measured, which was response inhibition. there are other parts of executive functioning and other tasks that measure these aspects (e.g., tower of london, trail making test, and wisconsin card sorting test) that could be used for future research (etnier & chang, 2009). future studies comparing all-male to all-female participants may be beneficial in observing whether there are any gender differences in these tasks as measured by psytoolkit. psytoolkit is a free and readily available resource for psychological testing. this makes it ideal for use by students and others with limited funding and resources. therefore, it is crucial to establish normative values and ecological validity for these specific versions of each task, which would enable future research and possibly clinical applications. conclusion our three hypotheses that global processing, local processing, and response inhibition would be impacted by elevated levels of anxiety were not supported. the results of this project are inconsistent with previous findings (basso et al., 1996; becker et al., 2017; derryberry & reed, 1998; hallion et al., 2017; pacheco-unguetti et al., 2010; rosa-alcázar et al., 2021; shilton et al., 2019). anxiety symptoms appear prevalent in college students, and academic achievement has been observed as one of the most significant stressors in a student’s life (asher blackdeer et al., 2021; beiter et al., 2015). additionally, while not replicated in this study, there is previous literature that suggests anxiety can harm not only attention but academic achievement, as well (basso et al., 1996; cassady & johnson, 2002; hoegler & nelson, 2018; pacheco-unguetti et al., 2010; rosa-alcázar et al., 2021; vitasari et al., 2010). literature suggests that better performance on the tasks used in this study can predict academic achievement. future studies are needed to address the uncertainty of the effects state anxiety may have on the stroop task, as there are mixed findings and conflicting theories about whether state anxiety is beneficial or detrimental to executive functioning (eysenck et al., 2007; 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(2012). improving communicative understanding: the benefits of global processing. journal of experimental social psychology, 48(5), 1179–1182. https://doi.org/10.1016/j.jesp.2012.03.004 77 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university examining coping skills, anxiety, and depression dynamics amidst the covid-19 pandemic lauren moment department of psychology, university of colorado, denver this cross-sectional study, conducted amid the covid-19 pandemic, delves into the intricate connections between coping strategies and levels of anxiety and depression, presenting vital implications for medical, clinical, and broader societal contexts. as crises like the pandemic highlight the importance of adaptive coping, this investigation underscores the imperative to comprehend and address maladaptive coping strategies. the study utilized a diverse sample of 386 participants during the pandemic's peak, employing online platforms for recruitment and ensuring broad demographic representation. data were collected through self-report measures, including the patient health questionnaire-4 (phq-4) for depression and anxiety symptoms and the brief coping orientation to problems experienced (cope) inventory to assess coping skills across various domains. the coping skills assessment measured strategies such as self-distraction, active coping, denial, substance use, emotional and instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. the colorado multiple institutional review board prioritized and approved ethical considerations, and participants provided informed consent. data analysis involved rigorous cleaning, recoding, and quantitative analysis using spss. descriptive statistics, regression analyses, and correlation analyses were employed to uncover nuanced relationships between coping strategies and mental health outcomes, contributing to understanding the phenomena under investigation within the context of the pandemic. the findings highlight the pivotal role of individualized approaches and the potential of humor as an essential coping mechanism, emphasizing the need for tailored interventions during crises. keywords: pandemic, covid-19, anxiety, depression, coping skills coping skills have gained significant attention for their profound impact on psychological well-being, particularly in the face of heightened stressors such as the ongoing covid-19 pandemic. this exploration delves into the intricate relationship between coping skills, depression, and anxiety, emphasizing critical studies that contribute to our understanding of these complex dynamics. the relationship between coping mechanisms and mental health outcomes, specifically depression and anxiety, has been extensively investigated. as the pandemic continues to present unprecedented challenges to global well-being, understanding the dynamics of coping in this context becomes crucial. the transactional model of stress and coping provides a foundational framework, emphasizing the dynamic nature of the stress-coping process (etchin et al., 2020). yeşiloğlu et al. (2023) further classify coping strategies into problem-focused and emotion-focused, shedding light on their distinct impacts on mental health. adaptive and maladaptive coping strategies play pivotal roles in elucidating the nuanced relationships between coping mechanisms and mental health outcomes. features of anxiety and depression may exhibit adaptive characteristics, emphasizing the need for an understanding of coping strategies beyond a binary categorization (morris, 2019). adaptive coping is conceptualized as strategies facilitating effective stress management, enhancing resilience, and contributing to overall psychological well-being. examples include seeking emotional and instrumental support, positive reframing, active problem-solving, and employing humor. these adaptive coping mechanisms are considered beneficial in navigating challenges and promoting mental health during times of crisis. in contrast, maladaptive coping is characterized by strategies that may exacerbate stress, contribute to symptomatology, and hinder psychological resilience, including self-blame, denial, substance use, and behavioral disengagement. specific coping mechanisms may be context-dependent, exhibiting adaptive or maladaptive qualities based on circumstances and individual differences. coping skills and anxiety the interplay between coping skills and anxiety unravels the complexities of adaptive and maladaptive responses to stress, shedding light on the diverse strategies individuals employ to manage anxious thoughts and emotions. aldwin and revenson (1987) have significantly contributed to our comprehension of this relationship by establishing a correlation between effective coping strategies and reduced levels of anxiety. the effectiveness of adaptive coping strategies, particularly those focused on problem-solving, has been consistently demonstrated in alleviating symptoms associated with anxiety (buffart et al., 2020). engaging in active problem-solving empowers individuals to confront stressors directly, disrupting the cycle of anxious thoughts and fostering a sense of control over 78 their circumstances. conversely, maladaptive coping strategies, such as wishful thinking or avoidance, fuel the perpetuation of anxiety symptoms, emphasizing the importance of distinguishing between adaptive and maladaptive coping approaches (carver et al., 1989). coping skills and depression the relationship between coping skills and depression has been a focal point in psychological literature. maladaptive coping strategies, such as avoidance and rumination, consistently surface as significant contributors to the exacerbation of depressive symptoms (aldao et al., 2010). southward, howard, and cheavens (2023) conducted a comprehensive study highlighting the detrimental effects of maladaptive coping strategies on mental health, particularly with depression. avoidance mechanisms may prolong negative emotional experiences. similarly, rumination, characterized by repetitive and intrusive negative thinking, has been identified as a significant risk factor for the development and perpetuation of depressive symptoms over time (nolen-hoeksema, 1991). addressing these maladaptive coping strategies is crucial for unraveling the complex dynamics underlying depression. coping during the covid-19 pandemic: a multifaceted perspective recent studies underscore the relevance of coping skills in navigating the challenges posed by significant life disruptions, such as the ongoing covid-19 pandemic. research by gurvich et al. (2021) and holmes et al. (2020) emphasizes the importance of effective coping mechanisms in fostering resilience during unprecedented times. in navigating the mental health implications of the covid-19 pandemic, individuals have been compelled to employ coping strategies to manage heightened anxiety levels. research by ogueji et al. (2021) on coping strategies in the united kingdom during the pandemic provides valuable insights into the adaptive mechanisms individuals adopt to cope with the stressors unique to this global health crisis. similarly, the survey by kar et al. (2021) delves into stress and coping during the pandemic, underscoring the importance of effective coping in mitigating the psychological impact of the crisis. these studies, situated within the context of a global pandemic, serve as examples of the relevance and urgency of understanding coping skills, particularly in managing anxiety during significant life disruptions. they underscore the need to understand coping dynamics and the potential adaptation of coping mechanisms in response to unprecedented stressors. adaptive coping as a protective factor in contrast to maladaptive coping, adaptive coping strategies emerge as protective factors in mitigating the impact of stress on mental health, particularly in the context of depression. problem-solving, a fundamental component of adaptive coping, involves actively addressing stressors and employing constructive solutions to navigate challenges effectively (compas et al., 2001). another adaptive strategy, seeking social support, has been consistently associated with positive mental health outcomes. compas et al. (2001) highlighted the protective effect of adaptive coping by linking problem-solving and social support-seeking with lower levels of depression. nuanced roles of coping mechanisms the understanding of coping mechanisms and their roles in influencing mental health outcomes sets the stage for an exploration of the interplay between coping and depressive symptoms. research has not only elucidated the distinct impact of maladaptive and adaptive coping but has also emphasized the need for a holistic approach to intervention. the complexity of the relationship underscores the importance of tailoring therapeutic strategies to address individual coping profiles and their specific implications for mental health. exploring coping styles in response to societal changes gurvich et al. (2021) delve into the intricate dynamics of coping styles in response to societal changes during the pandemic. this study sheds light on individuals' coping strategies as societal norms change. the significance of this research lies in its contribution to our understanding of coping as a dynamic and adaptive process that individuals engage in when faced with transformative societal challenges. diverse populations and coping dynamics studies conducted by savitsky et al. (2020) have taken a comprehensive approach to explore coping during the pandemic across diverse populations. these investigations unravel the intricate interplay between coping strategies, mental health outcomes, and overall quality of life. by examining coping mechanisms across various demographic groups, these studies contribute to understanding how different population segments moment 79 navigate stress and adversity during the pandemic. healthcare workers: coping on the frontlines the study conducted by rose et al. (2021) serves as an investigation into the coping mechanisms employed by healthcare workers, shedding light on the distinctive challenges faced by those on the frontlines of the covid-19 pandemic. healthcare professionals, as frontline workers, navigate an array of stressors, including high work demands, exposure to the virus, and witnessing the impact of the pandemic on patients. understanding the coping dynamics of healthcare workers is paramount for several reasons. healthcare professionals are subjected to heightened levels of stress and emotional strain due to the nature of their work, potentially leading to burnout and mental health challenges (shanafelt et al., 2020). a study by lai et al. (2020) highlights the prevalence of anxiety and depression among healthcare workers during the covid-19 pandemic, underscoring the need for effective coping strategies. moreover, the well-being of healthcare workers has broader implications for public health. an overburdened and stressed healthcare workforce is more susceptible to making errors, experiencing reduced job satisfaction, and facing challenges in delivering high-quality patient care (west et al., 2018). therefore, the psychological health of healthcare workers is essential to maintaining a resilient and effective healthcare system. in the context of the covid-19 pandemic, understanding and addressing the mental health of healthcare workers has also become crucial for the broader community. the psychosocial well-being of healthcare professionals influences their ability to effectively manage the challenges posed by the pandemic, contributing to the overall resilience of the healthcare system (kisely et al., 2020). as highlighted by greenberg et al. (2020), the mental health of frontline workers is critical in ensuring a sustained and robust response to public health crises. contributions to the evolving narrative these studies contribute to the evolving narrative on coping during the covid-19 pandemic. these investigations provide an examination of coping from various angles, considering different populations and contexts, and emphasizing the dynamic nature of coping strategies. the current investigation strategically adopts a cross-sectional design to align with this complex landscape, capturing a timely snapshot of how coping strategies relate to anxiety and depression during the ongoing pandemic. hypotheses 1. self-distraction hypothesis: individuals who employ self-distraction as a coping mechanism (redirecting attention to activities) will exhibit lower levels of anxiety and depression compared to those who do not engage in this coping strategy. 2. active coping hypothesis: participants who proactively address stressors through active coping strategies will demonstrate lower anxiety and depression levels than individuals who lack operational coping tendencies. 3. denial hypothesis: individuals who frequently resort to denial as a coping strategy (avoiding or refusing to acknowledge stressors) will display higher levels of anxiety and depression compared to those who employ alternative coping mechanisms. 4. substance use hypothesis: participants who turn to substances as a coping mechanism will exhibit elevated levels of anxiety and depression compared to those who utilize alternative coping strategies. 5. emotional support hypothesis: individuals who seek emotional support (seeking empathy and understanding from others) will demonstrate lower anxiety and depression levels compared to those who do not actively pursue emotional support. 6. instrumental support hypothesis: participants who seek tangible assistance or advice (use instrumental support) as a coping strategy will exhibit lower levels of anxiety and depression compared to those who do not engage in this coping mechanism. 7. behavioral disengagement hypothesis: individuals who frequently withdraw from stressors through behavioral disengagement will display higher levels of anxiety and depression compared to those who employ alternative coping strategies. 8. venting hypothesis: participants who express negative emotions through venting as a coping strategy will demonstrate lower levels of anxiety and depression compared to individuals who do not engage in this coping mechanism. 9. positive reframing hypothesis: individuals who reinterpret stressors in a positive light through positive reframing will exhibit lower levels of anxiety and depression compared to those who do not employ this coping strategy. 10. planning hypothesis: participants who engage examining coping skills, anxiety, and depression 80 in planning and strategizing to overcome stressors will demonstrate lower anxiety and depression levels compared to those who lack effective planning as a coping mechanism. 11. humor hypothesis: individuals who find humor in challenging situations will exhibit lower levels of anxiety and depression compared to those who do not use humor as a coping strategy. 12. acceptance hypothesis: participants who acknowledge and accept stressors (acceptance as a coping strategy) will demonstrate lower levels of anxiety and depression compared to those who struggle with accepting stressors. 13. religion hypothesis: individuals who turn to religious or spiritual beliefs as a coping mechanism will exhibit lower levels of anxiety and depression compared to those who do not engage in religious coping strategies. 14. self-blame hypothesis: participants who take responsibility for stressors through self-blame will display higher levels of anxiety and depression compared to those who employ alternative coping mechanisms. methods study design a cross-sectional design was employed to investigate the relationships among coping skills, anxiety, and depression. the selection of a cross-sectional approach allowed the researcher to examine these variables simultaneously, providing a snapshot of their associations within a specific timeframe. the adoption of a cross-sectional design conferred several distinct advantages to this investigation. it facilitated a thorough exploration of the dynamic interplay between coping skills, anxiety, and depression without necessitating a protracted observational period. this data collection and analysis efficiency is particularly noteworthy, enabling the researcher to understand the relationships among these variables within a relatively condensed timeframe. the cross-sectional design further empowered the researcher to discern patterns and associations in real-time, capturing a momentary cross-section of participants' experiences and mental health dynamics. by leveraging the advantages of the cross-sectional approach, the study not only efficiently investigated the interconnections among coping skills, anxiety, and depression but also provided a timely and relevant depiction of these associations. this design choice reflects a pragmatic and effective methodological strategy, enhancing the study's capacity to contribute meaningful insights to the existing body of knowledge in mental health research. participants these data were collected during the summer and fall of 2020, the pinnacle of the covid-19 pandemic. a total of 386 participants contributed to this study by completing assessments related to coping skills, anxiety, and depression. the diverse participants ensured a broad representation of demographics and experiences (see table 1). recruitment the study employed a recruitment strategy leveraging various online platforms such as canvas, facebook, twitter, instagram, and reddit. the recruitment aimed to assemble a sample (n = 386) that met specific eligibility criteria, including being over 18 years old and proficient in english. measures and coping skills assessment as part of the self-report measures, participants engaged with the patient health questionnaire-4 (phq-4), a succinct four-item tool designed to assess symptoms of depression and anxiety over the preceding two weeks. the phq-4 utilized a scoring system to categorize responses, where a total score greater than or equal to three for the first two questions indicated anxiety and the same threshold for the last two questions suggested depression. scores were further stratified into normal (0-2), mild (3-5), moderate (6-8), and severe (9-12) categories, offering an understanding of participants' mental health status. additionally, participants completed a coping skills inventory, a robust instrument known as the brief coping orientation to problems experienced inventory. this tool measured coping skills across various domains without employing reversals of coding. the following coping skills were assessed, each associated with specific items that were summed: 1. self-distraction (items 1 and 19): redirecting attention to activities to cope with stress. 2. active coping (items 2 and 7): proactively address stressors. 3. denial (items 3 and 8): avoiding or refusing to acknowledge stressors. 4. substance use (items 4 and 11): turning to substances as a coping mechanism. 5. use of emotional support (items 5 and 15): moment 81 seeking empathy and understanding from others. 6. use instrumental support (items 10 and 23): seeking tangible assistance or advice. 7. behavioral disengagement (items 6 and 16): withdrawing from stressors. 8. venting (items 9 and 21): expressing negative emotions. 9. positive reframing (items 12 and 17): reinterpreting stressors in a positive light. 10. planning (items 14 and 25): strategizing to overcome stressors. 11. humor (items 18 and 28): finding humor in challenging situations. 12. acceptance (items 20 and 24): acknowledging and accepting stressors. 13. religion (items 22 and 27): turning to religious or spiritual beliefs. 14. self-blame (items 13 and 26): taking responsibility for stressors. these coping skills, each measured by specific items, contributed to an understanding of participants' strategies for dealing with stress and adversity—the assessment aimed to uncover how individuals approach and navigate life challenges. procedures ethical considerations were paramount in conducting this research, and the study received approval from the colorado multiple institutional review board (comirb). participants provided informed consent before completing online surveys, a process overseen by the comirb (identification number 20-2870). the survey took approximately 30 minutes, thoroughly exploring participants' coping mechanisms and mental health. data analysis quantitative data, exported from qualtrics to spss v27, underwent a systematic analysis. initial recording aligned responses with predefined scales, facilitating categorization and interpretation—rigorous cleaning and recoding followed to enhance data reliability and validity. descriptive statistics provided an overview, including mean and standard deviations. regression analyses explored variable relationships, identifying potential predictors. correlation analyses delved into associations, unveiling patterns and interdependencies within the dataset. this analytical approach aimed to extract insights from the collected data, contributing to a robust understanding of the investigated phenomena. results the descriptive statistics and correlations for anxiety, depression, and various study variables were examined in a sample of 386 participants (see table 2). the mean anxiety score was 4.83 (sd = 2.04), which is within the range of mild anxiety, and the mean depression score was 4.72 (sd = 2.06), which is within the range of mild depression. among the coping strategies assessed, self-distraction exhibited a positive correlation with anxiety (r = 0.23, p < .01) and a positive, albeit less substantial, correlation with depression (r = 0.15, p < .05). active coping, on the other hand, showed a negative correlation with both anxiety (r = -0.16, p < .05) and depression (r = -0.29, p < .01). the use of emotional support was negatively correlated with both anxiety (r = -0.18, p < .01) and depression (r = -0.34, p < .01), indicating that higher utilization of emotional support was associated with lower levels of anxiety and depression. similar patterns were observed for the use of instrumental support, with a negative correlation with depression (r = -0.28, p = < .01). behavioral disengagement demonstrated positive correlations with anxiety (r = 0.22, p < .01) and depression (r = 0.36, p < .01). positive reframing demonstrates a negative association with depression (r = -0.18, p < .01), suggesting that individuals employing positive reframing may experience lower depression levels. planning demonstrates a positive association with anxiety (r = 0.27, p < .01) and depression (r = 0.23, p < .01). suggesting that individuals employing planning may experience higher anxiety and depression levels. notably, humor was strongly negatively correlated with both anxiety (r = -0.43, p < .01) and depression (r = -0.43, p < .01). religion showed a negative correlation with depression (r = -0.18, p < .01), but no significant correlation with anxiety. self-blame displayed positive correlations with both anxiety (r = 0.34, p < .01) and depression (r = 0.29, p < .01). the anxiety and depression scores were highly correlated (r = 0.65, p < .01), emphasizing a strong association between anxiety and depression within the sample. the regression analysis for anxiety (see table 3) reveals several coping styles with significant associations. notably, engaging in humor (b = -0.51, β = -0.29, t = -4.42, p < .001) is strongly linked to lower anxiety levels. additionally, self-blame (b = 0.35, β = 0.27, t = 3.36, p < .001) exhibits a positive associexamining coping skills, anxiety, and depression 82 ation with anxiety, indicating that individuals employing self-blame as a coping mechanism are more likely to experience heightened anxiety. these relationships are robust, as reflected in the wide 95% confidence intervals (ci) for both humor (ll = 0.28, ul = 0.74) and self-blame (ll = 0.14, ul = 0.55), further supporting the reliability of these findings. the regression analysis for depression (see table 4) also highlights significant coping styles. behavioral disengagement (b = 0.30, β = 0.253 t = 4.43, p < .001) is positively associated with depression, suggesting that individuals utilizing this coping mechanism may experience elevated depressive symptoms. in contrast, humor (b = -0.44, β = -0.23, t = -4.10, p < .001) is negatively associated with depression, suggesting that individuals utilizing these coping mechanisms may experience lower depressive symptoms. the use of emotional support (b = -0.19, β = -0.19, t = -2.68, p = 0.008) and religion (b = -0.20, β = -0.15, t = -2.35, p = 0.02) demonstrate negative associations with depression, indicating that these coping styles are linked to lower depressive symptoms. conversely, acceptance (b = 0.23, β = 0.17, t = 2.53, p = 0.01) is positively associated with depression, suggesting that individuals utilizing this coping mechanism may experience elevated depressive symptoms. the 95% ci for these significant relationships further strengthens their validity. several coping styles did not exhibit statistically significant associations with anxiety and depression. these include self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, venting, positive reframing, planning, acceptance, and religion in the context of anxiety, as well as self-distraction, active coping, denial, substance use, use of instrumental support, venting, positive reframing, and planning in the context of depression. the lack of statistical significance suggests that these coping styles may not be directly linked to anxiety or depression in the studied population, underscoring the diversity of coping mechanisms individuals employ, and emphasizing the need for personalized approaches in clinical interventions. the consideration of unstandardized coefficients (b), standardized coefficients (β), t-values, p-values, and 95% confidence intervals enhances the robustness and interpretability of these findings in the context of mental health outcomes. this analysis provides an understanding of how specific coping styles relate to anxiety and depression, shedding light on both significant and non-significant associations. discussion the multiple linear regression analyses yield crucial insights into the intricate relationships between coping styles and anxiety and depression. contextualizing these findings within the broader framework of significant life disruptions, such as those experienced during the covid-19 pandemic and other catastrophic events, is essential. regarding coping styles and anxiety, humor exhibits a negative association with anxiety levels, aligning with contemporary literature emphasizing its effectiveness as a stress-coping strategy (marziali et al., 2008). it emerges as a protective factor against depression, supporting its mood-enhancing and stress-reducing effects, particularly relevant during major life disruptions (chen & lim, 2022). the positive association observed between selfblame and anxiety underscores the maladaptive nature of this coping style, particularly during crises (maunder et al., 2010). the inclination toward self-blame may exacerbate anxiety symptoms, emphasizing the importance of identifying and redirecting such maladaptive coping. additionally, the link between behavioral disengagement and higher depression levels reinforces the need to address maladaptive coping that could lead to heightened depression (bonanno, 2004). the findings also highlight the potential vulnerability of disengaging from active coping strategies when facing adversity. the significant negative associations of the use of emotional support and acceptance with depression underscore the pivotal role of social support and adaptive acceptance in promoting mental well-being, aligning with studies emphasizing the importance of interpersonal connections during crises (rosen et al., 2022). behaviors that accentuate emotional and instrumental support, humor, and acceptance align with identified protective factors against depression and anxiety. recognizing the diverse nature of individual coping mechanisms is essential. (stanley et al., 2021). the unique nature of crises emphasizes the need for targeted interventions that address maladaptive coping strategies, such as self-blame, pervasive in the aftermath of catastrophic events. it is crucial to recognize ineffective coping mechanisms and redirect them towards more constructive approaches. this aligns with moment 83 established best practices outlined by the national academies of sciences, engineering, and medicine (2019), emphasizing the importance of psychoeducation to enhance emotional and instrumental support. the literature on coping during catastrophic events underscores the need for a multifaceted approach. studies highlight the importance of community-level coping strategies in the aftermath of large-scale disasters, emphasizing the interconnectedness of individual coping with broader societal responses (bonanno et al., 2010). the collective efficacy of communities in navigating and recovering from catastrophic events is an essential aspect that complements individual coping strategies (kocalevent et al., 2015). their research suggests that resilience is not a uniform trait, and individuals may employ various coping mechanisms based on their unique characteristics and circumstances (bonanno & diminich, 2013). the implications of effective coping mechanisms in the context of catastrophic events extend beyond individual well-being to encompass broader societal resilience (norris et al., 2008. the ongoing covid-19 pandemic serves as a backdrop to these insights, emphasizing the need for adaptive coping strategies at the community level. as we navigate the aftermath of such events, an approach that addresses maladaptive coping enhances support systems, contributing to a more resilient and mentally healthy society. non-professionals can also independently implement effective coping strategies. these strategies can promote an individual's resilience and well-being by fostering supportive social networks and seeking tangible assistance when needed. in the broader context of community and societal well-being, awareness campaigns and educational initiatives become crucial. by disseminating information about effective coping strategies, the public can learn to create a more supportive and resilient society. this can enable individuals to cope better with challenging situations (holmes et al., 2020; world health organization, 2020). future directions it is imperative to broaden our investigation into sleep patterns and their potential interplay with mental health challenges, specifically anxiety and depression. sleep, acknowledged as a pivotal factor in mental well-being, represents a relatively uncharted terrain within the context of coping skills. probing into how coping skills might influence sleep quality and, reciprocally, how disrupted sleep patterns might impact mental health outcomes holds the promise of unveiling novel dimensions in our understanding of these phenomena. recognizing the bidirectional relationship between coping skills and sleep could furnish insights into the holistic well-being of individuals contending with anxiety and depression. sleep disturbances have been correlated with a spectrum of mental health challenges, and exploring this link within the framework of coping skills may furnish valuable information for developing integrated interventions (zhao et al., 2022). to propel our understanding further, future research endeavors may employ methodologies such as longitudinal studies or ecological momentary assessments, to capture real-time fluctuations in coping skills and sleep patterns. additionally, investigating potential mediating or moderating factors, such as stress or anxiety, could contribute to a more comprehensive understanding of the intricate connections between coping skills, anxiety, depression, and sleep. this study not only advances our understanding of coping skills and their associations with anxiety and depression but also lays the groundwork for future research initiatives, therapeutic approaches, and support mechanisms tailored to the unique needs of individuals grappling with these complex mental health challenges. limitations this study is subject to certain limitations that should be considered when interpreting the results. one notable limitation is the overrepresentation of women in the clinically significant range for depression and anxiety. additionally, the study's focus on a sample of notably younger and technologically adept participants raises the possibility that the results may apply primarily to specific demographic subsets rather than the entire population. moreover, the study was conducted amid the covid-19 pandemic, a period associated with a heightened prevalence of depression and anxiety. this temporal context could impact the results, potentially leading to an overestimation of mental health issues. researchers conducting similar studies with larger samples experiencing depression and anxiety should be cautious about generalizing findings to populations unaffected by pandemic-related stressors. therefore, recognizing the influence of the pandemic on mental health trends is crucial for a nuanced interpretation of study outcomes. examining coping skills, anxiety, and depression 84 conclusion understanding coping strategies and their profound implications for depression extends beyond clinical settings. recognizing individual coping patterns and tailoring interventions accordingly empowers both clinicians and individuals to contribute actively to advancing mental health and alleviating depression. this approach addresses the immediate needs of individuals and fosters a cultural shift towards a more empathetic and informed approach to mental health and well-being. comprehending coping strategies becomes even more crucial amid significant life disruptions, such as the ongoing covid-19 pandemic, emphasizing the need for effective coping mechanisms on a societal scale. the insights gained from understanding coping strategies during such turbulent times aid in immediate crisis management and contribute to the resilience and adaptability of individuals facing adversity. this study unveils the myriad coping strategies individuals adopt to navigate the complexities of mental health challenges. the insights gleaned offer a nuanced perspective on how coping skills may relate to emotional experiences and well-being during heightened stress and uncertainty. exploring coping strategies within the context of life-altering events is crucial for tailoring interventions to the unique needs of individuals experiencing mental health challenges. this research provides a timely contribution to our understanding of coping dynamics amid significant societal upheavals, facilitating the development of targeted strategies to support mental well-being during times of crisis. comprehending coping strategies extends beyond individual well-being to societal resilience, especially during the unparalleled challenges posed by events like the covid-19 pandemic. tailoring interventions to the distinctive needs of individuals grappling with mental health challenges during such disruptive events is integral to fostering a more adaptive society. acknowledgments the author thanks dr. timothy benke and dr. erik oleson for their invaluable guidance and steadfast support throughout the research process. their expertise and unwavering commitment significantly contributed to the study's development and execution. the author profoundly appreciates their mentorship and scholarly advice, which greatly enhanced the quality of the work. dr. benke and dr. oleson's unwavering belief in the research, continuous encouragement, and commitment to academic excellence were instrumental in overcoming challenges. the author acknowledges their mentors' profound impact on the study and expresses sincere gratitude for the privilege of collaborating with such remarkable mentors. references aldao, a., 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(2023). depression and anxiety during thecovid-19 pandemic: epidemiology, mechanism, and treatment. neuroscience bulletin, 39(4), 675–684. https://doi. org/10.1007/s12264-022-00970-2 examining coping skills, anxiety, and depression 88 table 1 table of demographic data note. nationality, age, and sex of participants. moment 89 table 2 descriptive statistics and correlations for anxiety, depression, and study variables examining coping skills, anxiety, and depression note. the table includes descriptive statistics and correlations for anxiety, depression, and study variables. the table includes mean (m), standard deviation (sd), and correlations with anxiety and depression scores. *p < .05, **p < .01. 90 table 3 regression for anxiety and coping styles moment note. the table presents unstandardized coefficients (b), standardized coefficients (β), lower limit (ll), upper limit (ul), t-values, p-values, and 95% confidence intervals for each predictor variable in relation to the dependent variable total anxiety. *p < .05, **p < .01. 91 table 4 regression for depression and coping styles examining coping skills, anxiety, and depression note. the table presents unstandardized coefficients (b), standardized coefficients (β), lower limit (ll), upper limit (ul), t-values, p-values, and 95% confidence intervals for each predictor variable in relation to the dependent variable total depression. *p < .05, **p < .01. 3636 exploring the mediating role of mentalization in the relationship between attachment styles and suicidal ideation in a non-clinical pakistani sample hamna ali khan, haya naseem, zara sohail, & arshi shabnam institute of professional psychology, bahria university, karachi, pakistan the aim of the current study is to determine the relationship between attachment styles, mentalization, and suicidal ideation using a quantitative correlational survey design in a non-clinical pakistani sample. a purposive-convenience sampling technique was employed to recruit n = 295 adults (males, n = 81; females, n = 214) from pakistan, aged 18 to 55 years (m = 23.07, sd = 5.37), using a google survey. it was hypothesized that there is a relationship between attachment styles, mentalization, and suicidal ideation. moreover, it was also hypothesized that there is a relationship between anxious attachment style and self-mentalization. to test the hypotheses, data were collected through three questionnaires: the mentalization scale (ments), the revised adult attachment scale (raas), and the suicidal ideation attributes scale (sidas). the study's results were analyzed using spss 29.0.1.0. the findings revealed that attachment styles have a relationship with mentalization, self-mentalization (ments-s), and suicidal ideation, whereas no significant correlation was found between mentalization and suicidal ideation. only self-mentalization was found to have a negative correlation with suicidal ideation (r = −0.14, p = .01). anxious attachment style was found to have a negative correlation with self-mentalization (r = −0.42, p = .01) and a positive correlation with suicidal ideation (r = 0.26, p = .01). the current findings underscore the importance of integrating emotional regulation strategies in therapeutic work with individuals with anxious attachment styles to prevent the development of suicidal ideation. keywords: attachment styles, mentalization, suicidal ideation suicidal ideation and attempts are growing concerns across pakistani society, as literature highlights that 40% of pakistani university students have reported a history of suicidal ideation, out of which 30% experienced suicidal ideation in 2018, explicitly indicating the need for the development of suitable interventions (bibi et al., 2019). to comprehend the underlying mechanisms of suicidal ideation, it is necessary to investigate attachment style and mentalization as two significant predisposing psychological factors (green et al., 2021). this study was conducted to explore the relationship between attachment styles, mentalization, and the increasing rate of suicidal ideation in a non-clinical pakistani sample. to contextualize the present study within broader psychological literature, the following sections aim to provide a brief overview of attachment styles, mentalization, and suicidal ideation. each construct was analyzed in relation to its theoretical underpinnings, empirical evidence, and previously established associations with one another. this conceptual overview informs the rationale for the proposed mediation model that hypothesizes that mentalization may mediate the relationship between attachment styles an individual has and suicidal ideation in a non-clinical pakistani population. attachment styles refer to a person’s way of relating in intimate, receiving, and caregiving relationships, primarily with attachment figures such as parents, romantic partners, and children (levy et al., 2011). early caregiving relationships are fundamental to normative developmental processes in human beings (hofer, 1994). the evolutionary role that attachment plays extends far beyond providing physical protection to the child. a child’s attachment responses are triggered when their environment makes them feel insecure in some way. it has been found that the aim of developing an attachment system is to create a feeling of safety and security. thus, the attachment system is considered the primary regulator of emotional experience (warren et al., 1997). across an individual’s lifespan, internal representations and attachment styles remain moderately stable, progressing into adulthood (fraley, 2002). attachment styles have been conceptualized across a continuum between secure and insecure, drawing on bowlby’s (1969) foundational theory of secure attachment (sheinbaum et al., 2015). a securely attached child typically has a sense of reassurance that their primary attachment figure will be consistently available to fulfil their needs (main & morgan, 1996). this secure attachment fosters a positive self-image and optimistic expectations of others, especially within close relationships, leading to higher relational satisfaction and overall well-being (aronoff, 2012). ainsworth et al. (1971) further delineated insecure attachment into two primary categories: anxious graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 37 khan et al. and avoidant. these insecure attachment styles stem from inconsistent or unstable caregiving experiences during infancy and childhood and are often associated with difficulties in adult relationships and lower occupational functioning (ainsworth et al., 1971). insecure attachment is further categorized into insecure-avoidant and insecure-anxious subtypes. individuals who exhibit an insecure-avoidant attachment style tend to minimize their emotional reliance on their primary caregiver and avoid seeking proximity or comfort while distressed (behren et al., 2007). as they grow older, these individuals tend to devalue their close relationships, become emotionally distant, and struggle with emotional regulation (main & morgan, 1996). furthermore, they may express frustration and anger towards their caregivers as dysfunctional efforts to gain attention and connection (solomon et al., 1995). in contrast, individuals with an insecure-anxious attachment style tend to be overly emotionally sensitive and have an anxious fixation with the availability of their primary caregiver. they tend to seek excessive reassurance and can become extremely distressed when their need for closeness is not consistently met (cassidy & berlin, 1994). the heightened activation of the attachment system often stems from inconsistency in caregiving during childhood, usually when the response to distress is unpredictable. as these individuals mature, they may struggle with feelings of abandonment, heightened need for reassurance, and emotional volatility in their personal relationships (mikulincer & shaver, 2007). mentalization, operationalized through the construct of reflective functioning, is defined as the ability to make sense of one’s own and others’ behaviors through the attribution of thoughts, feelings, and intentions (fonagy et al., 2002). mentalization has also been referred to as ‘mind-mindedness’, a process by which an individual understands that the mind mediates one’s experience of the external world through the interpretation and the representation of different psychological states (liotti & gumley, 2009). literature also defines mentalization as a deliberate stance that emphasizes interpersonal awareness, which brings about specific emotions, beliefs, intentions, and desires, subsequently producing a similar behavior (liotti & gumley, 2009). bateman and fonagy (2006) identified three core dimensions of mentalization: the distinction between implicit and explicit functioning; the focus on two relational objects—the self and the other—and the integration of cognitive and affective aspects of both the content and process of mentalizing. implicit mentalization refers to the unconscious, involuntary, or procedural processes within an individual and their ability to imagine their own and others’ various mental states (bateman & fonagy, 2006). for example, a parent responds to their infant’s distress intuitively by soothing them without verbally reflecting on their child’s state of distress (fonagy et al., 2002). on the other hand, explicit mentalization is a process that is deliberately implied and used consciously. explicit mentalization can be illustrated through the process of psychotherapy. the therapist and patient work collaboratively to consciously highlight and reflect upon the patient’s mental states, encouraging the patient to deliberately imagine and focus on their cognitions, hence developing insight (bateman & fonagy, 2006). self-mentalization emphasizes the importance of understanding and being aware of what an individual is feeling, as well as having insight into the way we react towards other individuals (oldershaw et al., 2010). self-mentalizing leads to the development of self-regulation, and thus, it plays a role in understanding our own individual feelings (fonagy et al., 2002). other-mentalization is defined as the ability to understand and interpret other individuals’ mental states. an appropriate interpretation of others’ mental states is linked to better social functioning (perera & digiacomo, 2013) and a lower level of interpersonal conflicts (garcía-sancho et al., 2014). the third dimension of mentalization encompasses both cognitive and affective aspects, involving the content of mentalizing activity. the focus of this dimension is the ‘intentional mental state’ in the self and others, which is cognitively focused and affectively weighted to varying degrees. mentalization requires the display of intact cognitive skills that enable an individual to imagine mental states with flexibility, plausibility, and complexity, while optimally integrating reason and insight with emotion. the integration of the affective and cognitive aspects of both the processes and content of understanding mental states helps individuals to “feel clear” and increases “emotional knowing” (choi-kain & gunderson, 2008). literature indicates that the theory of mind, also referred to as mentalization, occurs within the pre38 attachment, mentalization, and suicidal ideation frontal cortex (fonagy et al., 2002). this brain region is associated with social intelligence and plays a vital role in controlling and processing behavior. the lateral fronto-temporoparietal network facilitates mentalization that is focused externally, enabling individuals to read facial expressions and posture. the bridge that connects affect regulation and social detection is primarily divided between the hypothalamus, amygdala, and bed nucleus of the stria terminalis, which gives emotional meaning to social cues and enables healthy individuals to react accordingly (kateryna & tanas, 2019). to develop mentalizing skills, children must experience proximity and care from their primary caregivers early on (meins et al., 2002). research suggests that children's capacity to mentalize is closely intertwined with the quality of their attachment relationships (fonagy et al., 2002). primary caregivers aid them in understanding their own mental states and the mental states of others, which in turn helps the development of mentalization. however, if a child were to develop an insecure attachment, their capacity to engage in mentalization would be impaired (fonagy & luyten, 2009). primary caregivers’ constructive feedback helps the child reflect on their thoughts, feelings, and intentions (sroufe, 2005). self-reflection and reflective functioning are integral components of the interactions between children and their caregivers (fonagy et al., 2002). the development of mentalization is associated with emotion regulation, impacting certain aspects of an individual’s functioning and possibly contributing to abnormal psychopathology. one product of this abnormal psychopathology can be the risk of suicidal ideation (allen et al., 2003). inability to understand mental states and insufficient regulation of emotions have been found to lead to problems in functioning (allen et al., 2003). a study by venta and sharp (2015) exploring the relationship between mentalization, attachment insecurity, and peer difficulties among adolescent inpatients found that mentalization mediated the relationship between disorganized attachment and peer problems. these findings highlight the central role of reflective functioning in shaping interpersonal outcomes and point to the potential relevance of mentalization as a psychological mechanism through which attachment-related vulnerabilities may influence broader emotional and relational difficulties (venta & sharp, 2015). in light of evidence linking peer problems and interpersonal dysfunction with a range of adverse mental health outcomes, these results offer a valuable framework for exploring how disruptions in mentalization may contribute to more severe internalizing experiences in vulnerable populations. mentalization is also influenced by the quality of specific attachment relationships (bączkowski & cierpiałkowska, 2015). attachment avoidance within particular relationships has been found to be associated with impaired perspective-taking ability in those contexts, whereas general mentalizing capabilities were not significantly influenced by overall attachment quality. therefore, the association between attachment and mentalization may be relationship-specific, with differences in reflective functioning being shaped by the emotional quality of each interpersonal bond (bączkowski & cierpiałkowska, 2015). suicidal ideation is an intricate public health issue that has its roots in social, etiological, biological, and psychological factors (joe et al., 2008). pakistan has a weak health system and even weaker mental health resources, as mental health is still widely considered a taboo due to the low literacy rate, financial disparity, and lack of awareness (mashood, 2025). as a function of these deficits, attention is required to consider and address the alarming prevalence of suicidal ideation. literature revealed that 35.6% of pakistani students experienced suicidal ideation in the past, out of which 13.9% of students made a plan for death by suicide, and 4.8% of them died by suicide (osama et al., 2014). other similar studies show that 31.4% pakistani students experience suicidal ideation, and there was no significant gender difference between males (29.2%) and females (33%) experiencing suicidal ideation (khokher & khan, 2005). adam (1994) explored the connection between attachment processes in suicidal behaviors, postulating that childhood attachment insecurities were considered a predisposing factor for developing suicidal ideation later in adolescence or adulthood. when an individual with an insecure attachment style faces loss or rejection, it leads them to an attachment crisis and distress, thus triggering the usage of maladaptive defense mechanisms. as a result, they become at high risk for indulging in self-destruction, self-harm, and developing suicidal ideation. in contrast, individuals who 39 khan et al. form a secure attachment with their caregivers tend to develop a more positive representation of not only themselves but also of others. when they experience interpersonal difficulties, they tend to be more resilient and manage distress better than those who have insecure attachment styles (adam, 1994). the interpersonal theory of suicide explains that suicidal ideation is a result of low belongingness and perceived burdensomeness. it is this desire that leads towards the act of suicide (orden et al., 2010). rohani and esmaeili (2020) aimed to elaborate on the susceptibility of suicidal ideation by examining the associations between psychological factors such as coping strategies, attachment styles, and dysfunctional attitudes. their findings revealed that dysfunctional attitudes and insecure attachment styles function as stress-diathesis models in predicting increased susceptibility of suicidal ideation by affecting emotion-focused coping strategies (rohani & esmaeili, 2020). empirical research has illustrated that attachment avoidance and anxiety are considered common risk factors for many psychological difficulties, including suicidal ideation (sheftall et al., 2014). furthermore, it has been found that those who have survived a suicide attempt reported significantly higher attachment avoidance and anxiety (sheftall et al., 2014). when conditional logistic regression analysis controlled for family alliance and depression, suicide attempt status was predicted by attachment avoidance and anxiety (sheftall et al., 2014). apart from deficits in attachment, deficits in mentalization are also independently linked to a higher risk of suicide. it is reported that compared to individuals with low risks of dying by suicide, individuals with moderate to severe risks of dying by suicide are 1.7 times more likely to report problems with mentalization (pompili et al., 2020). literature demonstrates that childhood trauma or distress can be directly associated with suicidal behaviors and indirectly associated through the pathways of attachment and mentalizing, indicating that an individual’s insecure attachment style, along with an impaired mentalizing ability, can explain the link between childhood trauma and suicidal behaviors (stagaki et al., 2022). theorized pathways between mentalization, attachment styles, and suicidal ideation figure 1 illustrates the direction of the relationship between the study's variables. it is proposed that attachment styles can have an impact on one’s ability to mentalize their risk of suicidal ideation. this can be attributed to early childhood attachment to the primary caregiver. if the attachment is not secure, when the child faces distress and feels insecure, it influences their mentalization. the primary caregiver facilitates the healthy development of mentalization (self, other, and motivation) by providing constructive feedback on the child’s experience and motivating them to reflect upon and pay attention to their various feelings, thoughts, and intentions. this fosters more social and situational awareness and indicates a relationship between attachment and mentalization (sroufe, 2005). individuals who have developed an insecure attachment style with their primary caregiver tend to have a higher predisposition to various psychopathologies, such as suicidal ideation, which can further develop into suicidal behaviors (adam, 1994). moreover, it was postulated that stress and threatening situations (proximal factors), as well as disruptions in the formation of secure attachment styles (distal factors) with the primary caregiver, disengage individuals’ mentalization capabilities, which can elicit psychopathologies, such as suicidal ideation (fonagy & luyten, 2009). hence, it creates a relationship between attachment styles, suicidal ideation, and mentalization. the significance of determining the relationship between attachment styles, mentalization, and suicidal ideation is essential and multifactorial. alarmingly, suicide is now a leading issue in pakistan that requires immediate attention (mashood, 2025). it is imperative to determine the underlying psychological mechanisms that serve as a precursor to suicidal ideation. there are many predisposing and distal factors identified that lead to the development of suicidal ideation among individuals; among them are attachment styles and mentalization. hence, the researchers decided to test these variables with a non-clinical sample, trying to understand early indicators of suicide risk. in times of stress, individuals with insecure attachment become predisposed to maladaptation of the mentalization capacity and, in turn, become vulnerable to suicidal ideation (green et al., 2021). the primary purpose of this research is to shed light on the role of attachment styles in early childhood that is linked to the development of mentalization and the development of suicidal ideation among individuals in later life. furthermore, these variables have not been pre40 attachment, mentalization, and suicidal ideation viously studied specifically in pakistan. as suicidal ideation is on the rise, finding a relationship between attachment styles, suicidal ideation, and the relationship between mentalization might help to create insight, identify early precursors for suicidal intent, and develop strategies for the betterment of the community. considering the prevalence of suicidal ideation across all age groups in pakistan and around the globe, this is a pivotal area of study (mashood, 2025). determining the relationship between these variables can help in having a better understanding and identifying early indicators of suicidal ideation and the predisposing mechanisms behind it. linking attachment styles with mentalization and suicide will help us understand their impact on the developmental period of the child. it will help us understand how early childhood trauma, neglect, and inconsistent care can impact their mentalization and eventually lead to psychopathology such as suicidal ideation. moreover, the findings of this research can help in the development and implementation of effective therapeutic strategies that take into account attachment style and mentalization. to accomplish the aforementioned research objectives, we hypothesized that: 1. there is a significant relationship between mentalization, attachment styles, and suicidal ideation. 2. mentalization mediates the relationship between attachment styles and suicidal ideation. 3. there is a relationship between anxious attachment style and self-mentalization. method a quantitative correlational survey design was carried out to determine the relationship between attachment styles, suicidal ideation, and mentalization in a non-clinical sample. the present study was conducted during the covid-19 pandemic, a time when there were widespread restrictions on physical access to clinical settings and the vulnerable population. moreover, due to the cultural stigma and taboo surrounding suicidal ideation in pakistani society, a non-clinical sample, selected through purposive convenience sampling, was used in this study. this research included responses from 295 adults aged between 18 and 55 years old, approached through a google survey. the researchers in this study were females, and data were collected from their social and academic groups, resulting in a disproportionate number of female respondents. gender disproportion emerged as a consequence of the sampling method rather than intentional selection. gender was not controlled for in this study. individuals diagnosed with a mental health disorder or those who did not disclose a reason to consult a psychologist were not included in this study. measures mentalization scale the mentalization scale (ments) is a 28-item self-report measure of self-related mentalization, motivation to mentalize, and other related mentalization, with higher scores suggesting a more sophisticated capacity for mentalization (dimitrijević et al., 2017). the age range for this scale is 18 to 65 years old. ments has three subscales which include self-related mentalization (ments-s) (items: 8, 11, 14, 18, 19, 21, 22, 26) other-related mentalization (ments-o) (items: 2, 3, 5, 6, 10, 12, 20, 23, 25, 28), and motivation to mentalize (ments-m) (items: 1, 4, 7, 9, 13, 15, 16, 17, 24, 27). mean and median scores were used to calculate the overall mentalization. ments-s measures one’s ability to mentalize or imagine mental states for one's own emotions and affect, ments-o measures one’s ability to mentalize or imagine mental states of others’ emotions and affect, and ments-m measures one’s internal motivation to mentalize or imagine mental states for one's own or others' emotions and affect. the ments is suitable for measuring mentalization in both clinical and non-clinical samples. it utilizes a 5-point likert scale that ranges from completely incorrect (1) to completely correct (5), with higher scores suggesting a more sophisticated capacity for mentalization. as determined by nunnally (1967), the ments has an acceptable reliability in clinical and non-clinical samples. the internal consistency of the scale, or cronbach's alpha, is .84 for non-clinical samples and .75 for clinical samples (dimitrijević et al., 2018). revised adult attachment scale the revised adult attachment scale (raas) measures interpersonal relationship attachments of individuals between the ages of 18 and 72 years old, using a 5-point likert scale. the scale ranges from not at all characteristic of me (1) to very characteristic of me (5), with higher scores reflecting stronger tendencies within the respective attachment (depend, close, 41 khan et al. or anxiety). developed by collins (1996), the raas is based on the earlier adult attachment scale (collins & read, 1990). raas was normed using 406 students at the university of southern california, and the age range for this test is 18–72 years. revised adult attachment scale is an 18-item scale that contains three dimensions: depend, (items: 1, 6, 8, 12, 13, 17), close (items: 2, 5, 7, 14, 16, 18), and anxiety (items: 3, 4, 9, 10, 11, 15; collins, 1996). the depend subscale measures an individual’s belief that others can be available or relied upon when needed. the close subscale assesses an individual’s comfort with intimacy and closeness. the anxiety subscale measures the extent to which a person feels anxious about elements such as abandonment or not being loved. the internal consistency of the raas subscales lies in an acceptable range (α = .78 for depend, α = .77 for close, and α = .85 for anxiety; collins, 1996; nunnally, 1967). suicidal ideation attribute scale the suicidal ideation attributes scale (sidas) was developed using a sample of 1,352 australian adults. the measure assesses the severity of suicidal ideation on a 10-point scale, with higher scores indicating greater persistence and severity of suicidal ideation, in individuals over the age of 18 years old (van spijker et al., 2014). the reliability of the sidas lies within the acceptable range, exhibiting high internal consistency (α = .91) with good convergent validity (nunnally, 1967). suicidal ideation is classified as having ideas, plans, or thoughts of ending one’s life. individuals with scores that are greater than or equal to 21 are considered to have a high risk of suicidal behavior. the sidas consists of five items, each targeting an attribute of suicidal thoughts: frequency, closeness to attempt, controllability level of distress associated with the thoughts, and impact on daily functioning (van spijker et al., 2014). procedure from inception to the culmination of the data-collecting procedure, a rigorously functional hierarchy of supervision was maintained to ensure that all work involved in this research met high-quality standards, integrity, and the probability of errors was effectively minimized. initially, a research proposal was designed, which explicitly outlined the research objectives to formally request authorization to collect data using the ments, raas, and sidas. after receiving approval from the university, a google survey was created based on the topic “relationship between attachment styles, mentalization, and behavioral tendencies” and disseminated across social and academic groups. participants completed consent and demographics forms prior to responding to the three-scale questionnaire. the demographics collected included participants’ gender, age, and socioeconomic class. all data were kept confidential. supervisors remained involved at every step of the data collection process. to incentivize participation, researchers included all participants' emails in a raffle. the emails of three participants were selected using a random picker tool to receive a gift basket or a onemonth netflix subscription. upon selection, the winning participants were contacted via email and awarded one of two gift baskets, which included snacks or a one-month free netflix subscription. the researchers made several ethical considerations, such as maintaining confidentiality by only discussing results with peers involved in the study. furthermore, participants were informed of their right to withdraw from the study at any point. additionally, no physical or mental harm was induced during the study. although slight deception was used where “suicidal ideation” was masked as “behavioral tendencies” to minimize the chances of self-report bias, participants were debriefed following their participation. data analysis the data were first arranged in microsoft excel before being transferred to spss (statistical package for the social sciences) 29.0.1.0 for analysis. to explore the internal consistency, cronbach’s alpha coefficient was calculated for each scale used in the survey. descriptive results include means, standard deviations, skewness, and kurtosis for the variables. skewness and kurtosis were used to assess the normality of the data. results indicated that all variables were normally distributed except for suicidal ideation. then, inferential statistical tests, which included correlation analyses, were used to examine the strength and direction of relationships between key variables, with the significance level set to p < .05. to examine the simultaneous effect of mentalization, attachment styles, and suicidal ideation, a multiple regression analysis was conducted to find out their unique contribution to the variable of suicidal ideation. to investigate whether anxious attachment style is associated with self-mentalization, 42 attachment, mentalization, and suicidal ideation a simple linear regression analysis was conducted. this helped to determine the direction and evaluate the predictive relationship. following the regression analysis, a mediation analysis was conducted where attachment style was entered as the independent variable, suicidal ideation as the dependent variable, and mentalization as a mediator. bootstrapping was used to estimate direct and indirect effects with a confidence interval of 95%. all statistical tests conducted used a significance level of p < .05. the findings were then interpreted and discussed in detail, along with consideration of the study’s limitations, recommendations for future research, and practical implications. results the following tables represent the results of the study,illustrating the statistical relationship between the variables of attachment styles, mentalization, and suicidal ideation examined in a non-clinical pakistani sample. table 1 frequency and percentages of demographic variables (n = 295) table 1 summarizes the demographic characteristics of the sample, including age, education level, and gender. the frequency and percentages of the demographic variables illustrate the composition of the sample. table 2 descriptive statistics and alpha reliability coefficients, univariate normality of study variables (n = 295) table 2 illustrates the mean, standard deviation, skewness, and cronbach’s alpha reliability coefficient for each variable. the data demonstrate normal distribution for all variables except suicidal ideation. the reliability of all scales and subscales falls within an acceptable range. table 3 correlations between attachment styles (close, depend, and anxiety), mentalization (ments-s, ments-o, ments-m), and suicidal ideation in the sample of pakistani adults (n = 295) table 3 illustrates a positive weak correlation (r = 0.19) between attachment style and suicidal ideation. the table indicates a significant positive weak correlation between a close attachment style and mentalization (r = 0.18) and between a close attachment style and self-mentalization (r = 0.25). a close attachment style was additionally found to demonstrate a negative weak correlation with suicidal ideation (r = −0.13). moreover, a dependent attachment style was found to have a significantly positive, extremely weak correlation with mentalization (r = 0.06) and a significantly positive moderate correlation with self-mentalization (r = 0.31). a significant negative weak correlation exists between a dependent attachment style and suicidal ideation (r = −0.14). close and dependent attachment styles were found not to correlate significantly with others' mentalization and motivation to mentalize (r = .01 and r = .07 for close; r < .001 and r = −.05 for dependent). furthermore, an anxious attachment style was found to have a significant moderate negative correlation with self-mentalization (r = −0.42) and a positive weak correlation with others' mentalization (r = −0.11). an anxious attachment style was also measured to have a significant, weak positive correlation with the motivation to mentalize (r = 0.23). an anxious attachment style demonstrated a significant positive weak correlation with suicidal ideation (r = 0.26). no significant correlation of mentalization (r = −0.06), others' mentalization (r < .001), and motivation to mentalize (r = .02) was found with suicidal ideation. however, self-mentalization was found to have a significantly weak negative correlation with suicidal ideation (r = -0.14). table 4 multiple regression analysis for attachment style, mentalization, and suicidal ideation table 4 indicates the impact of attachment style on mentalization and suicidal ideation. the r2 = .03 revealed that the predictors explained 3% variance in the outcome variable (f [3.33, 5.38] = 0.03, p < .05). table 5 simple linear regression between anxiety attachment and self-mentalization (n = 294) table 6 simple linear regression between anxiety attachment and self-mentalization (n = 294) table 7 regression coefficients of self-mentalization on anxiety attachment tables 5, 6, and 7 demonstrate that the overall regression model was statistically significant (f [1, 293] = 63.57, p < .001), indicating that anxious attachment accounted for 4.4% of the variance in self-mentalization (r² = .0442). the results revealed that anxious 43 khan et al. attachment was a significant negative predictor of self-mentalization (β = −.422, b = −.42, p < .001). therefore, findings suggest that individuals with an anxious attachment style tend to report low self-mentalization. table 8 mediation model for the effect of attachment style on suicidal ideation through mentalization table 8 indicates a mediation model that revealed a significant direct effect of attachment style on suicidal ideation (b = .20, se = .06, p < .001), whereas the indirect effect of attachment style and suicidal ideation through mentalization was not significant (b = .00, se = .00, 95% ci [−.00, .02]). this study shows a significant positive weak correlation (r = 0.19) between suicidal thoughts and attachment style. the association between attachment and suicidal ideation was not mediated by mentalization (indirect effect: b = .00, se = .00, 95% ci [−.00, .02]). with a prediction value of 4.42%, the current study shows an association between self-mentalization and anxiety attachment type. discussion the aim of the current study was to explore the relationship between attachment styles, mentalization, and suicidal ideation in a non-clinical sample. it was hypothesized that there is a relationship between attachment styles, mentalization, and suicidal ideation. more specifically, we proposed that there is a significant relationship between an anxious attachment style and self-mentalization. furthermore, it was also hypothesized that mentalization would mediate the relationship between attachment styles and suicidal ideation. the first hypothesis proposed that there is a relationship between attachment styles, mentalization, and suicidal ideation. results show several weak correlations between attachment styles, mentalization, and suicidal ideation. results indicate there is a weak positive correlation between closeness (r = 0.18) and mentalization. primarily, this finding may indicate that mentalization, particularly self-mentalization, is associated with certain aspects of an individual’s attachment style; however, given that the correlation was weak, other factors may also be precursors to this correlation. consistent with previous research (sroufe, 2005), the present study found that individuals with a secure attachment style were also skilled at mentalization of self. literature also showed that the primary caregiver of a child facilitates the development of overall mentalization and specifically, the self-mentalization by understanding the child’s subjective experience and creating a link by giving feedback on the particular experience (bowlby, 1978). this can influence the culmination of children paying attention to what they are experiencing, reflecting upon it, and having an understanding of their own emotional or mental state. moreover, a caregiver’s regulatory assistance can help develop secure abilities in a child while coping in times of stress, which may serve as a protective factor later on in life (bowlby, 1978). the findings of this study align with previous theoretical findings, further supporting the notion that early attachment experiences may contribute to the development of mentalization capabilities. similarly, it has been found that the parents' mentalizing style may also contribute to the child's mentalization development (fonagy & campbell, 2019). if parents have strong self-mentalization, they are likely to provide a secure base for the child, which is likely to lead to a secure attachment; hence, the child is more likely to develop a healthy overall mentalization as well as a healthy capacity to self-mentalize (fonagy & campbell, 2019). a positive relationship between children's mentalization and mothers' reflective functioning was seen in previous research (rosso et al., 2015). in line with prior studies, the present research also found a weak correlation between attachment styles and self-mentalization, reinforcing that attachment style may be crucial for the development of mentalization. a close attachment style was found to have a weak negative correlation with suicidal ideation (r = −0.13), and a significant negative weak correlation exists between dependent attachment style and suicidal ideation (r = −0.14). literature showcased that individuals with secure attachment tend to have a positive perspective of others and themselves. such individuals also develop a positive inner sense of self-worth and reassurance with their close figures (hietanen & punamäki, 2009). thus, there is a chance that those who have consistent positive beliefs may adjust better to situations as compared to insecurely attached individuals who are detached from their significant figures (hietanen & punamäki, 2009). along with this, indi44 attachment, mentalization, and suicidal ideation viduals who have a secure attachment may develop a positive inner working model about themselves (bowlby, 1988), consistent with the findings of this study. the findings of this study may also support the model proposed by bowlby (1988), postulating that closely attached individuals are more susceptible to asking for help when in a crisis or threatening situation, instead of feeling helpless or worthless, which, after long exposures, could turn into suicidal ideation later turning into action. additionally, it can be anticipated that, as securely attached individuals might have a positive thought pattern and schema about themselves, they are more likely to seek professional help in comparison to anxiously attached individuals (hong & park, 2012; simpson & rholes, 2017). thus, supporting the idea that individuals with secure attachment style may have a lower tendency to resort to suicidal ideation. furthermore, various studies reported that there exists an inverse statistically significant correlation between suicidal ideation and close or dependent attachment style (ozouni-davaji et al., 2013), and participants who have a secure attachment style with their fathers are less involved in sibling bullying and depression or suicidal ideation when compared to those who had an anxious or insecure attachment with their fathers, hence consistent with bowlby’s model (barzomer & klomek, 2018). there is a weak positive correlation between suicidal ideation and anxious attachment style (r = 0.26), as indicated by the results. adam (1994) proposed that when an individual with an anxious or avoidant attachment style faces distress or threatening situations, they are unable to draw resources from their close interpersonal relationships in comparison to an individual who has formed a close attachment with their primary caregiver. additionally, individuals with anxious or avoidant styles have an increased sensitivity to interpersonal threats like disappointment, rejection, and loss; this leads to increased and frequent activation of their attachment system (adam, 1994). furthermore, individuals with an anxious attachment style lack adaptive strategies, which is why they resort to suicidal ideation, thinking, and behavior to elicit support and care from others (adam, 1994). the findings of this research may support the developmental model provided by adam (1994). similar results were also found, postulating that those with anxious and avoidant attachment styles may face distress; they may feel overwhelmed, worthless, and hopeless. hence, this may later contribute to the development of suicidal ideation and behavior (kerns & stevens, 1996). additionally, literature states that the intensity of suicidal ideations and related behavior increases as the crisis upsurges in their life for those who are anxiously attached, which may be an explanation of the results of this research (sheftall et al., 2014). durkheim (1951), in his theory of suicide, proposed that individuals who opt for egoistic suicide are unable to find their place and face numerous shortcomings in adjusting to their given situations, as they feel abandoned by society itself. then gradually, they may resort to suicidal ideation and view suicide as the only solution to free themselves from the loneliness they are feeling (tremblay, 2005). other literature also provided similar findings, highlighting that two psychological states that are likely to increase the occurrence of suicidal ideation and suicidal behavior are social alienation and a sense of low belongingness (joiner, 2007). it can be presumed that if a person does not form a secure attachment, there is a chance that they may not have a secure sense of belongingness, and this may increase the probability of suicidal ideation (joiner, 2007). results indicate that self-mentalization has a significantly weak negative relationship with suicidal ideation (r = −0.14). literature proposes that individuals who lie in the higher range of emotional dysregulation tend to have a low level of mentalization. the two domains of emotional dysregulation that show close association with mentalization are the inability to develop an understanding of emotional responses and a deficiency of emotional clarity. this leads to various issues, including the inability of a person to make sense of experience, acting out, the use of splitting, etc. as a process to cope with the overbearing emotional content, these individuals tend to show suppression of emotional experience, distortion, denial, and a sudden upsurge in impulsivity (marszał & jańczak, 2018). disapproval and rejection of emotional responses are associated with low levels of mentalization, which are characterized by poor representation of experience, limited capacity of abstract and symbolic relation, and a lack of comprehensive emotional content (marszał & jańczak, 2018). another significant finding of the study is that 45 khan et al. no relationship was found between mentalization and suicidal ideation. it can be inferred that this may be due to the cultural non-acceptance of suicidal ideation (ahmed et al., 2016). suicide is considered a controversial topic in pakistani culture, due to which individuals find it difficult to display their intent or ideation of suicide (khan, 2025). this could be one of the factors for why no significant relationship between suicidal ideation and mentalization appeared in the statistical analyses, as individuals might be hesitant in answering questions regarding the topic. however, since this study ensured that the anonymity of the participants was a priority, it is a more likely conclusion that there was no correlation between the two variables, as the sample chosen is from a non-clinical population who may be better adjusted. an additional explanation of the sample being less prevalent in suicidal ideation is that the majority of the participants were in their adulthood, which is a more stable time comparatively; hence, it may lead to the development of stable ideologies and thought processes, given the prefrontal cortex has developed and stabilized (cash & bridge, 2009). the sample was selected from the non-clinical population as a deliberate step by researchers, as they were keen to study the results in a population unaffected by mental health difficulties to see a general, holistic picture of the relationship between these variables. another explanation that may be attributed to there being a weak correlation between suicidal ideation and all other variables and a lower level of suicidal ideation in the overall sample is that suicide is considered a contentious topic in pakistan. it is said to be a punishable act in islam and pakistan (mashood, 2025). hence, a lower prevalence of the variable has been seen in the sample, as individuals may be hesitant to talk about it and reveal their ideation. furthermore, section 325, which is a criminal law in the pakistan penal code, 1860, and is practiced throughout pakistan, states that “whoever attempts to commit suicide and does any act towards the commission of such offense, shall be punished with simple imprisonment for a term which may extend to one year, or with fine, or with both” (macaulay, 1860). results also showed a lower prevalence of suicidal ideation, which may be attributed to the possibility that, in the pandemic, individuals may have developed a beneficial coping mechanism; therefore, even in times of uncertainty, loneliness, and isolation, individuals did not resort to suicidal ideation. this is supported by recent studies revealing that healthy coping mechanisms and strategies were used by pakistanis during covid-19 to maintain their well-being, resulting in individuals' contributions to social welfare, new hobbies, exercise, eating healthy, and getting good sleep (khan et al., 2021). we further hypothesized that there is a significant relationship between anxious attachment style and self-mentalization. the findings confirmed a weak negative correlation between anxious attachment style and self-mentalization (r = −0.42). the development of mentalization is said to be correlated with different types of attachment systems, which are primarily associated with interactions with caregivers. during development, with the help of a caregiver, children learn to recognize and understand emotions. they do this through mirroring emotions around them and receiving an adequate affect response. these contingent representations created by the child’s state of mind are shaped by the extent of security in attachment relationships, which in turn facilitates the development of children's abilities to mentalize (fonagy & target, 1996); hence, it can be concluded that those with an anxious attachment style may have low mentalization of self (fonagy & target, 1996). one of the predominant concerns of individuals with an anxious attachment style is that they are very fearful of being abandoned by someone they love, so they are continuously searching for signs that it might happen (campbell & marshall, 2011). the mentalization model proposed that the understanding that the caregiver has of the child’s experience and the reaction given to them provides a model for the child to understand the emotional states within the world. this modelling ultimately leads to children learning to reflect upon and understand their states of mind. this progression from initial assistance to current independent observation of the self and others is dependent on a healthy, consistent, and reliable emotional interaction between the child and the caregiver. these healthy encounters occur only when close attachment is present. in contrast, when early caregivers are unable to reflect on the child’s state of mind or are unable to provide the modelling required for them to learn to perceive different states of mind, children do not receive the correct instructions they require to develop 46 attachment, mentalization, and suicidal ideation this extremely essential capability. therefore, anxious attachment may impact the development of the capacity to mentalize (allen et al., 2012). moreover, literature suggests that individuals who have an insecure attachment style face difficulties in regulating their own emotions, have unsatisfactory relationships with their peers, and experience anxiety symptoms (bosquet & egeland, 2006). given the results of the current study, a similar correlation has been found between self-mentalization and anxious attachment, where a significant, weak negative correlation has been found, pertaining to all the aforementioned reasons (dimitrijević et al., 2018). the third hypothesis was that mentalization will mediate the relationship between attachment styles and suicidal ideation. however, no mediation effect was found between the variables. this may be attributed to multiple underlying factors. firstly, this was a self-report survey; thus, there is a chance that the mentalization scale used in the study might not have been sensitive enough to capture its role as a mediator, as the scale is newly developed and lacks extensive research based on it. interviews or observation-based assessments or experiments might provide a better chance to find out the role of mentalization as a mediator in this study (stagaki et al., 2022). secondly, the study was conducted on a normal and non-clinical population; the sample characteristics, size, range, and variability might have affected the mediation effect. thirdly, there is a chance that other psychological or cognitive processes may mediate the relationship between attachment style and suicidal ideation, such as mental pain (lutzman & sommerfeld, 2024) or self-criticism (falgares et al., 2017), and several other variables, which were not explored in the study, may have confounded the mediation effect. furthermore, several reasons can be identified for weak correlations between the tested variables. firstly, various sample characteristics, such as size, diversity, and representativeness, may have influenced the study's results. the study was conducted on a non-clinical population; therefore, it might have shown low suicidal ideation, thus affecting the other variables. moreover, the study design was a self-report measure; therefore, it didn’t capture the depth of these constructs as interview-based assessments, experiments, or observational assessments could have. furthermore, there is a chance that mood, trauma, stress, or recent experiences could have influenced both attachment patterns and mentalizing capacities; hence, weak or no relationships were observed (bateman & fonagy, 2006). this study holds significant relevance within the pakistani cultural context, as its findings may contribute to increasing awareness of attachment patterns, mentalization capacities, and suicidal ideation, and help with the identification of early precursors of suicidal risk within non-clinical populations. the findings of this study show that there is a significant weak correlation between attachment anxiety and suicidal ideation. these findings can have positive implications in the pakistani population, as those who have attachment anxiety can benefit from learning more about emotional regulation and coping strategies to prevent themselves from developing suicidal ideation. they may also benefit from interventions such as mentalization-based therapy (mbt) or attachment-based family therapy (abft) that strengthen emotional regulation and reflective functioning within such individuals. moreover, this also provides insight into individuals struggling with such attachment styles, offering an opportunity for professionals to tailor therapy accordingly. it can also suggest that parents should be brought into the conversation to prevent further attachment issues, eventually leading to a decrease in suicidal ideation. furthermore, it highlighted that attachment styles and mentalization can pose as early indicators for suicidal risk, and preventative strategies can be developed for those who struggle with insecure attachment styles or low mentalization. additionally, this finding offers valuable insights for counselors, clinicians, and educators, enabling them to tailor interventions to address attachment vulnerabilities. furthermore, integrating psychoeducation about attachment styles, mentalization, and their relationship with suicidal intent into school and university counselling programs can help young adults build and develop resilience against suicidal ideation. several limitations were identified throughout this study. this was a correlational survey, making it difficult to draw causal interpretations of the data, and as the sample was recruited through a purposive-convenience sampling, it was difficult to understand the underlying mechanisms in-depth. therefore, as causality could not be determined, it was unclear whether attachment styles influence suicidal ideation or if oth47 khan et al. er unmeasured variables were at play. moreover, the study was conducted in pakistani society, where suicide is viewed as a taboo topic. hence, the possibility of response bias, including social desirability effects, could have led to an underreporting of suicidal thoughts as all of the tests used in this study were objective tests. therefore, it is recommended to use projective tests in the future to capture an accurate understanding of suicidal ideation in pakistan. another limitation of our study was that due to the pandemic, we ran an online survey that included a greater number of questions, so there is a possibility that participants might have felt fatigued or bored during the completion of the form, which could have produced biased answers. moreover, due to the pandemic, the available sample to recruit from was the community around us, which could have led to bias within the results or demand characteristics. as individuals were able to self-refer to the study and enter without consideration, this is why we have mostly female data and a mean age of 23 years. this limited the generalizability of the results to other genders and older adults, and other demographic groups, potentially reducing the applicability of the results across a wider population. therefore, it is recommended for future studies to conduct in-person surveys to eliminate bias. it is also recommended to conduct the study on an equal number of males and females to increase generalizability. the scale of mentalization was not an indigenous scale; therefore, it is also recommended that an indigenous survey be developed to understand the capability of mentalization in the pakistani population in detail, so that it can facilitate the improvement of mentalization-based interventions within the native population. moreover, to completely capture the essence of the mediation effect of mentalization, interview-based assessments or experiments should be used. as the researchers only chose a non-clinical population, there was no or very low suicidal ideation found in the sample; hence, it is recommended to replicate the study with individuals who are diagnosed or struggle with different mental health difficulties, giving a different perspective to the study itself. researchers could also choose to work with different age cohorts and test various attachment styles as well as types of mentalization, such as looking into intergenerational gaps and transfer of attachment. since this research was only a cross-sectional study, a longitudinal study could be conducted to gain better insight into the relationship between different variables. researchers found a gender disproportion within the sample, as due to the sampling style, mainly females opted to answer the questionnaire. future researchers could control the study for gender and see whether there is a difference between the genders and how that plays a role in suicidal risk. conclusion the purpose of the present study was to test the relationship between attachment styles, mentalization, and suicidal ideation. furthermore, the researchers wanted to find out if mentalization mediates the relationship between attachment styles and suicidal ideation. in conclusion, it was found that there is a partial correlation between the variables, and mentalization does not mediate the relationship between attachment styles and suicidal ideation. attachment styles were found to have a relationship with mentalization, self-mentalization, and suicidal ideation, whereas no significant correlation was found between mentalization and suicidal ideation overall. only self-mentalization was found to have a significant negative weak correlation with suicidal ideation. anxious attachment style was found to have a significant 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(1997). child and adolescent anxiety disorders and early attachment. journal of the american academy of child and adolescent psychiatry, 36(5). https://doi.org/10.1097/00004583-19970500000014 52 attachment, mentalization, and suicidal ideation figure 1 theorized pathways between the constructs of mentalization, attachment styles, and suicidal ideation note. the model draws links between the three hypotheses: (1) attachment styles, mentalization, and suicidal ideation are significantly interrelated; (2) mentalization functions as a mediating mechanism between attachment styles and suicidal ideation; and (3) anxious attachment is specifically associated with self-mentalization. 53 khan et al. table 1 frequency and percentages of demographic variables (n = 295) 54 attachment, mentalization, and suicidal ideation table 2 descriptive statistics and alpha reliability coefficients, univariate normality of study variables (n = 295) note. ments = mentazlization, ments-s = mentalization of self, ments-m = motivation of mentalization, ments-o = mentalization of others (**p < 0.01, *p < 0.05),, sk = skewness, k = kurtosis, actual = actual range, potential = potential range 55 khan et al. table 3 correlations between attachment styles (close, depend, and anxiety), mentalization (ments_-s, ments-o, mentsm), and suicidal ideation in the adult sample of pakistan (n = 295) note. ments = mentalization, ments-s = mentalization of self, ments-o = mentalization of others, and ments-m = motivation of mentalization **p < 0.01, *p < 0.05. 56 attachment, mentalization, and suicidal ideation table 4 multiple regression analysis for attachment style, mentalization, and suicidal ideation note. (p < 0.01), b = unstandardized beta coefficient, se = standard error, df = degrees of freedom, f = f-statistic, t = t-value, p = significance level 57 khan et al. table 5 simple linear regression between anxiety attachment and self-mentalization (n = 294) note. r = correlation coefficient, r² = coefficient of determination, adj r² = adjusted r-squared, ᵃ predictors: (constant), anxiety attachment 58 note. sum of squares = total variation, df = degrees of freedom, mean square = average variation (sum of squares divided by df), f = f-statistic, sig. = significance level, ᵇ predictors: (constant), anxiety attachment table 6 simple linear regression between anxiety attachment, and self-mentalization (n = 294) attachment, mentalization, and suicidal ideation 59 table 7 regression coefficients of self-mentalization on anxiety attachment khan et al. note. b = unstandardized beta coefficient, se = standard error, β = standardized beta coefficient, t = t-value, p = significance level 60 table 8 mediation model for the effect of attachment style on suicidal ideation through mentalization note. b = unstandardized beta coefficient, se = standard error, t = t-value, p = significance level, ll = lower limit of confidence interval, ul = upper limit of confidence interval attachment, mentalization, and suicidal ideation microsoft word manuscript 2_12.12.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 correlates of perceived discrimination in healthcare amongst black women tykera marrow, m.s. department of psychology, jackson state university this paper examined the impact of medical racism on black women. topics explored include black racial identity, emotion regulation, group-based medical mistrust, perceived social support, and perceived discrimination experiences. the socioecological model was used to examine the interplay of factors at the interpersonal, intrapersonal, and institutional levels concerning experiences of perceived discrimination in healthcare settings. the research interest is in how implicit biases contribute to health disparities amongst black american women. bivariate correlations suggest relationships between centrality, social support, group-based medical mistrust, and perceived discrimination. hierarchical regression analysis was indicative of medical mistrust as the most meaningful indicator of perceived discrimination. this study significantly identified relationships between centrality and group-based medical mistrust, centrality, and perceived discrimination, with group-based medical mistrust as a considerable standalone predictor. keywords: medical mistrust, perceived discrimination, social support, emotion regulation, black women, health, health disparities the centers for disease control and prevention (2018) defines health disparities as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations" (p.1). researchers studying health disparities have observed the intersection of societal factors such as race, education levels, employment, socioeconomic status, and many other factors that impact different population groups differently. drayton-brooks & white (2004) state, "african americans account for only 12% of the population in the united states, yet african americans, as a group, have the poorest health status indicators in the nation and are disproportionately represented among underserved populations. 55 % of the 33.9 million african americans in this country are women" (p. 84). stewart & nápolesspringer (2013) suggest minority patients receive suboptimal medical care compared to white americans, with discrimination inside healthcare systems compounding the physiological and psychological effects of discrimination felt from the outside (p. 1213). implicit biases, unconscious attitudes about a person or group, and discriminatory practices within the healthcare system have long been examined and reported, with implicit biases favoring white americans. also, implicit bias is a significant predictor of black patients either mistreated or not receiving treatment (dehon et al., 2017). efforts to explain racial differences in healthspan from institutional barriers, employment, lifestyle choices, physiological factors, and legislation (massoglia, 2008). comparatively, minority women in america are increasingly vulnerable to unequal healthcare treatment, particularly low-income, uninsured black women in comparison to higher income and insured white women (karliner et al., 2016). a report published by the institute of medicine in 2003 cited that even when controlling for patient outcomes, insurance status, and access factors, african american patients still did not receive equal treatment compared to their white counterparts (townsend & belgrave, 2009). © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. marrow graduate student journal of psychology understanding the historical and cultural influences that impact healthcare services is essential, especially for women of ethnic/racial minorities. the general mistrust and anticipation of stigmatization that african americans feel in general and concerning the medical context and larger american systems can negatively impact the utilization of healthcare services (penner et al., 2009). black people who report discrimination from their healthcare providers report decreased likelihood of critical health care screenings such as cancer, diabetes, cholesterol screenings, and other health-related behaviors like getting the flu shot (penner et al., 2009). additionally, black patients who experienced increased discrimination related to deteriorating physical and mental health and more significant chronic illnesses when treated by a medical physician (penner et al., 2009). for this study, the term black, a socio-political racial construct, is used to refer to descendants of the african diaspora or those who self-identify as black. in an effort not to exclude, women from various ethnic groups such as haitian, jamaican, continental african and others that fall under the racial stratification of black were included in this study. this paper focuses on the experiences of black women and the american healthcare system. while the terms black and african american are used synonymously in research, it is understood that the terms differ. statement of the problem black american women are dually marginalized due to their race and gender. despite recent public health efforts to promote health equity in the united states, research suggests that physical and sexual health conditions disproportionately impact black american women than women of other races. molina and colleagues (2015) assert, "the unique and severe forms of racism african americans experience, including segregated healthcare systems and overt interpersonal racism by providers, can contribute to elevated levels of medical mistrust and sub-optimal adherence as well as lower satisfaction and quality of life" (p. 4). a meta-analysis of 66 studies examining the effects of racism on mental health conducted by pieterse and carter (2007) found that in a sample of 18,140 black americans, there was a positive correlation between perceived racism and psychological distress. research efforts in trying to understand the relationship between individual beliefs, interpersonal relationships, medical mistrust, patient-practitioner relationships, and health outcomes for black women are severely lacking. noting this gap in the literature, this paper aims to answer the following questions: what is the association between racial salience and medical mistrust on experiences of discrimination? how do emotion regulation and social support affect the perception of discrimination in healthcare settings? how do sociodemographic factors influence the perception of discriminatory experiences? literature review theoretical framework the socioecological model (sem) identifies the social determinants of health and how factors are produced and sustained across various overlapping subsystems. within the sem, there are five levels of interaction: (1) the individual/intrapersonal level, (2) interpersonal level, (3) organizational/institutional level, (4) community level, and (5) the policy level (family and youth services bureau, 2015). due to its vast applicability, the sem can be used to understand social determinants of issues across multiple disciplines. the sem allows for the linkage between biopsychosocial factors and individual and community health outcomes based on examining individuals' systemic and epidemiological distribution accounting for demographic and economic variables. while utilized heavily in public health, the sem has its place in psychological research, and correlates of perceived discrimination in healthcare amongst black women graduate student journal of psychology many of its core components are rooted in psychological theory. due to the complex interrelationships of health determinants, targeted research and interventions are most effective when examined at all levels. mcleroy and colleagues (1988) insert "the importance of ecological models in the social sciences is that they view behavior as being affected by and affecting the social environment. many models—like bronfenbrenner's— also divide the social environment into analytic levels that can focus on different levels and types of social influences and develop appropriate interventions. thus, ecological models are system models, but they differ from traditional systems models viewing patterned behavior—of individuals or aggregates—as the outcomes of interests" (p. 355). the version of sem most used to address health education and behavior change is dr. kenneth mcleroy's. in this version, two main concepts are identified: multiple levels and reciprocal causation (winch, 2012). reciprocal causation, a concept like bandura's reciprocal determinism, states that their surrounding environment shapes their behaviors. a prominent example of reciprocal causation can be viewed with seat belts. seat belt use is impacted by the cultural norms and attitudes surrounding their use. still, norms and attitudes are mutually affected based on the laws and regulations encompassing usage. for this study, the interaction between the first three levels of leroy's sem was examined. emotion regulation the american psychological association (2018) defines emotion regulation as "the ability of an individual to modulate an emotion or set of emotions" (p. 1). emotion regulation (er) is typically identified through two strategies; cognitive reappraisal and expressive suppression. gross and john (2003) outline cognitive reappraisal as "the attempt to reinterpret an emotion-eliciting situation in a way that alters its meaning and changes its emotional impact" and expressive suppression as "the attempt to hide, inhibit or reduce ongoing emotion-expressive behavior" (p. 14). it is difficult to classify which type of regulation strategy is adaptive or maladaptive as gender and cultural differences must be accounted for. research examining cultural differences between black americans and other racial groups is limited as a vast amount of research centers around differences between asian and white populations. er deficits have been linked to poor outcomes for both mental and physiological disorders such as cardiovascular disease (sirois & burg, 2003), early mortality (harburg et al., 2003), and anxiety and depression (consedine et al., 2005). pascoe and richman (2004) state, "…some work suggests that active coping strategies, such as confrontation, positive reappraisal, and seeking social support, may buffer the effect of discrimination distress by enabling an individual to challenge the validity of discriminatory events and reduce negative feelings about the self, thereby reducing the chance that discriminatory experiences will exert an enduring impact on mental health outcomes" (p. 9). for this study, er was explored to examine how er strategies impact african american women's health. perceived social support social support is an interpersonal exchange of emotions and cognitions between various friend groups, familial networks, and organizations. social support is quantified based on the number of social relationships individuals have, such as their marital status, religious affiliation and membership to select groups. gülaçti (2010) defines perceived social support as "the existence of support resources when they are needed, and it can be identified in subjective qualitative perspectives and be measured and also it is reported that perceived social support is more determinative than received social support." in other words, perceived social support is the overall impression of the amount of support individuals receive from their social network. this is significant to the sem as it posits graduate student journal of psychology marrow that individuals are influenced by their friends, families, and colleagues – their social environment. culture is a significant predictor of health behavior. gersteen (1997), as cited by harvey and alexander (2012), posits, "considerable evidence links social support with increased health-promoting behaviors and decreased health-compromising behaviors," providing examples of "dietary habits, physical activity, smoking habits, alcohol intake, and adherence to medical regimens" (allgöwer et al., 2001; campbell et al., 2000; cohen et al., 2000; povey et al., 2000; sternfeld et al., 1999). perceived discrimination the university of cambridge (2019) defines perceived discrimination as "discrimination based on a perception that an individual is a member of a relevant protected group" (p. 1). the federal government identifies protected group membership to the following designations based on age, race, gender, physical or mental disability, religion, and nationality. perceived discrimination in healthcare settings has been associated with a myriad of adverse psychological and physical health outcomes, including but not limited to less engagement with medical physicians, decreased treatment compliance and medication adherence, increased use of alternative medicine, and less utilization of preventative care (hausmann et al., 2011). blanchard and lurie (2004) posit "over 14% of blacks, 19% of hispanics, and 20% of asians reported they had been treated with disrespect by their doctor. members of these groups were also more likely than whites to report that they were maltreated because of their race or their language and that they would have received better care had they belonged to a different race" (p. 725). african americans are also more likely to report perceived discrimination following an emergency room visit related to the increased stress and fatigue associated with emergent health crises and frustrations concerning their medical concerns being dismissed if they are discharged with minimal medical attention (abramson et al., 2015). black racial identity perry and colleagues (2016) assert "racial identity—a specific form of social identity—can play a crucial role in the psychological well-being of african american children, adolescents, and adults" (p.2). racial identity is a construct related to an individual's relationship to and understanding of in and out-group differences. this self-conceptualization of identity can lend itself to how one selfidentifies, interacts with other people within their racial classification, and moderate experiences within the macrosystem. although steeped in racial superiority and sociopolitical constructions, racial categorizations have a level of individual agency, allowing individuals or communities to subvert the meaning of the classification in empowering ways (crenshaw, 1991). chae and colleagues (2017) state "…individuals who diminish the salience of race or the significance of racism may be less likely to interpret negative interactions as being instances of racial discrimination”. on the other hand, those emphasizing the importance of race or who show a greater awareness of systemic social inequalities may be more inclined to attribute motivationally ambiguous experiences of unfair treatment to racial discrimination. reports of racial discrimination can sometimes be dependent on an individual's perception of whether negative life experiences are racially motivated. pascoe and richman (2004) states, correlates of perceived discrimination in healthcare amongst black women graduate student journal of psychology "although higher levels of stigmatized identity may be capable of buffering the effect of discriminatory experiences by making negative stereotypes less likely to be incorporated into one's self-concept, these high levels of identity might also lead to a higher vigilance regarding discriminatory experiences, potentially increasing the number of times discrimination is perceived" (p. 10). medical mistrust black americans have a discomfiting history with the medical institution in america, and centuries of crude unethical and inhumane experimentation on black bodies have contributed to the legacy of mistrust. the tuskegee syphilis experiment, the relf cases of 1974, and the gynecological experiments of dr. marion j. sims are examples of medical abuse, coercion, and institutional racism in black communities. prather and colleagues (2018) assert, "the legacy of medical experimentation and inadequate healthcare has exacerbated african american women's complex relationship with healthcare systems, past and present, and laid a foundation of mistrust of the medical establishment" (p. 30). "mississippi appendectomy" was a phrase created by african americans from the south to denote the routine medical practice of sterilizing african-american women who were admitted to the hospital for other operations – these procedures continued into the early 1970s. while many research studies have focused on the impact of medical mistrust on black american males, research centered around women's health has also denoted significant areas of need. kolar and colleagues (2015) state "medical mistrust is associated with disparities in cancer stage at diagnosis, breast cancer surgical and postsurgical adjuvant treatment and quality of life, underutilization of health services, routine health examinations, and cancer screening" (p. 78). although anecdotal, the history of racism in america and atrocities carried out by the healthcare system has contributed to a legacy of mistrust in black americans that has spanned decades, negatively impacting generations. methods participants this study's total sample size was n =205, with a little more than half of the respondents relating that they were mothers, n = 105, (51.2%). table 1 illustrates that most women were between the ages of 21-30 years old, n = 75, (36.6%). married women compromised the largest relational group, n = 75, (36.6%), with fewer than 20 respondents identifying as lesbian or bisexual, n = 18, (8.8%). the majority of respondents were employed full-time (n = 157). research design a correlational research design was used to describe the relationship between the variables. with this design, measures were conducted once. as this design does not require the manipulation of any variables, a control group is not required. moreover, a quantitative rather than qualitative design was employed for this study as it intended to serve as a pilot study to gather preliminary results and examine the feasibility of future research. procedures the collaborative institutional training initiative (citi) training courses were completed as required by all active researchers. certificates of completion were submitted for both the principal investigator and the supervising clinician. permission to conduct this research was granted by the institutional review board (irb) of jackson state university. the qualtrics database was then used to house the consent forms and approved measures (demographic questionnaire, erq, mssps, eds, mmbi, gbmms) for the study. a recruitment flyer with a generic description of the study and the principal and supervising graduate student journal of psychology marrow investigator's contact information was created and publicly uploaded to the social media platform facebook and the qualtrics link to access the study. the public link allowed other facebook members to publicly disseminate and access the study with other members within their networks. participants who meet the inclusion criteria were then directed to the qualtrics site to complete the study. inclusion criteria consisted of the participants' self-identification as black american women over the age of 21. exclusion from participation was limited to age (under 21) and race (non-black). after reviewing the consent form, potential participants provided or declined consent to participate in the research study. participants who consented to their involvement in the study were instructed to create a participant identification number using the first two letters of their last name and their date of birth, e.g. ja012386. the participant identification number allowed the researcher to track and maintain all documentation related to the said participant. however, no other identifying information (name, address, social security number) was collected. participants then completed the survey instruments within the database taking approximately 30-40 minutes for completion. upon completing the study, participants were provided with a debriefing form explaining the minimally associated risks and the principal and supervising investigator's contact information. following the data collection period, the data was transferred from the qualtrics database directly into spss for data analysis. the raw data was securely stored on an encrypted usb drive. deidentified printed copies of the data are also secured in a locked file cabinet for five years. remuneration was not provided for participation in this survey. demographic questionnaire a demographic questionnaire was created to collect background information such as age, sexual orientation, socioeconomic status, educational history, employment status, marital status, general health history. emotion regulation questionnaires (erq) the erq (gross & john, 2003) was developed to measure engagement in two broad categories of regulatory strategies: cognitive reappraisal (six items) and expressive suppression (four items). independent scores are computed for each emotion regulation strategy. the 10-item erq measures respondents' reports of aspects of their emotional life using a 7-point likert scale with options ranging from one (strongly disagree) to seven (strongly agree). a neutral selection, four, is available as well. items such as "i control my emotions by changing the way i think about the situation i'm in" (reappraisal) and "i control my emotions by not expressing them" (suppression) are inserted within the erq. since its development, the erq has presented good psychometric properties with internal consistency based on cronbach's alpha of α = .82 for cognitive reappraisal and α = .76 for expressive suppression (wiltnik et al., 2011). multidimensional scale of perceived social support (mspss) the mspss authored by zimet and colleagues (1988) is a 12-item 7-point likert scale with options ranging from one (very strongly disagree) to seven (very strongly agree). total scores range from 12 to 84, with total scores of 50 and over indicative of beneficial perceived social support. the mspss measures subjective perceptions of emotional support based on three dimensions; family, friends, and significant others. an example of an item on the measure is, "i get the emotional help and support i need from my family" the mspss has strong internal consistency based on cronbach's alpha of α =.81 to .98 (zimet et al., 2011). correlates of perceived discrimination in healthcare amongst black women graduate student journal of psychology the everyday discrimination scale (eds) the eds is a nine-item self-report questionnaire created by williams and colleagues in 1997 to measure the frequency in which ethnic and gender minorities experience discrimination throughout areas of life including, lifetime and daily discrimination. the eds is based on a 6-point likert scale with options ranging from one (never) to six (almost every day). respondents are asked to provide the frequency to which they have experienced discrimination through items such as "you are treated with less courtesy than other people." the eds has strong internal consistency based on cronbach's alpha of α=.88 (kim et al., 2014). the multidimensional model of black identity (mmbi) the mmbi (sellers, 1997) was adapted from the multidimensional model of racial identity (mmri) to measure the multidimensional conceptualization of black identity based on three fundamental scales; centrality, regard, and ideology. the 56-item mmbi measures respondents; reports using a 7-point likert scale response system with items ranging from one (strongly disagree) to seven (strongly agree); neutral selection, four, is also available. as the mmbi assesses racial identity from a multidimensional view, independent scores are computed for each subscale; an overall scale score is inappropriate. for this study, centrality was used to assess black racial identity. centrality (10 items) is an autonomous scale, with four subscales for ideology (nationalist, assimilation, minority, and humanist) and two subscales for regard (public and private regard). an example of an item listed on the mmbi is "blacks and whites have more commonalities than differences." since its development, the mmbi has presented sound psychometric properties with internal consistency based on cronbach's alpha ranging from low, α = .60 for private regard and high for nationalism, α = .79 for expressive suppression (sellers et al., 1997). the group-based medical mistrust scale (gbmms) the gbmms (thompson et al., 2004) is a 12-item self-report measure that assesses individual beliefs about group-based mistreatment within medical communities. the gbmms uses a 5-point likert scale response system with selections ranging from one (strongly disagree) to five (strongly agree). there are three subscales within the gbmss; suspicion (6 items), discrimination (3 items), and lack of support (3 items). typical items within the measure are phrased as, "people of my ethnic group should not confide in doctors and healthcare workers because it will be used against them." the gbmss is a new assessment tool with psychometric properties being reviewed thus far for gender (male and female) and cultural differences (african americans and latinos). however, in its' infancy, it shows a strong internal consistency with cronbach's alpha α = .87-.88 (shelton et al., 2010; thompson et al., 2004). results table 3 presents the correlation matrix between variables based on predicted hypotheses. a bivariate correlational analysis was conducted with results suggesting a significant relationship between centrality and perceived discrimination r(198) = -.29, p <.01. thus, as respondents' centrality scores decreased, they tended to perceive more discrimination. the opposite was true for centrality and group-based medical mistrust r(202) = .15, p <.05. as centrality increased, group-based mistrust increased. additionally, a positive relationship was established between social support and perceived discrimination, r(195) = .21, p <.01. more specifically, familial social support depicted a very weak correlation to perceived discrimination, r(196) = .18, p <.05, and support from friends depicted a weak graduate student journal of psychology marrow correlation, r(197) = .21, p <.01. additionally, group-based medical mistrust reports and perceived discrimination frequency have a moderate negative correlation, r(197) = -.41, p <.01. the third research question was not substantiated as a significant correlation between age, education, employment, relationship status, and perceived discrimination was not identified. as such, there was no clear influence of sociodemographic factors on the perception of discriminatory experiences. table 4 reflects the results of the stepwise hierarchical regression. gbmss, centrality, and friend support, as a regression model, explained 24% of the variance in perceived discrimination. significant variables comprising the regression equation indicated centrality, which explained 6%, and friends' social support contributed 3% of the variance in the dependent variable of perceived discrimination. medical mistrust emerged as the most significant predictor, b = -.79, t(194) = 6.03, p < .01. group-based medical mistrust explained a significant percentage of the variance in perceived discrimination, f(1, 194) = 36.35, p < .001, r2 = .16. thus, this variable is a significant standalone variable in this equation. collectively, group-based medical mistrust, centrality, and perceived social support from friends account for 25% of the variance, not attributed to chance, in perceived discrimination. discussion over the years, the socioecological model has presented itself as a comprehensive and inclusive theoretical framework. in the context of this study, the sem was used to examine how those varying levels interplay and influence factors related to health. at the individual level, appreciating the significance of black racial identity and cultural experiences can hypothetically improve patient-practitioner relationships and decrease perceptions of discrimination and mistrust. recent studies have provided evidence to support incorporating socio-cultural factors like religiosity holistic treatments in communications about health practices with black women to bolster communications and increase adherence (sheppard et al., 2011). in considering community-level interactions, support networks, specifically between friends and family, are essential to black women's psychological well-being and their ability to mitigate discriminatory events. similar findings have established that targeted social support can decrease depressive symptoms in black women who have experienced racists or discriminatory events (seawell et al., 2014). enabling and empowering black women to be more reliant on their support networks when navigating the medical community's interactions can increase comfort and communication with physicians and other health professionals. engaging black women as stakeholders in policy at the legislative level and as outreach partners at the community level can encourage peers and families to further their involvement and advocacy within medical communities. by respectfully incorporating the lived experiences of black women in culturally sensitive non-disposal roles, this potentially can assist in bridging the gap between the black and medical community. while relationships between social support and black racial identity were weak, it is important to note how these correlations impact black women's experiences working through the american healthcare system's various and sometimes rugged terrain. this is historically and presently relevant as black women face preventative and tertiary health disparities. altering and improving the healthcare landscape in america through systemic changes from public and health policy theoretically can transform the culture of health practices that moderate and maintain racism in healthcare and, subsequently, medical mistrust. these changes can be made by increasing implementation strategies that enhance patient-practitioner relationships, encourage implicit bias training to dispel correlates of perceived discrimination in healthcare amongst black women misconceptions about black health, and increasing cultural competency training for medical professionals considering the other sem levels, the consequences of medical mistrust can impact black women, their families, and communities. at the institutional level, issues with accessibility, affordability, and quality of care can culminate in an environment that can reduce discrepant health outcomes. disproportionate health outcomes and instances of decreased quality of care experienced by women may contribute to their perceptions of discrimination and overall feelings of mistrust towards medical institutions. medical mistrust can present negative consequences like decreased healthcare services and inadequate management of health conditions at the individual level. such experiences can impact the overall family as they may relate to delays in scheduling or attending medical appointments, medication compliance, vaccinations, engaging in healthpromoting behaviors, and participation in clinical trials. these experiences consequently lend themselves to a detrimental rippling effect through communities and generations. at the organizational-institutional level, with group-based medical mistrust contributing to decreased health utilization and compliance, late identification of chronic illnesses, and limited participation in clinical trials, laws, and policies cannot be put in place to meet population-specific needs appropriately. thus, the interaction between variables at one level interplay and impact factors in more distal levels. limitations several limitations of the current study should be considered, including the inability to determine causality. given the research's correlational nature and the possibility of bidirectional effects, the findings should be interpreted cautiously. while the study aimed to be inclusive of all female gender identities, it was later realized that some of the questions included in the demographic questionnaire were not transinclusive. for example, questions about motherhood and delivery methods only had traditional delivery modes--vaginal and caesarean. this demographic question ignored the birthing routes of trans-women and missed the alternative modes to motherhood that cis-gendered women also utilize, such as adoption and surrogacy. future studies will include more inclusive responses. another noted limitation of the study is its reliance on quantitative measures. despite the extensive evidence highlighting the adverse health outcomes for black american women due to medical racism, simple likert scales may not adequately encapsulate the breadth of these lived experiences. qualitative questions would have allowed women to share their direct medical racism experiences to showcase the disparities through first-person recollections. qualitative statements could have provided powerful, impactful, and insightful declarations that could have provided a more exploratory, thorough, and personalized depiction of this unfortunate phenomenon. moreover, data collection was conducted using snowball sampling from facebook. provisions were made via qualtrics to reduce ballot stuffing; however, there is no way to ensure that participants met the requested inclusion criteria. additionally, the link was shared within my professional network, comprised of many professional women who further disseminated the study within their networks. this potentially resulted in an over-representation of black women with post-secondary education and, as a result, underestimates levels of perceived discrimination. other collegeeducated women shared the initial survey link within the principal investigators' social network and in professional groups like "phdiva," "black women in public health," "ethnic counselors," and "black girl doctorate. accurate probability sampling would have included a more diverse collection of black women from various educational and socioecological backgrounds. furthermore, internet data collection raises concerns about sample graduate student journal of psychology graduate student journal of psychology marrow selectivity as participants would have access to mobile or computer-based internet access to complete the questionnaire digitally. in future studies, the methodological issues related to sample representation should be considered to secure a more representative sample. conclusion in summary, exposure to racism and discrimination in medical institutions can influence medical mistrust in various manners. there is an urgent need to provide more research data documenting the interplay of interpersonal, intrapersonal, and institutional factors concerning the impacts of medical racism on the health outcomes of black women. a comprehensive evaluation of group-based medical mistrust in black and other minority communities will. the medical community must be held accountable for their past injustices and actively work toward correcting present inequalities. due to the racist origins and maintenance of medical mistrust, long-term interventions at the interpersonal and institutional levels need to be enacted to elicit significant change. implementation strategies and interventions can include but should not be limited to increasing the representation of minorities in the medical field, collaboration with faith-based and other culturally relevant resources, encouragement of shared-decision making practices between patients and practitioners, and implicit biases training throughout medical school and throughout training. future considerations should focus on the importance of incorporating natural support networks in treatment interventions and other aspects of medical care as relational support is positively associated with increased patient-practitioner communications and potentially increased compliance with medical advice. incorporating natural supports also allow for culturally sensitive practice in communities that value their health impacts on the overall family system. these insights can generally be used to develop or strengthen population-specific interventions that address the multisystemic factors related to medical mistrust and decreased health outcomes. thus, reducing medical mistrust as a barrier is an essential first step toward eliminating health disparities experienced by black women and other vulnerable racial, gender, sexual, and socioecological minority groups. acknowledgements the authors declare no conflict of interest associated with the publication, and no significant financial support for this work that could have influenced its outcome. references abramson, c. m., hashemi, m., & sánchez-jankowski, m. 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(2011) psychometric characteristics of the multidimensional scale of perceived social support. journal of personality assessment. https://doi.org/10.1080/00223891.1990.9674095 correlates of perceived discrimination in healthcare amongst black women graduate student journal of psychology appendix table 1 frequency distribution for age, sexual orientation, employment, marital status, and education variables frequency valid percent age 21-30 75 36.6 31-40 56 27.3 41-50 40 19.5 51-60 25 12.2 61 and older 9 4.4 sexual orientation heterosexual 187 91.2 homosexual 8 3.9 bisexual 10 4.9 relationship status single 62 30.2 dating 46 22.4 married 73 35.6 divorced or widowed 24 11.7 employment status full time 157 77.0 part-time 30 14.7 unemployed 13 6.4 retired 4 2.0 education less than high school 1 .5 high school, ged 24 11.7 bachelor’s degree (b.a, b.s) 40 19.5 master's degree 110 53.7 professional degree (md, ph.d., jd) 30 14.6 marrow graduate student journal of psychology table 2 frequency distribution for access to health insurance, primary care physician, physician gender and race variables frequency valid percent health insurance yes 195 95.1 no 10 4.9 primary care physician yes 174 84.9 no 31 15.1 primary care physician gender male 45 25.7 female 130 743 primary care physician race black or african american 63 30.7 hispanic or latino 9 4.4 native hawaiian or other pacific islander 2 1.0 american indian or alaska native 4 2.0 asian 14 6.8 white 71 34.6 other 14 6.8 table 3 correlations matrix variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 age 1 sexual orientation -.138* 1 education -.074 -.200** 1 employment .103 .094 -.050 1 health insurance -.040 .090 -.054 .096 1 perceived discrimination .081 -.023 -.022 .026 -.119 1 centrality -.099 .048 .065 -.078 .018 -.290** 1 medical mistrust -.078 .173* -.151* -.029 .030 -.411** .154* 1 perceived social support .029 .042 .069 -.068 .045 .206** .113 -.298** 1 family support -.007 -.011 .083 -.034 .046 .180* .080 -.235** .845** 1 significant other support .042 .067 .016 -.047 .064 .119 .033 -.224** .842** .595** 1 friend support .036 .051 .059 -.092 -.003 .214** .149* -.279** .771** .443** .488** 1 reappraisal .058 .056 -.016 -.015 .056 -.058 .138* -.009 .052 -.016 .003 .138 1 suppression -.132 -.081 -.050 -.084 -.043 -.066 -.112 .144* -.406** -.309** -.310** -.358** -.124 1 correlates of perceived discrimination in healthcare amongst black women graduate student journal of psychology table 4 regression analysis summary for perceived discrimination model summary model r r square adjusted r square std. error of the estimate change statistics r square change f change df1 df2 sig. f change 1 .397a .158 .153 8.78020 .158 36.352 1 194 .000 2 .464b .215 .207 8.49828 .057 14.085 1 193 .000 3 .491c .242 .230 8.37568 .026 6.691 1 192 .010 a. predictors: (constant), gbmss composite score b. predictors: (constant), gbmss composite score, centrality c. predictors: (constant), gbmss composite score, centrality, friend support scale score 120 graduate student journal of psychology 2023, vol. 21 copyright 2023 by the department of counseling and clinical psychology teachers college, columbia university the role of social support in determining perinatal anxiety and depression outcomes for black and latina women black and hispanic mothers in the united states face higher maternal morbidity and mortality rates and more elevated risks for postpartum depression than their white counterparts (gennaro et al., 2020; howell, 2018). black mothers are three times more likely to die from birth to their child’s first year of life, and latina mothers are 2.5 times as likely to experience the same outcome (hoyert, 2023). social support (ss) protects against perinatal mental health issues among these groups (pao et al., 2019). maternal health disparities for black and latina women severe maternal morbidity (smm) has increased by 200% in the united states from 1993 to 2014 (liese et al., 2019). smm, or unintended consequences of pregnancy that could pose shortor long-term health issues, are 50 to 100 times more common than maternal death (liese et al., 2019). smm rates disproportionately affect racial and ethnic minoritized groups in the us, and this disparity has continued to widen over the last century (howell, 2018). risk of pregnancy-related deaths in some regions of the u.s. for black women in particular is similar to risk for women in lowand middle-income countries (howell, 2018). ethnically/racially minoritized women are disproportionately affected by multiple pregnancy complications. black and hispanic women have a 50% greater risk of having a baby at low birth weight and a 20% greater risk of having a preterm baby (borrell et al., 2016; gennaro et al., 2020). black women have a significantly higher maternal mortality rate than their white counterparts. approximately 42.4 deaths occur out of every 100,000 live births for black women as compared to 13.0 deaths per 100,000 live births for white women (center for disease control, 2008). similarly, latina women are 20% more likely to experience severe maternal morbidity than non-hispanic white women. the risks that black and latina women experience in the perinatal period are driven by the numerous manifestations of structural racism. ethnic/racial minoritized groups have unequal access to healthcare, education, housing, stress, and implicit bias (liese et al., 2019). racism harms health through physical, social, and economic pathways along with maladaptive coping strategies and stereotype threats (bailey et al., 2017). racism is considered a social stressor, which leads to neurobiological and behavioral responses that impact mental and physical health, while chronic exposure to racism elevates the changes occurring in the brain and metabolism in response to prolonged stress (bailey et al., 2017). poor birth outcomes have been linked to racial discrimination and psychosocial stress through early health deterioration or weathering (bediako racial and ethnic minoritized groups in the united states face higher maternal morbidity and mortality rates and elevated risks for postpartum depression and other perinatal mood disorders. social support (ss) protects against perinatal mood disorders, particularly for black and latina women. this study aimed to determine if having two or more ss people was related to perinatal anxiety and depression outcomes in a convenience sample of black and latina women. mothers (n = 51) with children between ages zero and three completed a socio-demographic and mental health status (phq4) survey. a two-way anova was performed to analyze the effect of high ss and race on mental health scores. there was no significant difference in mental health scores for those with two or more social supports versus those with one or fewer social supports (p = 0.4865). two-group comparison generally showed that mothers with high ss had a lower mental health score (m = 0.39) and mothers with low ss had a higher score (m = 0.60). there was a significant relationship between ss and both race and age (p = 0.0498, race, p = 0.0010, age). therefore, this study found no relationship between having two or more ss people and perinatal anxiety and depression outcomes. future studies should examine how other contextual factors impact ss and mental health outcomes for black and latina mothers. keywords: maternal morbidity, perinatal depression and anxiety, black and latina women clara l. b. parsons1, may-lorie saint laurent2, yu bi3, valeriy korostyshevskiy3, & keri f. kirk4 1department of global health, milken institute school of public health, george washington university, 2division of general pediatrics, norwell health, 3department of biostatistics, bioinformatics, and biomathematics, georgetown university medical center, 4department of family medicine, georgetown university school of medicine/medstar georgetown university hospital 121 et al., 2015). weathering is defined as the cumulative impact that repeated exposure to social or economic adversity and marginalization have on health (geronimus et al., 2006). when underserved groups perpetually practice high-effort coping strategies in response to acute and chronic stressors, physiological deterioration results (geronimus et al., 2006). therefore, maternal and child health are intertwined with the mother’s experiences of racial discrimination and chronic stress that are unique to women of color. perinatal mental health outcomes in black and latina women pregnancy can encompass a period of elevated stress, anxiety related to the pregnancy or fetus, and pain during labor and birth, posing significant stress on the body that increases vulnerability to mood disorders (alfayumi-zeadna et al., 2021). the general population has a postpartum depression prevalence of 10-15%, which is disproportionately lower than rates for minoritized communities (pao et al., 2019). for latina women, the prevalence of perinatal depression is estimated to be between 54.2-60% (center for disease control, 2008; lucero et al., 2012; shellman et al., 2014). similarly, over 40% of black women experience postpartum depression, over double the rate of the general population (hernandez et al., 2022; wisner et al., 2013). furthermore, women of color experience more serious and chronic symptoms of depression than white women, despite meeting comparable criteria for mental illness (guintivano et al., 2018; mukherjee et al., 2018; parker, 2021). black and latina women are more likely to experience complications throughout their pregnancies, making the provision of perinatal mental health screenings and intervention services especially important for these groups. social support determines perinatal anxiety and depression outcomes although all pregnant women, especially ethnic or racial minorities, are at risk of perinatal mental health disorders, risk is substantially reduced when protective factors such as social support are present. social support, or psychological and material resources provided by friends, family, and romantic partners, has been found to protect against perinatal mental health disorders (cohen & wills, 1985). for the purposes of this study, social support is defined as the number of support people a person reports having in their life (shiba et al., 2016). a mother’s satisfaction with her social support is dependent on maternal needs and expectations that vary across the perinatal period; thus, the quality of and satisfaction with social support is crucial (li et al., 2017). perceived social support is associated with stress, coping, and distress/depression. both lack of positive support and presence of negative interpersonal relationships have been linked to depression (coyne & downey, 1991; mendelson et al., 2013). numerous studies have focused on the protective nature of social support, finding that increased social support and greater satisfaction with the support protects against symptoms of anxiety and depression (alfayumi-zeadna et al., 2021; coburn et al., 2016; lefkovics et al., 2018; li et al., 2017; pao et al., 2019; razurel et al., 2017). similarly, lowered social support or dissatisfaction with support significantly increases risk of perinatal depression and raises the levels of depressive/anxious symptoms experienced (nisar et al., 2020; ohara et al., 2017; shakeel et al., 2018; sheng et al., 2010; terada et al., 2021; umuziga et al., 2020; verreault et al., 2014; zhou et al., 2021). for example, having a lower number of support people during the perinatal period significantly predicted scores on measures of depression and mother-infant bonding in a prospective study of 494 women (ohara et al., 2017). social support has been found to have a direct relationship to perinatal depressive/anxious symptoms, postpartum depression, and other mood outcomes (ngai & chan, 2012; racine et al., 2018). based on research findings that suggest social support directly predicts symptoms of anxiety and depression during the perinatal period, social support must be discussed during perinatal visits to better screen for mental health risk. assessing support in primary care visits during the perinatal period may allow providers to link mothers of highest need with relevant community resources (barr & caruso-mcevoy, 2018). importance of social support among black/latina women many studies show that the majority of research conducted on social support and mental health has been performed in predominantly white samples (garthus-niegel et al., 2022; wenzel et al., 2021); however, social support is extremely relevant to the well-being of black and latina women. in collectivistic cultures, significant cultural values include social connection, intergroup harmony, connectedness, and interdependence (boroş et al., 2019). collectivistic social support and perinatal anxiety and depression outcomes 122 parsons et al. cultures also place more weight on close relationships among family, friends, and community members than western cultures, which are typically individualistic (her & joo, 2018). research on racial/ethnic minorities in the u.s. indicates that social support may be used in order to reduce the psychological distress that discrimination causes, especially for those from collectivist cultures (steers et al., 2019). both black and latinx communities rely on close social ties for support and have reported stronger and more supportive relationships with family, friends, and others than white individuals do (ai et al., 2014; erving, 2018). when family stress is present, latinas may be particularly vulnerable during pregnancy based on the violation of cultural expectations about relationships and the role of the family (coburn et al., 2016). significance, hypothesis, and study questions in washington, d.c., women die from pregnancy-related causes at a higher rate than anywhere else in the country, at 36 deaths per 100,000 live births (medstar health, 2021). african american women are three times more likely to die of pregnancy-related causes than white women. washington, d.c.’s african american infant mortality rate is the highest in the nation, at 59.7 deaths per 100,000 live births (roberts et al., 2020). however, white women in d.c. have the lowest maternal mortality ratio in the us; thus, adequate maternal care, which includes mental health support, is not equally available to all residents in the district (roberts et al., 2020; zubatsky et al., 2018). despite the existence of high-quality maternal healthcare in d.c., racial disparities in access to care put black and latina women at risk of severe maternal mortality. in response to the severe maternal mortality crisis in d.c., the d.c. safe babies, safe moms (sbsm) initiative delivers pre-conception, pregnancy, delivery, postpartum, and family care up to a child’s third year of life. this study aimed to assess maternal mental health and social support in the context of primary care visits for two critically underserved groups of women. for the purposes of this study, symptoms of anxiety and depression as reported on a self-report measure constituted measurements of maternal mental health. exploring the role of social support in perinatal anxiety and depression outcomes can facilitate better understanding of the relationship between social support and mental health during and after pregnancy. our objective was to determine if a significant relationship between social support and perinatal anxiety and depression outcomes exists. we hypothesized that women who had two or more social support people in their lives would report fewer symptoms of anxiety and depression after giving birth. this is one of the first studies examining d.c. sbsm outcomes and the first of this regional sample to evaluate social support and anxiety and depression outcomes. method sample and procedures this study was part of standard clinic care encompassed within a larger program supported by the sbsm/healthysteps program at a large health system on the east coast. institutional review board approval was obtained through the georgetown university irb on december 23, 2021. this study includes participants who attended well-child checks for their children during the first 6 months of enrollment into the sbsm/healthysteps program. the convenience sample initially consisted of 58 black and latina mothers with infants or toddlers ranging from age zero to three who received their care at a primary care clinic within the hospital system. mothers were invited to participate in this study during their child’s well-child checks and primary care visits as part of standard of care procedures. overall primary care screening and assessment for children occurred by physicians, and mothers were screened for various social determinants of health issues, mental health concerns, and social support status by mental health faculty and staff. families were screened using the family health survey (fhs), a demographic survey assessing the social determinants of health. the fhs was administered depending on the child’s age, at one month, 16 months, 24 months, and 36 months. this survey also assessed social support and mental health status. the survey took approximately 15 minutes to complete. the practitioner explained what the survey included and why it was being given so that the care team could better meet the patient’s needs. when this study launched, the fhs was not yet available online. the final 18 participants in this study completed the survey online once it was made available. for participants completing the electronic survey, a link to the survey was generated and sent to the participant automatically when their child was scheduled for a visit; they would then click on the link to complete the 123 survey. online surveys could be completed outside of well-child checks, allowing participants to complete the survey at home. for surveys completed by hand for parents who spoke spanish, an interpreter assisted with administering the survey in spanish over the phone. surveys administered on paper were filled out during the well-child checks within the clinic. we report how we determined all data exclusions, sample size, and measures in this study in compliance with reporting standards for non-experimental quantitative research (american psychological association, 2020). this study is consistent with the transparency and openness promotion (top) guidelines at level one for all eight aspects (nosek et al., 2023). all data, analysis code, and research materials are available by emailing the corresponding author. this study’s design and its analysis were not pre-registered. measures demographics socio-demographic characteristics. socio-demographic information was assessed through the perinatal and family health survey, which included information such as age, race, gender, educational attainment, employment status, and living arrangements. race was assessed by asking participants to select one of the following racial groups that they identified with, which included the following options: black/african american, white, asian/asian american, american indian/alaskan native, native hawaiian/pacific islander, multiracial, or other race. ethnicity was assessed by asking participants to select either not hispanic/latino/a or hispanic/latino/a. perinatal and family needs perinatal and family needs. in order to determine family needs, the fhs was administered. the full survey assessed social determinants of health, experiences with racism, and other aspects of the family’s current social and health needs. for the purpose of this study, only the measures of social support and mental health were utilized in analyses. the independent/ predictor variable was social support, measured by a mother’s open-ended answer to the question “who are your most important support people?” when two or more people were listed, this was counted as “yes,” or having two or more social support people. having fewer than two support people listed was counted as “no.” the dependent variable was experiences with anxiety and depression symptoms after giving birth. for the purposes of this study, anxiety and depression outcomes were measured by a combination of 5 items from the personal health questionnaire-two (phq2), phq4, and gad7 (kroenke et al., 2009), and the ninth question about selfharm on the phq-9. participants rated four statements on a 4-point likert scale ranging from 0 (not at all) to 3 (nearly every day); the first two statements comprise the anxiety score (phq1 and phq2), and the remaining statements comprise the depression score (phq3 and phq4). statements measuring anxiety included “feeling nervous, anxious, or on edge” and “not being able to control or stop worrying.” statements measuring depression included “feeling down, depressed, or hopeless” and “little interest or pleasure in doing things.” scores were summed to yield a total mental health outcome variable, which comprised the fourth variable of the mental health score. the fifth question asked participants if the thought of hurting themselves has occurred to them in the last seven days; the yes/no answer choices were coded as yes = 1, and no = 0. internal consistency of the phq4 is 0.82 (mendoza et al., 2022). analytical strategy all analyses were conducted using r 4.1.3. statistical significance was set as p<0.05. seven mothers with missing values for either social support or mental health outcomes were removed from the dataset: two participants lacked social support information, three participants lacked data for all phq questions, one participant lacked data for phq3, and one participant did not have data for phq4. after removing seven participants from the analysis due to missing data, we had a final sample of n = 51 used in analyses. the mean mental health scores, anxiety scores, and depression scores were computed and compared between mothers with and without social support using the two-sample t-test. fisher’s exact test was used to compare the proportion of race between groups, the proportion of educational levels between groups, the proportion of mothers who have completed a physical exam or well-woman's exam in the last year between groups, and the proportion of relationship status between groups. pearson’s chi-squared test was used to compare the proportions of mothers who worked outside the home between groups. the two-sample t-test was used to compare age between groups. a two-way anova was performed to analyze the effect of having high social support and race on the mental health score. two-way anova is social support and perinatal anxiety and depression outcomes 124 parsons et al. suitable for assessing the impact of categorical independent variables (social support and race) on a continuous dependent variable (mental health scores). twoway anova was chosen for its ability to highlight main effects, vital for understanding individual contributions to observed variations in mental health scores. results demographic characteristics of participants the demographic characteristics of the study cohort are reported in table 1. thirty-one mothers had two or more social support people, and 20 mothers had one or fewer social support people. thirty-seven percent of the sample were black women, 43% were latina, and 18% were categorized as “other” races. there are two mothers whose race was both black and latina. one mother in the low social support group was missing a race value; one mother in both social support groups were missing values for physical exam status. additionally, 24 caregivers were missing values for age. on average, mothers with high social support were 28.47 years old (sd = 4.45), and those with low social support were 35.5 years old (5.02); there was a statistically significant difference between age (p = 0.0010). there was a slightly statistically significant difference between races (p = 0.0498). the three racial groups were not uniform in social support reported. there was a similar distribution of black and latina mothers across the two social support groups; for the other race group, there were more people with no social support than with two or more social supports. the results of the two-way anova are presented in table 2. simple main effects analysis showed that the levels of race did not have a statistically significant effect on the mental health score (p = 0.4942). simple main effects analysis showed that the levels of high social support did not have a statistically significant effect on the mental health score (p = 0.2439). we also verified that there was no statistically significant interaction between the effects of high social support and race (p = 0.5802, not included in table 2). relationship between social support and perinatal mental health outcomes the two-sample t-test was run to compare mental health scores between the two groups; the means, standard deviations, and p-values for the overall mental health score and stratified by each question are reported in table 3. cronbach's alpha for the study was α = 0.378. in this study, the maximum score on the phq-4 for our sample was four. mothers in our sample did not endorse thoughts of self-harm; thus, the p-value for the self-harm question measure is not applicable as the mean score is zero. the two-sample t-test for the mean mental health score across the two groups yielded a p-value of 0.4865. thus, there is no statistically significant difference between the mean mental health scores of mothers with and without social support. the results of the two-sample t-test for anxiety and depression similarly did not demonstrate statistical significance. there was no difference between anxiety scores for those with and without social support (p = 0.4872), and no difference between depression scores for those with and without social support (p = 0.7137). the distribution of responses to each mental health question measure for both social support groups is illustrated in figure 1. discussion this study aimed to determine if having two or more social support people was related to anxiety and depression outcomes after giving birth in a sample of predominantly black and latina women within the context of primary care visits. this study is one of the first to examine outcomes from the d.c. sbsm initiative, which delivers perinatal and family care up to a child’s third year of life, and the first of this regional sample to evaluate social support and anxiety and depression outcomes. we found no significant difference in mental health scores for those with two or more social supports versus those with one or fewer social supports. our hypothesis was that women who had two or more social support people in their lives would report fewer symptoms of anxiety and depression after giving birth. we expected to find a significant relationship between social support and perinatal anxiety and depression based on prior literature in largely white populations, but did not find a statistically significant difference between anxiety and depression symptoms of mothers with high versus low social support. despite lacking statistical significance, two-group comparisons generally showed that mothers with two or more support people had a lower mental health score, and mothers with one or fewer support people had a higher mental health score (figure 1). this general trend must be interpreted with caution due to high variability (high standard deviation) in both groups. 125 it is important to continue discussing mental health and social support in primary care visits with black and latina mothers. practitioners must recognize that minoritized communities often under-report mental health struggles for a variety of reasons. a study found that african americans’ recent experiences of discrimination predicted unique variance in beliefs about mental health problems and higher concerns about stigma (williston et al., 2019). since mental health concerns may be viewed as a point of stigmatization, study participants may have hesitated to disclose mental health symptoms in fear of being further discriminated against (williston et al., 2019). for many latina individuals, psychological distress often manifests physically (e.g. shortness of breath, elevated heart rate); thus, latina participants may not report symptoms on the phq-4 due to the lack of somatic symptom assessment (abarca et al., 2022). additionally, latinx cultural constructs such as “susto” or “nervios'' refer to somatic symptoms experienced due to significant life stressors; thus, participants may not report symptoms as these words are not directly translated on the spanish version of the phq4 (abarca et al., 2022; matías-carrelo et al., 2003). of further note is the significance of family ties and collectivism when discussing social support and mental health in black communities in particular. seminal work posits that black families’ strong ties provide a buffer against the mental health implications of structural and systemic disadvantages (stack, 1975). current research has continued to demonstrate that black americans’ mental health is associated with perceived closeness to family and friends such that family closeness is associated with lowered odds of 12-month major depressive disorder among african americans (taylor et al., 2015). outside of family dynamics, black americans rely on support from church members and fictive kin networks. black americans attend church more frequently than white americans and rely more on loosely defined networks of family that go beyond biological relatives. the utility of fictive kin networks for black individuals provides an important source of resilience and, historically, an adaptive response to economic difficulties (chatters et al., 1994; chatters et al., 2009; roxburgh & macarthur, 2020; stack, 1975). our study found a difference between the two social support groups in terms of race, where those in the other race/ethnicity category experienced less social support than black and latina participants. black and latina mothers were distributed similarly across the two groups, whereas the other race/ethnicity category had a larger ratio of participants in the one/no social support group. however, we did not find a statistically significant interaction between race and social support that impacted mental health scores. limited prior research generally shows that racial and ethnic minority groups tend to report lower levels of social support, but our study had more black and latina participants with high social support than the other category, which included white participants (roxburgh & macarthur, 2020). thus, likely due to our racially diverse sample, we found that our other group participants had lower social support. prior literature has shown that, despite black individuals reporting less closeness in friendships, this type of social support is more salient for black than for white participants (roxburgh & macarthur, 2020). minoritized groups often place high value on things like family, collectivism, and interdependence; thus, because black individuals in particular have highly interconnected cultural beliefs, they may be more susceptible to the effects of social support (assari & lankarani, 2018). in a prior study, the associations between familialism with social support and stress were larger for latina women than for white women (campos et al., 2008). latinos also report greater reliance on and disclosure to family than to friends compared to whites and asian americans; similarly, their friend support significantly predicted mental health service utilization (chang et al., 2014). since black and latina women may value interpersonal relationships more than white participants, placing unique emphasis on their friendships and family ties compared to whites, they may be more likely to have more social support. there were significant age differences between the two social support groups. on average, mothers with high social support were younger than those with low social support. this may be partially due to how different age groups seek out social support. for example, prior research has found that older adults sought less explicit social support, particularly instrumental social support, despite using a similar amount of implicit social support during stressful experiences (jiang et al., 2018). older adults were more worried about social costs than younger adults, and thus sought less explicit social support. additionally, research has shown that social support and perinatal anxiety and depression outcomes 126 parsons et al. 126 perceived social support is most strongly negatively associated with depression and loneliness at younger ages (anderson, 2019). thus, older adults may have underreported social support as they perhaps relied more on implicit support than younger adults, viewed social support as potentially costly, and were concerned about social implications of seeking help. as individuals become more involved in their social networks or communities, there may be hesitancy to disclose symptoms of mood disorders. black individuals in particular report learning early in life that mental illness is a topic to be avoided, and to keep mental health issues within the family (alvidrez et al., 2008). thus, there may be hesitancy to disclose symptoms to loved ones. social responses to illness must be considered when examining the role of social support on mental health: based on one’s perception of the impact of stigma, one may view their social support differently (kondrat et al., 2018). individuals experiencing symptoms of depression or anxiety, in this case, may expect rejection, devaluation, or discrimination upon disclosing mental health concerns (kondrat et al., 2018). racial and ethnic differences in the role of social support, as noted previously, are evidenced through differences in social embeddedness of black and white americans. as stigma varies across cultures, racial and ethnic minoritized individuals may vary in disclosing mood problems to their communities based on their involvement in these groups. our insignificant results may be further explained by the nature of conducting research studies within the context of primary care visits. participants may have felt rushed, not have read through the study information thoroughly, or experienced response bias. the survey consisted of a large number of questions that may have been taxing for participants to undertake, and their responses may not be as accurate as if they were to take the survey outside of their care visits (booker et al., 2021). limitations there are several limitations to consider in this study. first, the small sample size (n = 51) limited the statistical power of analyses. due to the study’s timing, which fell during the first six months of enrollment into the sbsm/healthysteps program, there were only 58 participants enrolled before analysis and seven needed to be removed due to missing data. this yielded a low-power sample after removing missing data from participants, limiting the ability of the analyses to find true effects (button et al., 2013). smaller sample sizes confer larger variability, as seen in our wide standard deviations. secondly, the non-random nature of the sample limited the reliability of the study. convenience sampling was used because mothers were screened as part of standard of care during their primary care visits, and thus the variability and bias cannot be measured or controlled (acharya et al., 2013). the generalizability of the results is limited beyond the sample (acharya et al., 2013). thirdly, our assessments were made across electronic and paper surveys. not all participants were offered the electronic mode of survey completion, as it became available after many participants had already completed pen-and-paper versions (booker et al., 2021). web-based surveys allow participants to complete studies in a more comfortable environment, without time constraints, and are more convenient (booker et al., 2021). many questions asked were of high sensitivity (e.g., mental health symptoms), which is linked to lower response rates in patient surveys, which might have been improved if the participant could have taken the survey electronically in a private space (booker et al., 2021). lastly, despite the advantages of the two-way anova, it is important to acknowledge that this method may not be capable of including more confounders in the analysis. our study emphasized group differences rather than predictive potential, thus factoring additional confounders into the model was beyond the scope of our current investigation. additionally, our low cronbach's alpha (α = 0.378) may be attributed to our survey's small question set (total of five questions for mental health scores). future directions despite limitations, this study highlights important areas for next steps in perinatal mental health research for black and latina women. future studies must examine how racism and discrimination, on the interpersonal and systemic level, impact birth outcomes and complications in women of color, particularly black and latina women. understanding the pathways by which discrimination impacts infant health, in addition to maternal outcomes, will be instrumental in reducing maternal and infant mortality. in terms of statistical analysis approaches, future research topics may consider the application of regression analysis to delve deeper into the relationships between social support, mental scores, and other confounders, particularly for predictive modeling. such an approach 127 could provide a more comprehensive understanding of the factors influencing mental well-being within our target demographic. future research should consider a more comprehensive approach to understanding mood outcomes by taking into account additional variables within a broader scope. additionally, future studies might incorporate covariates in predictive modeling for a more comprehensive understanding of these relationships. although we did not find a significant relationship between social support and perinatal anxiety and depression outcomes, this is still an important relationship to explore in perinatal research. conclusion this study found a significant relationship between social support and both race and age, which may suggest that there are other points of intervention for similar communities. given how contextual factors such as race, socioeconomic status, and the like intersect within health care systems, placing black and latina moms at a disadvantage in receiving equitable perinatal support, future studies should examine how everyday racism impacts social support and mental health outcomes. in places such as washington, d.c., where access to adequate perinatal care is disparate, initiatives such as sbsm may improve mental health care accessibility. more research is needed on how to best examine patients’ social support and mental health symptoms during primary care visits, the mechanisms by which racism and discrimination impact health outcomes, and the influence of resilience on perinatal outcomes for black and latina women. references abarca, g. j., tornberg-belanger, s. n., ryan, d., price, c., rao, d., & ornelas, i. j. 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(2018). integrated behavioural health in primary care across the world: three countries, three perspectives. family practice, 35(6), 645-648. https://doi.org/10.1093/fampra/cmy034 132 parsons et al. table 1 sociodemographic characteristics of participants 133 social support and perinatal anxiety and depression outcomes table 2 means, standard deviations, and two-way analyses of variance in race and social support 134 parsons et al. 134 table 3 relationship between social support and anxiety or depression scores 135 social support and perinatal anxiety and depression outcomes figure 1 relationship between social support and mental health score 53 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university the effects of psychosocial and traumatic stressors on mci diagnosis katherine goulden department of psychiatry and behavioral sciences, stanford university there is no single cause of mild cognitive impairment (mci), a neurodegenerative condition defined as “clinically significant memory impairment that does not meet the criteria for dementia” (petersen, 2011, p. 2). mci is an amnestic disorder representing an intermediate stage between normative aging and alzheimer's dementia. though all mci demonstrate neuropsychological impairment, diagnosis can be broken into subtypes amnestic or non-amnestic (rountree et al., 2007) for more stable estimates of prevalence and rates of returning to normal cognitive functioning (jak et al., 2009). as age increases, so does the risk of developing mci. a lifetime’s worth of factors and exposures can affect the risk of developing this unhealthy form of cognitive decline. apolipoprotein genotype (tang et al., 2023), education (tervo et al., 2004), and general cognitive ability during adulthood (corbo et al., 2023) have been associated with an increased risk of developing mci, but neither the exact causes of mci nor the influence of a lifetime of stressors is completely understood. there is no known cure for mci, thus the identification of modifiable risk factors is important for prevention and earlier detection of those at risk. although research on mci risk factors is extensive, the identification of the role of stress is incomplete and has never been investigated in a sample of twins. exposure to stress in adulthood and midlife has been shown by previous studies to increase the likelihood of an mci diagnosis on the neurobiological level (kritikos et al., 2023; song et al., 2020). stress occurs during a threat and when environmental demands exceed adaptive capacity, with threat associated external and internal stimuli eliciting the reactions defined as stressors. potential stressors encountered during adulthood include a long list of adverse psychosocial and physical forces. a psychosocial factor is defined by hemingway and marmot (1999) as phenomena that are “potentially related to the social environment and to pathophysiologic changes…psychosocial factors may act alone or combine in clusters and may exert effects at different stages of the life course” (p. 2). the stressor can be a discrete event such as the death of a spouse, or a prolonged exposure, such as racial discrimination experienced by minority americans (turner et al., 2017). in the diagnostic and statistical manual of mental disorders (4th ed.; dsm-4), criterion a1, traumatic events are defined as “an event that involves actual or threatened death or serious injury, or other threat to one’s personal integrity” and includes “learning about the unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate” (first et al., 2004, p. 14). posttraumatic stress disorder (ptsd) is a disorder that can be present at any age. it is triggered by either witnessing or experiencing an event that presents a threat to one’s safety. symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable background and objective: toxic stress exposure can have effects across the lifespan. studies of civilians and veterans suggest a connection between psychosocial and traumatic stressor exposure in adulthood and a diagnosis of dementia later in life. the objective of this study was to investigate the impact of psychosocial and traumatic stressors on rates of mci (mild cognitive impairment) diagnosis in vietnam era twin study of aging participants. methods: 1,237 twin participants from the vetsa study were aged 61.72 ± 2.44 years at the time of data collection. traumatic stress was measured by clinical interviewing, with psychosocial stressors quantified by self-report measures. neuropsychological assessment determined mci diagnosis. previously conducted genotyping determined apoe genotype. mixed model analysis was used to determine effects on mci diagnosis. results: our results from the mixed model analysis did not find a significant relationship between psychosocial and traumatic stress exposure and mci diagnosis. ptsd diagnosis, measured by the dis-iii-r, collected for the harvard drug study in 1996 (f = 0.249, p = 0.618) does not have a significant effect on mci diagnosis. life stress exposure, measured by holmes and rahe (1967), (f = 0.249, p = 0.618) does not have a significant effect on mci diagnosis. significant associations were determined using the type iii fixed effects. associations were considered statistically significant at p < 0.05, two-tailed. implications: few subjects in wave 2 of vetsa had mci (n = 147), due in part to the age of the participants at the time (mean 61.72 ± (2.44 years)). this led to a lack of power in our analysis. future studies should examine all available vetsa data. keywords: veterans, mild cognitive impairment, psychosocial stress, traumatic stress 54 goulden thoughts about the event (hathaway et al., 2010). it is also associated with cognitive impairments unique to the condition in the domains of verbal learning, speed of information processing, attention, working memory, and verbal memory (scott et al., 2015). a neurobiological pathway has been proposed to describe how ptsd influences dementia, with traumatic exposure triggering persistent over-activation of the hypothalamic-pituitary-adrenal (hpa) axis and the adrenergic system (leister & menke, 2020). the literature on the impact of psychosocial and traumatic stress on mci outcomes has been mixed. a study by wang et al., (2018) of non-military elders of both sexes found a significant dose-dependent relationship between ptsd symptom severity and developing dementia later in life. a study by peavy et al., (2009) also found that chronic stress and stressful life events led to general memory decline in cognitively normal (cn) individuals as well as those diagnosed with mci. as for conversion from cn to mci, peavy et al., (2012) did not find an association between stressful experiences and change to mci. these findings could result from the variability of ways that stress and ptsd were operationalized. although research with elderly veteran participants varies from that of elderly civilian participants, most vetsa participants were not exposed to combat (kremen et al., 2013). however, veterans are exposed to factors that are unique to military service (sibener, 2014). in a study of 181,093 elderly veterans by yaffe et al. (2010), the 7-year cumulative incident dementia rate amongst veterans with ptsd was 10.6% while those without ptsd had a rate of 6.6%. while yaffe et al. (2010) did not specify the veterans’ era, in another study greater incidence of mci was observed specifically in vietnam era veterans who had also been diagnosed with ptsd (weiner et al., 2017). previous studies have indicated that psychosocial factors such as racism (moon et al., 2019), workplace adversity (nabe-nielsen, et al., 2019), and divorce (eriksson, 2015) are risk factors for dementia. but in a meta-analysis of 24 longitudinal studies examining categories of toxic psychosocial and trauma-related stress, bougea et al. (2022) found suggestive, yet non-robust evidence that psychosocial and traumatic types of stress are associated with increased risk of dementia in later life. as vetsa participants have aged, the focus of the multi-institutional vetsa study has shifted from a focus on substance use to early identification of risk for mci and alzheimer’s disease (ad). vetsa participants are all part of the vietnam era twin registry. vetsa selection criteria were (1) being in one’s fifties at the time of recruitment and (2) that both twins in a pair had to be willing to participate in the baseline assessment (kremen et al., 2013). a narrow subject age range of participants enhances vetsa’s ability to examine within-individual differences and change over time. another key aspect of the study design was an extensive neuropsychological test battery. the study is also unique in that we have cognitive assessment scores from participants when they were inducted into the military at the age of 17 to 25 years old. the present study was designed to investigate the influence of psychosocial and traumatic stressors on mci diagnosis. it is hypothesized that participants with exposure to psychosocial and traumatic stressors would be more likely to have developed mci. methods participants vetsa participants were recruited from the harvard drug study (tsuang et al., 2001). 1,237 twins participated (349 monozygotic pairs, 265 dizygotic pairs, and 9 unpaired). attrition-replacement participants were included as a subset of the wave 2 participants. the attrition-replacement participants are twin pairs from the vietnam era twin registry in the same age range as the returning wave 2 participants. at wave 2 of data collection, the mean age of participants was 61.72 ± (2.44 years). all vetsa participants were in the military sometime between 1965 and 1975. the majority did not see combat or serve in vietnam. the sample was entirely male and 95.4% (n = 712) white. black americans made up 4% (n = 30), hispanics represented 0.3% (n = 2) and 0.3% were missing information on race (n = 2). the average lifetime education was 12.4 (± 1.3 years) (see appendix). instrumentation holmes and rahe stress scale life stressors were measured using the holmes and rahe social readjustment rating scale. the holmes and rahe social readjustment rating scale is a 100-item questionnaire (α = .8458), composed of 43 life events. an individual's total score measures the amount of stress the individual has experienced in the past year. the tool has been exten55 stressors on mci diagnosis sively studied, and its reliability and validity are well established. cronbach's alpha for various populations ranges from 0.82 to 0.90 (holmes & rahe, 1967). dis-iii-r subjects were interviewed using the diagnostic interview schedule version iii revised (dis-iii-r), a structured interview employed in epidemiological research. interviews were performed over the telephone by the institute for survey research at temple university. responses to the dis-iii-r were used to diagnose psychiatric disorders according to the revised third edition of the diagnostic and statistical manual of mental disorders (coopers and michels, 1988). ptsd checklist (pcl-r) the ptsd checklist (pcl) is a self-report rating scale for assessing posttraumatic stress disorder. it consists of 17 items (α = 0.87) which correspond to the dsm-iii symptoms of ptsd. examinees are instructed to indicate how much they have been bothered by each symptom in the past month using a 5-point (1-5) scale. the anchors for the severity ratings range from "not at all" to "extremely." the pcl can be used as a continuous measure of ptsd symptom severity by summing scores across the 17 items. afqt the armed forces qualification test (afqt) is a 50-minute paper-and-pencil test consisting of 100 multiple-choice items (α = .88) that was administered just prior to military induction (bayroff & anderson, 1963). the items equally represent the four domains of vocabulary, arithmetic word problems, knowledge of tools and mechanical or electrical equipment, and spatial visualization, which involves matching folded and unfolded box patterns (uhlaner & bolanovich, 1952). originally intended as a measure of military trainability, further research has found the afqt to be a highly g-loaded test (orme et al., 2001), with g being the construct of general intelligence (humphreys, 1979). vetsa investigators received permission from the united states department of defense to re-administer a version of the afqt that is similar to the afqt versions that had been administered to vetsa subjects just prior to their induction into the military (1965–1975). this version has been used in previous research (grafman et al., 1988). scores from the time of induction are also available to vetsa investigators. genotyping apoe genotype is integral in ad and mci research as it accounts for as much as 50% of the attributable risk for ad in many populations (ashford, 2004). as per lyons et al. (2013), apoe genotyping was conducted for the 1,237 vetsa participants at either the boston university or university of california, san diego site. apoe genotype was determined using previously described conditions (emi et al., 1988; hixson & vernier, 1990). due to the low rate of participants that possessed e4 allele, homozygous and heterozygous carriers were grouped. jak-bondi mci this study uses vetsa data that utilized the jak-bondi (jak, et al., 2009) operationalization of mci. conservative criteria were used in vetsa, such that it requires impairment on two measures within a domain, with impairment identified as 1.5 sd below normative data (jak et al., 2009). according to these standardized criteria, individuals in vetsa were classified as normal if, at most, performance on one measure within one or two cognitive domains fell more than 1.5 sd below age-appropriate norms. procedure mixed modelling was used to test the association between demographic factors, psychosocial and traumatic variables, and mci diagnosis. all analyses were conducted in spss 29.0.0.0. all measures were assessed at the individual level. because our sample consisted of twins, we used a linear mixed modelling approach to account for the clustering of twins within families by including a family id variable as a random effect. separate analyses were performed for each measure. standardized scores were used for all outcome measures and for afqt, education, and performance on neuropsychological tests. model 1 tested whether age at testing date for wave 2 (61.72 ± 2.44 years) had an effect on mci outcome. model 2 tested the association of intelligence, as measured by afqt performance upon military induction (collected between 1965–1975) with mci outcome. model 3 tested the association of apoe e4 allele status on mci outcome. model 4 examined the correlation between years of education on mci outcome. model 5 tested the association of race on mci outcome. model 6 tested the association of ethnicity (hispanic/non-hispanic) on mci outcome. model 7 tested the association of ptsd diagnosis at harvard drug study (tsuang, et al., 2001) data collection date (1996) as measured by the dis-iii-r on mci out56 goulden come. model 8 tested the association of psychosocial stressors over the last two years before the wave 2 testing date on mci outcome. model 9 tested the association of ptsd symptoms at harvard drug study (tsuang, et al., 2001) data collection date (1996), as measured by the dis-iii-r collection on mci outcome. significant associations were determined using the type iii fixed effects. associations were considered statistically significant at p < 0.05, two-tailed. results table 1 shows that age (f = 3.879, p = 0.05) did not have a significant effect on mci diagnosis, although it exhibited a trend towards a predictive effect. intelligence, measured by the afqt taken between ages 18-25, was found to have no significant impact on mci diagnosis (f = 3.523, p = 0.061). the apoe e4 allele(s) status (f = .236, p = 0.628) was also found to have no significant impact on mci diagnosis. education, however, (f = 4.667, p = 0.031) was found to have a significant effect on mci diagnosis. neither race (f = 2.195, p = 0.139) , nor ethnicity (f = 2.252, p = 0.134) had a significant effect on mci diagnosis. ptsd diagnosis, as measured by the disiii-r (coopers and michel, 1988), collected for the harvard drug study in 1996 (f = 0.249, p = 0.618) did not have a significant effect on mci diagnosis. life stress exposure, as measured by the holmes and rahe (1967), (f = 0.249, p = 0.618) also did not have a significant impact on mci diagnosis. lastly, table 1 shows that ptsd symptoms (f = 0.006, p = 0.936) did not have a significant impact on mci diagnosis. discussion our findings in a mixed model analysis of vetsa wave 2 did not support the hypothesis. no significant associations between the stress factors we examined and mci diagnosis in wave 2 was observed. a significant relationship between education and mci was observed, but is not surprising, as epidemiological studies consistently report that a high level of education is associated with a reduced risk of cognitive impairment (anttila et al., 2002; fratiglioni & wang, 2007; ngandu et al., 2007). the results of these studies indicate that education might reflect the extent of early cognitive stimulation of the brain which may influence global cognitive abilities. the average lifetime education of the participants was 12.4 (± 1.3 years; see appendix a). previous studies investigated the relationship between psychosocial and traumatic stressor activities with cognitive decline. we hypothesize that our results may vary from those obtained by yaffe et al. (2010) because their study tracked health records over a period of seven years, while our analysis looked at new mci diagnoses over a shorter time span between each vetsa data collection point. further, their subjects were more racially diverse and included women. our study only investigated the onset of mci, while their study included all types of dementias, including end-stage alzheimer’s disease. most importantly, the mean baseline age of their veteran subjects was 68.8 years. the study by weiner et al. (2017) primarily aimed to establish the relationship between traumatic brain injury, ptsd, and alzheimer’s disease biomarkers. their study’s conceptualization of ptsd may have been more relevant to finding the connection between traumatic exposure and cognitive impairment, as it accounted for current and lifetime ptsd instead of ptsd status at one point in 1996. another feature of their study that contributed to their finding was that their subjects had a mean age of 67.8. as for peavy et al. (2009), their operationalization of mci was the less stringent peterson et al. (1999) criteria. in one study by oltra-cucarella et al. (2018) criteria for mci misclassified 24% of the sample compared to the more conservative jak-bondi mci criteria (jak et al., 2009) used for the current study. stress was also measured as a cortisol rating and from responses to the life events and difficulties schedule (brown & harris, 1978), which quantified events over the participants’ entire adult life instead of within the last two years before the study visit. stressful events were also self-reported every six months, at which time cortisol was measured. this data was collected for two to three years. aside from this difference in operationalization of toxic stress, the mean age of participants was 78.8 years old, making their participants much older than ours. wang et al. (2018) studied non-military elders and found a significant dose-dependent relationship between ptsd symptom severity and developing dementia later in life. though the average age of their participants was 55.44 years, ptsd severity was indicated by the frequency of psychiatric clinic visits for ptsd. this operationalization of ptsd is not through clinically supported or uniform diagnosis criteria. as for psychosocial and trauma-related 57 stressors on mci diagnosis stress, bougea et al. (2022) may have found results that differed from ours because they used a wide variety of conceptualizations of psychosocial stress. for dementia diagnosis, one included study used self-report responses to quantify dementia. all participant data examined was for people 65 years or older. one of the main limitations of the current study was the small number of people that met the diagnostic criteria for mci, which in total was only 147 after adjusting for age, education, and practice effects. this small number resulted in a lack of statistical power. additional issues with the analysis may be from our operationalization of psychosocial and traumatic stressors. the measure of psychosocial stress used, the holmes and rahe (1967), only pertained to the two years of the participant’s life prior to test administration. a measure that accounts for the entirety of adulthood, from 18 years old onwards, would more accurately quantify the total adult stress burden. as for using the ptsd diagnosis conferred in 1996, the literature supports that just one incidence of ptsd permanently alters the brain (hendrickson & raskind, 2016). the mechanism is that trauma causes permanent neuronal changes that harm learning, habituation, and stimulus discrimination. some of these neuronal changes that have a continuing impact do not even depend on actual exposure to reminders of the trauma for expression (van der kolk, 2003). even so, a diagnosis back in 1996 may not be as relevant to cognitive status during the data collection period of vetsa wave 2, which occurred in the 2010’s (between 2009 and 2014). our insignificant findings are still relevant to mci risk factor research. our limitations highlight the importance of subject selection and support existing research on the typical age of onset for mci (howieson et al., 2008). future analyses should be conducted with vetsa study data that covers a longer period of the twins’ lives. future analyses should also include data collected when the participants were older. these two suggestions should be followed so that a longer period of toxic stress exposure can be quantified and so that the subjects will be older, giving more time for mci to develop. higher rates of mci can be expected to emerge as the participants age. the results did not indicate that toxic psychosocial stress exposure and/or traumatic stress had an impact on rates of mci diagnosis within a subject pool of veterans from the vetsa study. monitoring the health of veterans as they age is important for addressing the epidemic of cognitive impairment in the general population. even those with primarily non-combatant roles are at risk for adverse health outcomes due to their service. veterans have made great sacrifices and the scientific community must ensure that their unique healthcare needs are met. references anttila, t., helkala, e. l., kivipelto, m., hallikainen, m., alhainen, k., heinonen, h., mannermaa., a., tuomilehto., j., soininen, h., & nissinen, a. 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(2010). posttraumatic stress disorder and risk of dementia among us veterans. archives of general psychiatry, 67(6), 608-613. https://doi.org/10.1001/ archgenpsychiatry.2010.61 goulden 61 stressors on mci diagnosis table 1 mixed model tests of fixed effects on mci diagnosis note. dependent variable: mci diagnosis at vetsa wave 2. *at ages 17–25 years, as measured by the afqt upon military induction between 1965–1975, collected for the harvard drug study **no e4 allele vs. homoor heterozygous for e4 *** as measured by the dis-iii-r, collected for the harvard drug study in 1996 **** measured over the last two years from testing date by the holmes and rahe (1967). 62 goulden appendix a note. subject demographic data from lyons et al. (2013). 22 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university loneliness during the covid-19 pandemic: implications for mental health and substance use natural disasters, school and public shootings, community violence, domestic terrorism, and most recently, the covid-19 pandemic are all profound instances of complex traumatic stressor events. while each of these stand alone, the covid-19 pandemic was a global traumatic stressor event that invoked feelings of fear, uncertainty, and confusion, consequently disrupting one’s sense of safety, stability, and security worldwide (taylor, 2022). the collective trauma caused by the covid-19 pandemic included all the devastating societal complications and disruptions to daily living that negatively affected individuals, families, and communities worldwide (holman et al., 2023). following the covid-19 pandemic, the collective trauma included the broader psychological reactions to the traumatic event itself along with details of the event held in the collective memory of people (hirschberger, 2018; macias et al., 2021). the traumatic stressors associated with the covid-19 pandemic, such as mandated social distancing, contributed to the risk of psychological vulnerability to psychopathology with detrimental impacts on mental health and well-being (cordaro et al., 2021). however, the effects on mental health from traumatic stress associated with the pandemic often overlook loneliness and its psychosocial correlates to anxiety and depression symptomology and substance use (cadigan et al., 2023). understanding these associations can mitigate the onset and severity of loneliness and psychopathology for future traumatic stressor events (vindegaard & benros, 2020; wang et al., 2020). loneliness is broadly defined as dissatisfaction with the quality of one’s social relationships, and the perceived absence of connection co-occurs with psychological distress (pinquart & sorensen, 2001). the cognitive dissonance between an individual’s desired level of social harmony and their perceived experience of lacking connection causes feelings of inadequacy, regardless of the objective quality of their social network (burholt et al., 2017). this implies that an absence of social contact does not predict loneliness. instead, discontent with the perceived intimacy of one’s relationships produces loneliness. outside traumatic stressor events, a broad range of risk factors are associated with loneliness, and a comprehensive theoretical framework has yet to be fully developed (clark et al., 2021). previous studies suggest that loneliness is prevalent throughout all demographics and cultures (hutten et al., 2021; victor & yang, 2012). there is a consistent pattern of loneliness across the human lifespan, and individuals under 18 and over 65 experience loneliness at higher rates than other age groups (hawkley & cacioppo, 2010). furthermore, other demographic factors, such as sex, education level, socioeconomic status, ethnicity, and immigration status, are predictors of loneliness, with age increasing the likelihood of risk (beutel et al., 2017; bosma et al., 2015). some key aim: traumatic stressor events disrupt the normal daily functioning of individuals and groups, and the consequences of collective trauma magnify psychopathology and mental health issues. one overlooked mental health implication of traumatic stress is loneliness. the current study examines loneliness as a result of traumatic stress and its psychosocial correlates, including substance abuse and changes in daily health behaviors. design: cross-sectional, nationwide, online survey. methods: this study was a cross-sectional, nationwide online survey that included 2,530 adults in the united states, 18-83 years old, and examined the associations between loneliness and psychosocial factors and substance use during the initial part of the covid-19 pandemic. results: increased loneliness was associated with younger age, single marital status, and lower levels of education. mental health disorders, including major depression, generalized anxiety, and somatization, were also associated with high levels of loneliness. further, individuals with high levels of loneliness were more likely to report increased substance use, including alcohol and illicit drugs. discussion: the findings of this study indicate that during times of collective traumatic events, high levels of loneliness are a risk factor for mental health and substance use. further initiatives are warranted to create awareness and institute routine screenings for symptoms of loneliness to mitigate mental health distress and increases in substance abuse. keywords: loneliness, isolation, mental health, alcohol use, traumatic stress millie cordaro1, emma johnson1, chris kinstley1, kelly haskard-zolnierek1, rachel medina2, jessica perrotte1, jeffrey t. howard3, & krista j. howard1 1department of psychology, texas state university, 2seaton foundation, & 3department of public health, university of texas at san antonio 23 cordaro et al. factors influencing loneliness are physical health, mental health, and social support (hawkley et al., 2008). loneliness combined with depression is associated with an increased morbidity risk, including major chronic health conditions and poor physical health (stek et al., 2005). specifically for older adults, social isolation is associated with a higher likelihood of premature mortality. it is related to an increased risk for secondary aging, such as cognitive decline and various forms of dementia, including alzheimer’s disease (lara et al., 2019; wilson et al., 2007). social isolation is also associated with higher levels of psychological distress (campagne, 2019). loneliness is a common predictor of well-being, and higher levels of loneliness are associated with mental health issues and psychopathology (ernst et al., 2022). in addition, chronic isolation can undermine daily functioning and has been extensively linked with suicidality and self-harm (mushtaq et al., 2014; stravynski & boyer, 2001). several common mental health disorders demonstrate comorbidity with loneliness, particularly major depressive disorder (mdd) and generalized anxiety disorder (gad; muyan et al., 2016). in fact, social isolation resulted in a 25% increase in the global prevalence of depression and anxiety (world health organization, 2022). while the literature is sparse regarding loneliness and traumatic stressor events prior to the pandemic (palgi et al., 2012), loneliness during the pandemic has been linked to drug and alcohol abuse, and the relationship between loneliness and substance use is mediated by depression and anxiety (horigian et al., 2020). this suggests that as loneliness levels increase, substance use also increases, and at least part of this relationship operates through poor mental health. it has been suggested that substances like alcohol and marijuana use temporarily alleviate feelings of social isolation (ingram et al., 2020). as with mental health, the pandemic has caused an increase in substance use across a wide range of demographics (fitzke et al., 2021). however, quality social support and relational connectedness can buffer the adverse effects that loneliness can have on mental health and daily functioning. likewise, resilience and post-traumatic growth associated with traumatic stressor events are significantly related to social support derived from social connection (hall et al., 2010; xu & ou, 2014). the study while there is ample research about general social isolation and loneliness, less is known about social isolation and traumatic stressors caused by the pandemic, which is considered a historical traumatic stressor event (usher et al., 2020). given the adverse outcomes of loneliness within the general population, it is essential to understand the factors related to loneliness during the initial part of the covid-19 pandemic. similar studies have examined the relationship between loneliness, mental health, and substance use during the pandemic. the present study captures these factors while also examining other psychosocial factors, including stress, somatization, fatigue, quality of life, and changes in daily behaviors. thus, the broad aim of this study was to investigate how loneliness during a historical traumatic stressor event (i.e., pandemic) affected u.s. adults. it was hypothesized that high levels of loneliness would correspond with poorer mental health and increased substance use. method study setting and sampling between april 14 and april 22, 2020, a total of 2,530 participants included in this study were recruited through a nationwide facebook sponsored ads campaign, while the recommended stay-at-home initiatives were in place in the united states. the posted online campaign targeted the facebook newsfeeds of 76,100 users 18 years of age or older, inviting individuals to participate voluntarily in an anonymous online study that evaluated the psychological responses to the covid-19 pandemic. the post provided a link directing the participants to a qualtrics survey. from the online post, 4,406 respondents clicked on the link, and 2,739 provided informed consent and completed the online survey. participants were informed that they could skip any questions they were uncomfortable answering. only participants who completed the ucla loneliness scale portion of the survey are included in the current study (n = 2,530). the mean age of participants in this study’s sample is 47.7 (sd = 12.9) years, ranging between 18 and 83 years, with 89.0% female and 91.3% white. of the participants in this study, 28.7% (725) were single, 55.1% (1390) were married, and 16.1% (407) were divorced, separated, or single. further, the education level breakdown for the participants in this study was 5.6% (141) with at most a high 24 loneliness, mental health, and substance abuse contains nine stated problems to which the respondents indicated if they have been bothered by these problems in the past two weeks using one of four options ranging from “not at all” (0) to “nearly every day” (3). an example of a problem is “feeling down, depressed, or hopeless” (spitzer et al., 1999). the phq-9 is a psychometrically sound questionnaire commonly used in research and clinical practices for general populations (kroenke et al., 2010). generalized anxiety disorder. generalized anxiety disorder was determined using the patient health questionnaire – generalized anxiety disorder subscale (gad-7; spitzer et al., 2006). the gad-7 is a brief screening tool commonly used in research and clinical practices that provides a provisional diagnosis of generalized anxiety disorder (gad; lowe et al., 2008). the gad-7 includes seven statements in which participants indicated if they have been bothered by them in the past 2 weeks ranging from “not at all” (0) to “nearly every day” (3). this study used the scoring algorithm rather than the cut-off scores to determine if participants met the criteria for the gad diagnosis. fatigue. aspects of fatigue were assessed using the checklist of individual strength (cis; vercoulen et al., 1999). the cis includes four domains: general fatigue, motivation, physical activity, and concentration. the composite scale consists of 20 items to which the participants respond to prompts such as “thinking requires effort” on a 7-point likert scale ranging from “yes, that is true” (7) to “no, that is not true” (0). the overall scale (m = 85.2, sd = 25.4) for this study provided good internal consistency (α = .94). quality of life. quality of life was assessed using the world health organization quality of life bref scale (whoqol, 1996; whoqol-group., 1998). the whoqol-bref instrument uses 26 items to assess four specific domains related to the quality of life: physical health, psychological health, social relationships, and environment. examples of items from this instrument include, “to what extent do you feel your life to be meaningful?” and “how satisfied are you with the support you get from your friends?” using specific criteria to transform raw scores into standardized scores, the final scores range from 0 to 100, with higher values indicating better quality of life (whoqol, 1996). specific measures developed for the current study school diploma, 30.4% (766) with some college, 31.5% (796) with a 4-year degree, and 32.5% (820) with a graduate or professional degree. this study was approved by the university institutional review board (#7221). demographics participants were asked to provide information about their age, gender identity, race and ethnicity, marital status, education level, and if they had children under 18. instruments psychosocial measures loneliness. loneliness was assessed using the 20-item ucla loneliness scale (ucla; russell et al., 1978). this measure assesses feelings of loneliness and social isolation using a 4-point likert scale with responses ranging from “i never feel this way” (1) to “i often feel this way” (4), and total scores range between 20 to 80, with higher scores indicating greater loneliness. examples of items from this scale include “how often do you feel left out?” and “how often do you feel isolated from others?” this is a reliable and validated scale (russell, 1996; russell et al., 1980). for this study, the overall scale (m = 44.9, sd = 11.7) provided excellent internal consistency (α = .94). the cut-offs for loneliness severity on the ucla scale were adapted from cacioppo and patrick (2008), which included: total score < 28 = no/low loneliness, total score 28 43 = moderate loneliness, and total score > 43 = high loneliness. perceived stress. stress was measured using the perceived stress scale (pss; cohen et al., 1983). the pss assesses general life stressors using ten items within a 1-month time frame. participants were asked to respond to each item using a 4-point likert scale ranging from “never” (1) to “very often” (4), with total scores ranging between 10 and 40, with higher scores indicating greater stress. an example of an item on this scale is, “how often have you felt nervous and stressed?” the pss is commonly used in both research and clinical practices and is shown to be a valid and reliable scale (cohen et al., 1983; lee, 2012). the overall scale (m = 19.3, sd = 7.4) for this study provided good internal consistency (α = .90). major depressive disorder. major depressive disorder (mdd) was assessed using the patient health questionnaire – major depression subscale (phq-9; spitzer et al., 2006). using a scoring algorithm to determine if the participants meet the criteria for a provisional diagnosis of mdd, the phq-9 25 cordaro et al. n = 945), and high loneliness (> 43; hl; n = 1,421). the comparisons of the demographic variables are shown in table 1. there was a significant difference between the comparison groups when evaluating age, such that the participants in the nll group were older than those in the ml and hl groups (p = .014). no significant differences were identified between the participants in the comparison groups when evaluating gender, race/ethnicity, living arrangements, or children under the age of 18 (all ps > .05). when comparing participants on marital status, there was a significant difference in proportions of participants in each of the comparison groups, such that there was a higher proportion of participants in the hl group were either single or divorced/widowed and a higher proportion of participants in the nll group who were married (p = .011). further differences were identified between the comparison groups based on education levels. a higher proportion of participants identified as having some college (possibly being college students) were in the hl group. in contrast, many participants in the nll group indicated having graduate or professional degrees (p = .025). age, marital status, and education level were included as covariates for the comparisons of psychosocial variables (see table 2). there was a significant difference in levels of perceived stress between the participants in the three comparison groups. those in the hl group had the highest mean score, followed by those in the ml group, and those in the nll group had the lowest level of perceived stress (p < .001). when comparing rates of psychopathology, participants in the hl group had the highest proportion of individuals who met the criteria for major depressive disorder (mdd, 33.8%), generalized anxiety disorder (gad, 25.3%), and somatization disorder (sd, 20.1%), compared to those in both the ml (mdd, 9.4%; gad, 9.4%, sd, 9.8%) and nll (mdd, 1.7%; gad, 3.9%, sd, 1.6%) groups (all ps < .01). when comparing the four domains of the cis, the participants in the hl group had significantly higher scores in all subscales (fatigue, concentration, motivation, and physical activity; all ps ≤ .001) compared to the participants in the nll group. further differences were identified when comparing the quality-of-life indices between the participants in the comparison groups on the four subscales of the whoqol-bref. the participants in the nll group reported significant changes in daily behaviors. changes in daily behaviors were assessed through specific items created by the researchers for this study. the participants were asked to indicate whether certain general daily health behaviors, including sleep, food consumption, and technology use, had stayed the same, increased, decreased, or were not applicable since before the pandemic began. changes in substance use behaviors. changes in substance use behaviors were assessed through specific items created by the researchers for this study. the participants were asked to indicate whether certain substance use behaviors had stayed the same, increased, decreased, or were not applicable since before the pandemic began. the specific substance use behaviors assessed included: alcohol use, cigarette use, marijuana use, opioid drug use, illicit drug use, anti-anxiety medication use, and sleep aid use. data collection and data analysis the data collected for this study were weighted to the total u.s. population based on the 2018 u.s. census bureau population estimates by age, sex, and race/ ethnicity (u.s. census bureau, 2020). four age strata, two sex strata, and four race/ethnicity strata were used for the weighting procedure. to account for geographic clustering, a variable was also created based on the first two digits of the u.s. zip codes requested during data collection. complex sample designs were used to conduct chi-square tests of independence for categorical comparisons and one-way anovas for continuous variables, controlling for age, marital status, and education level and adjusting for population weights, strata, and clustering. post-hoc comparisons are reported in the tables for variables with significant differences. the significance level was set at α = .05, and pairwise deletion was used for any missing data points. a posthoc power analysis using a one-way anova, with n = 2,530, α = .05, and moderate effect size, indicated adequate power (1-β) = 1.00. all analyses were conducted using spss version 27 (ibm, inc., chicago, il). results a total of 2,530 participants were included in the study and were placed into one of three comparison groups based on their total scores on the ucla loneliness scale. the cut-off scores for loneliness severity on the ucla scale were adapted from cacioppo and patrick (2008) and included: no/low loneliness (< 28; nll; n = 164), moderate loneliness (28-43; ml; 26 loneliness, mental health, and substance abuse .003). of the other substances compared, no significant differences in increases between the comparison groups were identified based on cigarette use, anti-anxiety medication use, or sleep aid use (all p > .05). discussion the purpose of the study was to identify and profile individuals in the u.s. population who reported high levels of loneliness during the initial pandemic lockdown, and to examine how loneliness relates with mental health, pandemic concerns, and substance use. we found an effect of age, with the youngest participants expressing higher rates of loneliness. this is consistent with previous research on age as a risk factor for loneliness in studies that used the same measure, such as the ucla-3 loneliness scale (von soest et al., 2020). younger populations tend to emphasize social group size and closeness of relationships as more critical facilitators of social support (green et al., 2001). in the current study, younger individuals may have been more impacted by the pandemic as a result of loneliness since they were isolated from broader networks of social support. this finding adds to the literature that tends to focus solely on older adult populations traditionally identified as at risk for loneliness (chawla et al., 2021). married individuals made up a large majority of the group with no/low loneliness (76.9%), while single and divorced/widowed participants showed the largest percentage in the high loneliness category. research indicates that having a spouse increases overall well-being and reduces feelings of loneliness. it is likely that having a committed partner in residence during the covid-19 lockdown provided built-in social connection and social support, reducing many married couples’ levels of loneliness (stack & eschleman, 1998). within education levels, individuals with a graduate or professional degree made up over half of the no/low loneliness group. this confirms previous findings, as education is associated with numerous factors that may be protective against loneliness, including increased well-being, broader social circles, greater job satisfaction, better health, and lower divorce rates (oreopoulos & salvanes, 2011). conversely, adults without a college degree experienced more financial hardships and disproportionately lost their jobs during the lockdown; both are risk factors for loneliness and may help explain this result (parker et al., 2021). as expected, high loneliness scores were associatly better quality of life in the physical health (p = .013), psychological (p <.001), social relationships (p <.001), and environmental (p <.001) subscales compared to the participants in the hl comparison group. the comparisons of the changes in general daily behaviors from before the onset of the pandemic also controlled for age, marital status, and education level and are shown in table 3. there was a significant difference between comparison groups on the change in sleep, such that a higher proportion of the hl group indicated a decrease in sleep (p = .006). a question was asked about changes in eating behaviors. while no significant differences were identified between the groups based on junk food consumed, there was a difference in total food consumed. a greater proportion of participants in the hl group indicated an increase or a decrease in food consumption, while a greater proportion of participants in the nll and ml groups reported no changes in food consumption (p = .011). questions about changes in physical activity showed that a greater proportion of participants in the hl group indicated a decrease in outdoor physical activity (both p = .005). changes in technology use also differed significantly among the comparison groups. a higher proportion of participants in the ml and hl groups reported increased news coverage (watched or read; p = .038). a higher proportion of the hl group reported a significant increase in tv watching (p = .015). the last set of comparisons is focused on increases in substance use behaviors during the initial covid-19 pandemic (see table 4). for these comparisons, only those individuals who indicated that they use those substances are included. there is a significant difference in the increased rates of alcohol use since the pandemic began for the participants in the ml (36.5%) and hl (39.5%) groups compared to the participants in the nll group (18.4%; p = .002). likewise, the hl group had higher rates of increased marijuana use (42.5%) as compared to the nll group (30.9%) and ml group (37.7%; p = .002). increases in opioid use were also significantly higher for those in the hl group compared to the nll or ml groups (p = .006). while the overall number of participants who use illicit drugs is small, there was a significant increase noted in illicit drug use between the participants in the comparison groups, with the highest proportion (38.4%) in the hl group, followed by 20.5% in the nll group, and 14.9% in the ml group (p = 27 cordaro et al. swing in psychological distress, psychopathology, and maladaptive coping via alcohol, marijuana, opioids, and illicit drug use. in addition, individuals experiencing higher levels of loneliness were sleeping less, eating more or less food compared to pre-pandemic functioning, and were less likely to be physically active. last, participants reporting higher levels of loneliness showed increased smartphone use, internet use, and increased news consumption and tv watching. collectively, these findings suggest that the use of alcohol, marijuana, opioids, illicit drugs, food consumption, and news consumption were behaviors that could temporarily alleviate or numb depression and/or anxiety symptoms and perceived loneliness. these findings on daily health behaviors are striking in that these changes are not typically associated with loneliness and can easily go unrecognized. this creates cause for concern in that individuals suffering from loneliness likely are not being screened for changes in general health behaviors. therefore, these individuals with higher levels of loneliness are likely to elude screening, detection, and ultimately intervention and treatment (gordy et al., 2021). finally, results showed that higher levels of loneliness were associated with increased alcohol consumption, marijuana, opioid, and illicit drug use. however, there were no significant associations between loneliness and the increased use of other substances such as cigarettes, anti-anxiety medications, or sleep aids. previous studies showed a link between loneliness and substance use (horigian et al., 2020) and between loneliness and regular alcohol use (bragard et al., 2022), and are consistent with the findings in the current study. limitations while the findings of this study have several practical implications for therapeutic interventions and bring awareness to the potential negative effects associated with high levels of loneliness, several factors in this cross-sectional study limited the interpretation of the data collected. participants were recruited randomly via facebook ads, and respondents (n = 2,530) were 47.7 (sd = 12.9) years old, ranging between 18 to 83 years, with 89.0% being female and 91.3% white. since this sample is not representative of the population, results must be interpreted accordingly. secondly, this study was cross-sectional and used self-report measures, which may increase self-presentation bias. further, since the participants were recruited through facebook, it is plausible that ed with stress, depression, anxiety, and somatization symptomology. previous research has documented loneliness as a predictor of mental health issues and disorders, whereby perceived loneliness acts as a risk mechanism for the onset and a sustaining factor for maintaining psychopathology symptoms (law et al., 2023). in addition, participants in the ml and hl groups had increased rates of alcohol use, marijuana use, opioid use, and illicit drug use, demonstrating higher levels of loneliness as a risk factor for maladaptive coping. however, in the current study, cigarette use, anti-anxiety medication use, and sleep aid use were not significantly different among loneliness comparison groups. previous research findings on loneliness and substance abuse are mixed and inconsistent in the literature, depending on the type of substance being used and measured (cadigan et al., 2023). in addition, those reporting higher loneliness levels had more difficulty with sleep, focus, motivation, and physical activity than the ml or nll groups. all four items from the cis used in this study share symptoms of loneliness, anxiety, and depression. recent research shows that perceived stress levels during the beginning of the pandemic increased globally, and women, students, and young adults were the most at-risk (gamonal-limacoco et al., 2022). similarly, prevalence rates of gad, which is related to loneliness and stress (cordaro et al., 2021), were higher at the beginning of the pandemic than before the outbreak. health and physical safety concerns and uncertainty about the future are examples of uncontrollable, pandemic-related worries that can help explain the increase in gad symptoms. notably, participants with hl reported depressive symptoms at a higher rate than perceived stress, gad, or somatization disorder. not surprisingly, the nll group had the highest quality of life and best scores on physical health, psychological, social relationships, and environmental measures. this stable pattern of the results of the psychosocial comparisons confirms previous findings about the symptomology of loneliness and the broad domains of life that social isolation influences (hawkley & cacioppo, 2010; jaremka et al., 2013). loneliness was a major mechanism of covid-19 pandemic traumatic stress through the disruption and upending of general daily behaviors established prior to the onset of this traumatic stressor event. perceived loneliness due to social isolation contributed to an up28 loneliness, mental health, and substance abuse connections play in buffering 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(2014). resilience and quality of life among wenchuan earthquake survivors: the mediating role of social support. public health, 128(5), 430–437. https://doi. org/10.1016/j.puhe.2014.03.002 33 cordaro et al. table 1 demographic comparisons (n = 2,530) note. values shown are means or column percentages (standard errors). post-hoc comparisons use alphabetical superscripts to denote significant group differences with a = no/low loneliness; b = moderate loneliness; and c = high loneliness. 34 loneliness, mental health, and substance abuse table 2 psychosocial comparisons (controlling for age, marital status, and education level) note. values shown are means or column percentages (standard errors). post-hoc comparisons use alphabetical superscripts to denote significant group differences with a = no/low loneliness; b = moderate loneliness; and c = high loneliness. 35 cordaro et al. table 3table 3 changes in daily behaviors (controlling for age, marital status, and education level) note. values shown are means (standard errors). post-hoc comparisons use alphabetical superscripts to denote significant group differences with a = no/low loneliness; b = moderate loneliness; and c = high loneliness. 36 loneliness, mental health, and substance abuse table 4 substance use increases during initial covid-19 pandemic (based on current users; controlling for age, marital status, and education level) note. values shown are column percentages (standard errors). post-hoc comparisons use alphabetical superscripts to denote significant group differences with a = no/low loneliness; b = moderate loneliness; and c = high loneliness. 5 graduate student journal of psychology fall 2024 vol. 23 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university sexual and intimate partner violence against women with schizophrenia: a scoping review intimate partner violence (ipv) is defined as any conduct occurring within an intimate relationship that inflicts physical, sexual, or psychological harm. ipv has sparked significant public health apprehension due to the growing prevalence highlighted by diverse global news outlets. it has infiltrated all societal levels, emerging as the predominant manifestation of gender-based violence, leading to immediate and enduring health repercussions for those affected. population-based prevalence estimates typically fail to accurately represent the problem’s magnitude due to substantial underreporting; nonetheless, ipv still significantly contributes to crime statistics in all societies (afe et al., 2016). indeed, as many as 38% of all murders of women are committed by intimate partners (world health organisation [who], 2021). research findings, as highlighted by afe et al. (2017), indicate that women, who are disproportionately impacted by sexual violence— covering non-consensual sexual activities, coercion, exploitation, harassment, or advances, irrespective of the perpetrator's relationship with the victim or the setting— and ipv are at heightened risk if they experience severe mental illness (smi). smi is defined as individuals with persistent or recurrent mental disorders significantly affecting their functioning, compared to the general population. this negatively affects women’s physical, mental, sexual, and reproductive health (who, 2021). thus, minimal research has been conducted on the sexual and ipv victimization experienced by women with schizophrenia, a severe mental illness characterized by hallucinations, delusions, social withdrawal, diminished pleasure and motivation, cognitive deficits, and other symptoms (darves-bornoz et al., 1995). as such, the objective of this research is to elucidate our knowledge on this topic. while ipv encompasses verbal, psychological, physical, and sexual abuse, we have opted to draw a distinction between ipv and sexual violence. specifically, our discussion of ipv encompasses sexual violence perpetrated by intimate partners, whereas the section on sexual violence includes acts perpetrated by intimate partners as well as by individuals other than partners. intimate partner violence against women globally, 641 million women are affected by partner violence, establishing it as the most prevalent form of violence affecting women (buchholz, 2021). during their lives, one out of three women worldwide will experience ipv (buchholz, 2021). adding to this distressing statistic, globally, women constitute 20 percent of all murder victims, and the majority of these cases involve killings by a partner or ex-partner (buchholz, 2021). characterized by any behaviour within an intimate relationship causing physical, sexual, or psychological harm, ipv can account for physical aggression, sexual manipulation, psychological maltreatment, and controlling conduct done by a present or past partner (afe et al., 2016). the rising media coverage of this behaviour has raised substantial public health concerns kellie-anne bélisle, adriana mendrek, sarah hepworth & joel montanez psychology department, bishop’s university, sherbrooke, canada background: globally, 641 million women are touched by intimate partner violence (ipv), establishing it as the most prevalent form of violence affecting women. women, who are already disproportionately affected by sexual and ipv, face an elevated risk when dealing with severe mental illnesses (smi) compared to the general population. schizophrenia, classified as an smi, poses numerous obstacles that impact women’s ability to maintain employment, good health, and sustain stable relationships. nevertheless, limited data exists on ipv against women with schizophrenia and its effect. aims: the objective of this scoping review was to summarize the available literature on sexual and ipv against women with schizophrenia and underlie future avenues of research. methods: we conducted an electronic search using keywords in the following databases: apa psychinfo, pubmed, scopus, google scholar, and psychology and behavioral sciences collection. the search yielded a total of 6,099 articles. upon title and abstract review, 97 articles were retained for full-text reading, after which 7 articles were included in this review. results: the available articles reveal an association between sexual violence and ipv against women with schizophrenia. younger women diagnosed with schizophrenia, especially those with low income or unemployed, are at a higher risk of experiencing sexual and ipv. this victimization increases the likelihood of suicide and exacerbates psychopathology. conclusion: research should examine care-setting interventions for women with schizophrenia, who are at increased risk of sexual and ipv, aiming to prevent severe harm. implementation of preventive measures is essential for enhancing healthcare and societal transformation. keywords: ipv, sexual violence, schizophrenia, women, victimization 6 bélisle et. al globally. beyond the immediate potential traumatic events, it is imperative to acknowledge the enduring short and long-term consequences faced by survivors. this underscores the urgent need for multifaceted approaches to prevention and intervention, addressing the root causes of ipv while providing comprehensive support for survivors to rebuild their lives. sexual violence against women according to the world health organization’s multi-country study (mcs), the lifetime prevalence of women experiencing sexual abuse by a partner was between 6% and 59% (who, 2002). sexual violence is a profound human rights violation that encompasses any sexual activity involving coercion, sexual exploitation, harassment, or advances committed by an individual, irrespective of the relationship with the victim, and the environment (dartnall & jewkes, 2013; krug et al., 2022). as perpetrators are generally men known by the victims and commonly intimate partners, it is important to acknowledge that sexual violence is pervasive in every society and frequently targets women (dartnall & jewkes, 2013; who, 2002). notably, women facing mental health challenges experience a higher victimization rate, reaching 53 incidents per 1000 individuals, in contrast to the general population's rate of 17 incidents per 1000 people (van deinse et al., 2019). indeed, violent victimization against women with smi was estimated at 25% greater than the general population (van deinse et al., 2019). therefore, it is crucial to acquire deeper insights into the topic, given that sexual violence can lead to lasting adverse effects, worsen mental health challenges, and contribute to the emergence of concurrent disorders. schizophrenia as of 2019, approximately 0.3 percent of the world population was reported to have schizophrenia (owid, 2019). this disorder can disturb various facets of an individual’s mental faculties such as thoughts, perception, speech, emotions, behaviour, and social functioning (schultz et al., 2007). symptoms may encompass hallucinations (e.g., hearing voices), delusions (e.g., paranoia), social withdrawal, lack of pleasure, loss of motivation, cognitive deficits, and other problems disrupting patients’ lives (schultz et al., 2007). as schizophrenia affects various facets of women’s lives, many have difficulty relating and connecting to the world around them, making these women vulnerable to feelings of loneliness and isolation. moreover, the entourage of women with schizophrenia may have difficulty understanding that their illness may complicate their relationships. this challenge becomes especially daunting when attempting to establish intimate relationships, as these women are more vulnerable to emotional and physical victimization. indeed, in chernomas’s (2000) research, women expressed how they feared intimacy as many felt preyed upon once their psychiatric history was known. additionally, numerous women shared experiences of childhood abuse, rape, and physical mistreatment, leading to a strong reluctance and fear towards engaging in sexual intimacy (chernomas et al., 2000). these acute stressors have been identified as factors contributing to an elevated risk of suicidal behaviours (chernomas et al., 2000). as the lifetime prevalence of suicide in the schizophrenia population has been estimated to be ten times higher than in the general population, the severity of symptoms and victimization leads to a greater number of suicide attempts in women with schizophrenia (carlborg et al., 2010; thara & kamath, 2015). in terms of employment, certain women opt to be homemakers, remain on disability pensions, or engage in work fields (chernomas et al., 2000). while some express a desire to work, they are apprehensive about their ability to cope with the stress of employment. they fear the potential of falling ill and being financially strained, coupled with the challenge of finding alternative employment (chernomas et al., 2000). moreover, many women diagnosed with schizophrenia have encountered limiting messages regarding their ability to pursue employment or education due to their disability, underscoring their apprehension about entering the workforce (chernomas et al., 2000). schizophrenia has devastating effects not only on women’s emotional and cognitive health but also on their physical health. the negative impacts of antipsychotic medications include weight gain, amenorrhea, reduced libido, lactation, and facial hair growth (chernomas et al., 2000). these side effects have a detrimental impact on women’s well-being and undermine their sense of self and femininity. furthermore, women with schizophrenia have expressed a lack of sufficient information from health professionals regarding family planning, pregnancy, parenting, or menopause, particularly in light of their mental health condition and its psychopharmacologic treatment (chernomas et al., 2000). the lack of communication and sup7 violence against women with schizophrenia port from healthcare professionals can lead women to be hesitant to discuss menstrual irregularities and sexuality as they face insufficient responses to their concerns on these matters (chernomas et al., 2000). women with schizophrenia constitute a vulnerable population as their illness impacts multiple aspects of their lives, including their potential for employment, pursuit of higher education, health, and ability to establish and maintain stable relationships. given that symptoms may exacerbate in the face of challenges, women with schizophrenia also exhibit a higher likelihood of suicide compared to the general population, highlighting the pressing need to improve our comprehension of women’s circumstances and their vulnerability to victimization. ipv, sexual violence and schizophrenia as ipv against women is highly prevalent, past literature has indicated that women with smi are at elevated risk of being victims of sexual and ipv (afe et al., 2017). across various research, the lifetime exposure to sexual and physical abuse fell between 43% and 81% for women with smi (kim et al., 2006). these women are more susceptible to abusive and violent relationships due to the persistent, debilitating impact of the illness and social stigmatization. particularly, it was found by thara & kamath (2015), that women with schizophrenia were severely disabled compared to women with other diagnoses. this highlights the need to intensify focus on schizophrenia, particularly considering the insufficient available data regarding the prevalence of sexual and ipv against women diagnosed with schizophrenia and its potential impact on their condition. following the methodological framework proposed by arksey and o’malley (2005) and levac et al. (2010), this scoping review seeks to describe the present literature regarding ipv and sexual violence among women with schizophrenia worldwide. given the pervasive nature of violence against women worldwide, causing harm to millions, and being especially prevalent among women with smi, it is imperative to thoroughly investigate this phenomenon. the impact of such violence on symptoms, treatment complexities, and the overall quality of life for these women cannot be understated. mental health professionals must be aware and diligent surrounding this issue by carefully assessing for this factor (afe et al., 2016). by gaining a deeper understanding of the relationship between sexual violence, ipv, and women with schizophrenia, more effective strategies for prevention, intervention, and support can be developed. ultimately, this examination can contribute to an enhanced comprehension of the issue, offering insights into potential avenues for future research. methodology as a scoping review, this article is based on the methodological framework developed by arksey and o’malley (2005) and refined by levac et al. (2010) following prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines (tricco et al., 2018). the purpose of scoping reviews is to provide a comprehensive overview of a new area of research and identify potential gaps that need to be addressed. according to recent literature, five key steps are necessary for conducting scoping reviews: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting the data; and 5) collating, summarizing, and reporting results (arksey and o’malley, 2005; levac et al., 2010). the main question directing this review is “what is the state of knowledge regarding sexual and intimate partner violence against women with schizophrenia?” literature research an electronic literature search was initiated on september 6, 2023, through the following databases: apa psychinfo, pubmed, scopus, google scholar, and psychology and behavioral sciences collection. in collaboration with an academic librarian, kab developed a search strategy using controlled vocabulary (mesh and index terms) and keywords relevant to “sexual violence,” “intimate partner violence (ipv)” and “schizophrenia.” continual collaboration, validation, and discussion followed with sh and am. for sexual violence and intimate partner violence, the terms employed for the search were: “sexual violence” or “intimate partner violence” or “intimate partner abuse” or “sexual viol*” or “sexual abuse” or “sexual assault” or “sexual coercion” or “sexual harassment” or “sex offenses” or “acquaintance rape” or “domestic violence” or “victimization” or “marital rape.” for schizophrenia, the terms employed were: “schizophrenia.” the search strategy is presented in figure 1. study selection after conducting the database search, all identified literature was imported into zotero reference 8 bélisle et. al management software (v6). the search generated 6,099 articles, of which 4,459 remained after removing duplicates. to determine eligibility for full-text review, kab and sh screened titles and abstracts. to be selected, studies had to meet the following inclusion criteria: (1) the primary theme had to be related to both sexual violence, ipv, and schizophrenia (2) articles were published in a peer-reviewed journal, (3) articles were available in english or french, (4) articles could not be systematic reviews, (5) article population had to be women (included studies that distinguished findings between sexes), (6) excluded children and (7) article population was diagnosed with schizophrenia. the authors chose to exclude children from the study due to childhood-onset schizophrenia being recognized as a distinct subtype of the disorder, necessitating separate research. incorporating studies involving children would primarily delve into child sexual abuse, which warrants dedicated investigation on its own. a total of 97 articles were retained for full-text review, and the final selection was agreed upon by sh and am. following the full-text review, seven articles were retained and included in the review. for each included article, references, authors, and “cited by” were scanned to identify additional relevant studies. the flowchart of the study selection and screening process can be seen in figure 2. data extraction and analysis a charting form was used to facilitate team discussion and approval during full-text screening and descriptive analysis. using charting forms developed by peters et al. (2020), lauzon-schnittka et al. (2022), and arnstein et al. (2020), we extracted the following information for each article: authors, journal, year of publication, study location, the number of participants, age of participants, the aim of the study, methodology, and important results. the extraction was done by kab and validated by sh and am. the results were then summarized, and narrative synthesis was employed to report the findings (popay et al., 2006). results the characteristics of the 7 retained articles are displayed in table 1. study characteristics among the selected articles, one was published in 1995 (darves-bornoz et al., 1995) and one in 2006 (kim et al., 2006). a total of 5 articles were published after 2013 (afe et al., 2016, 2017; khalifeh et al., 2015; leslie et al., 2023; yildirim et al., 2014). two studies were conducted in nigeria (afe et al., 2016, 2017), one in turkey (yildirim et al., 2014), one in south korea (kim et al., 2006) and one in canada (leslie et al., 2023). two studies were from europe, including one from france (darves-bornoz et al., 1995) and the other from england (khalifeh et al., 2015). the number of participants in the selected studies ranged from 70 to 1,802,645. two articles examined female outpatients diagnosed with schizophrenia with an average age of 38.3 years (afe et al., 2016, 2017), while kim et al. (2006) had an average age of 33.5 years. two studies consisted of in-patients undergoing treatment (khalifeh et al., 2015; yildirim et al., 2014). yildirim et al. (2014) sample consisted of female patients with an average age of 39.24 years. khalifeh et al. (2015) randomly recruited patients with smi (59.7% with schizophrenia) through community mental health services, with an average age of 40.8 years. two studies had a sample of in and outpatients with schizophrenia (darves-bornoz et al., 1995; kim et al., 2006). kim et al. (2006) had a sample with an average age of 33.5 years while darves-bornoz and colleagues (1995), recruited females with an average age of 34.3 years. lastly, leslie et al. (2023) study compared women in ontario with or without schizophrenia and who became pregnant between april 1, 2004, and march 31, 2018, with an average age of 30.6 years. methodology the seven articles were quantitative (afe et al., 2016, 2017; darves-bornoz et al., 1995; khalifeh et al., 2015; kim et al., 2006; leslie et al., 2023; yildirim et al., 2014). one article was surveyed through a computer-assisted face-to-face interview while also incorporating a self-completion module (khalifeh et al., 2015). one article utilized a population-based cohort study involving the registry of administrative health and clinical data from 2004 to 2018 in ontario, canada (leslie et al., 2023). two studies employed semi-structured interviews (darves-bornoz et al., 1995; kim et al., 2006). finally, afe et al. (2016, 2017) studies employed interviews to survey women. even though these studies share the same sample, they vary in terms of the assessment measures employed and the number of participants recruited. 9 violence against women with schizophrenia prevalence of intimate partner violence among women with schizophrenia in four articles, the authors aimed to explore ipv among women with schizophrenia (afe et al., 2016, 2017; khalifeh et al., 2015; leslie et al., 2023). the four studies reported a higher prevalence of ipv among women with schizophrenia than women without this diagnosis. afe et al.'s (2016) aim was to study the various patterns of ipv against women with schizophrenia and its association with psychopathology. the results indicated that 75% of the participants experienced at least one occurrence of ipv (afe et al., 2016). afe et al. (2017) investigated socio-demographic and other attributes of partners of women with schizophrenia in nigeria. they reported that 73% of the participants experienced ipv at least once which is much higher than the prevalence of non-mentally ill women found at 40% in nigeria (afe et al., 2017). khalifeh et al. (2015) assess and compare the prevalence and consequences of domestic and sexual violence among individuals with smi, with 59.7% of the participants diagnosed with schizophrenia, and the general population. their research found that women with smi reported higher domestic violence (69%) compared to the control group (33%) (khalifeh et al., 2015). the smi population also had a higher rate of sexual violence (10%) compared to the control group (2%) (khalifeh et al., 2015). lastly, leslie et al. (2023), aimed to assess and compare the risk of interpersonal violence necessitating an emergency department (ed) visit during pregnancy or within one year postpartum among women with and without schizophrenia. they found a higher risk of ed visits for interpersonal violence among women with schizophrenia (4%) compared to women without schizophrenia (0.4%) (leslie et al., 2023). prevalence of sexual violence among women with schizophrenia in three studies, the authors examined sexual violence committed against women with schizophrenia (darves-bornoz et al., 1995; kim et al., 2006; yildirim et al., 2014). all three studies indicated that women with schizophrenia have a high prevalence of sexual abuse. in kim et al.'s (2006) article, the aim was to present findings on the prevalence of sexual abuse in female patients attending a mental hospital for schizophrenia in south korea. they found that 37% of the study’s population had a history of sexual abuse where 29.7% were abused by a family member, 32.4% by an unrelated perpetrator and 60% by a stranger (kim et al., 2006). in darves-bornoz et al. (1995), the aim was to study women with schizophrenia and bipolar disorder in relation to sexual victimization. it was discovered that the prevalence of rape was found to be 23% among women with schizophrenia, in contrast to the general population rate of 7% or 8% (darves-bornoz et al., 1995). in this research, the perpetrators of sexual violence were family members (darves-bornoz et al., 1995). lastly, yildirim et al. (2014), aimed to explore the effect of adulthood trauma such as sexual harassment and sexual abuse experienced by patients with schizophrenia who did not have a history of child abuse. they found that 24.3% of patients had experienced sexual abuse during their adulthood whereas 14.3% were abused by a stranger and 10% by someone they knew (yildirim et al., 2014). for sexual harassment, 28.6% were sexually harassed (yildirim et al., 2014). these three studies focused on sexual abuse not committed within an intimate relationship. nonetheless, three articles which focused on ipv also assessed sexual assaults committed towards schizophrenic women. khalifeh et al. (2015), found in their population that 61% of women experience sexual assault compared to 21% of women without schizophrenia. in both afe et al.'s (2016, 2017) studies, the authors reported that 24% of the sample was sexually assaulted. ipv & sexual violence association with symptomology out of the seven articles, four found an association between ipv, sexual violence and higher psychopathology (afe et al., 2016, darves-bornoz et al., 1995; kim et al., 2006; yildirim et al., 2014), while afe et al. (2017) revealed that patients who do not adhere to treatment and experience symptom improvement are more likely to become victims of ipv. afe et al. (2016) found that participants who reported sexual, verbal, and physical ipv indicated higher psychopathology (e.g., worsened psychiatric symptoms). higher psychopathology was also associated with a decrease in physical health, such as “injuries, gynecological problems, depression of immunity and possibly untimely death” (afe et al., 2016, p. 8). kim et al. (2006), identified higher psychopathology scores within the abused population indicating increased distress in somatization, obsessive-compulsive behaviours, depression, and anxiety, while also indicating greater dissociative 10 bélisle et. al expression. yildirim et al. (2014), reported higher psychopathology such as anxiety, aggression, hallucinations, and delayed gratification among patients who experienced sexual abuse. darves-bornoz et al. (1995) also stated a relationship between the occurrence of rape and the increased chronicity of the disorder. lastly, regarding treatment adherence, afe et al. (2017) noted a counterintuitive finding suggesting that irregular medication use increases the odds of ipv and individuals with a shorter duration of illness are more likely to experience sexual, physical and verbal ipv. suicide among the seven articles, five studies discussed the risk of suicide when victimized (afe et al., 2016, 2017; darves-bornoz et al., 1995; khalifeh et al., 2015; kim et al., 2006). kim et al. (2006), discovered a higher risk of suicidal attempts among abused patients compared to non-abused patients. darves-bornoz et al. (1995) found that victimization of women with schizophrenia was associated with an elevated risk of suicidal attempts. afe et al. (2016) claimed that victimization increased the rates of suicide risks while afe et al. (2017) emphasized how abuse within smi like schizophrenia raises the incidence of suicide. lastly, khalifeh et al. (2015), revealed that half of the women in their sample who were coping with smi and had encountered sexual assault went on to report instances of attempted suicide. age of the seven selected articles, five discussed the relationship between age and victimization. afe et al. (2016), found that the younger group had higher chances of reporting ipv than the general population. afe et al. (2017), similarly showed a higher prevalence of ipv reports within adults younger than 40 years old. yildirim et al. (2014) discovered that patients who had experienced sexual abuse were notably younger compared to those who did not report a history of sexual abuse. leslie et al. (2023) indicated that younger mothers had a higher risk for an ed visit for interpersonal violence. lastly, darves-bornoz et al. (1995) found that women with schizophrenia were more at risk of being raped during the end of adolescence and early adulthood. unemployment/ low income five studies assessed victimization and its association with unemployment/low income. afe et al. (2016) found higher rates of ipv, more precisely verbal abuse among unemployed women. afe et al. (2017) also found that participants’ unemployment status was linked with higher chances of experiencing ipv. indeed, women who were unemployed and had low or no income were found to have increased odds of experiencing physical, verbal and sexual abuse from their partners (afe et al., 2017). darves-bornoz et al. (1995), also expressed how low income had an important role in sexual victimization. leslie et al. (2023), found in their sample that women who experienced interpersonal violence were residing in lower-income neighbourhoods and were also more likely to have an ed visit for interpersonal violence. lastly, khalifeh et al. (2015), indicated that within their population who experienced domestic and sexual violence, 80% of the participants were unemployed. discussion the objective of this scoping review was to analyze the existing peer-reviewed literature on sexual and ipv against women with schizophrenia to summarize the current state of knowledge on this subject and highlight future research avenues. as shown through the seven selected studies in this scoping review, a strong association was found between sexual violence, ipv, and women with schizophrenia. across four studies, it was observed that women diagnosed with schizophrenia demonstrated a significantly higher prevalence of experiencing ipv compared to women without this diagnosis (afe et al., 2016, 2017; khalifeh et al., 2015; leslie et al., 2023). in leslie et al.'s (2023) study, women with schizophrenia were ten times more likely to experience ipv when pregnant. in contrast, research by afe et al. (2017) and khalifeh et al. (2015) showed that women with schizophrenia were twice as likely to experience ipv. the findings from the three remaining studies pointed toward a heightened prevalence of sexual abuse of approximately 28% among women diagnosed with schizophrenia (darves-bornoz et al., 1995; kim et al., 2006; yildirim et al., 2014). this highlights how women with schizophrenia are more likely to be victims of sexual and ipv. yet, this issue is rarely discussed by mental health professionals and physicians creating a lack of awareness (afe et al., 2017). through the seven articles, various themes arose describing the risk factors and effect of victimization upon women with schizophrenia. regarding symptomology, four articles found a relationship between ipv, sexual violence, and elevated psychopathology (afe et al., 2016, darves-bornoz et al., 1995; kim et 11 violence against women with schizophrenia al., 2006; yildirim et al., 2014). studies have identified that instances of abuse and victimization contribute to heightened psychiatric symptoms in women. this is manifested through increased levels of depression, anxiety, dissociative expression, and hallucinations (darves-bornoz et al., 1995; kim et al., 2006; yildirim et al., 2014). the amplification of symptoms can be attributed to women’s response to victimization and having limited resources in a society that stigmatizes them (chernomas et al., 2000). furthermore, women not only face heightened psychiatric symptoms but also encounter physical health issues. given that individuals with schizophrenia confront a notably shorter life expectancy than the general population, with approximately 90% of deaths attributed to physical illnesses, it becomes apparent that sexual and ipv play a role as contributing factors to the deterioration of health (chernomas et al., 2000). this form of violence can result in injuries, gynecological problems, and compromised immune function, thereby intensifying the overall health challenges experienced by these women (chernomas et al., 2000; seeman, 2018). conversely, afe et al. (2017) demonstrated that individuals who do not comply with treatment and show symptom improvement are at a higher risk of ipv. this counterintuitive finding suggests the need to further explore the repercussions of victimization on symptomology. among the seven articles analyzed, five studies (afe et al., 2016, 2017; darves-bornoz et al., 1995; khalifeh et al., 2015; kim et al., 2006) investigated the relationship between victimization and the risk of suicide. in each instance, there was a uniform observation of an increased risk of suicide. given that suicide is more prevalent in women with schizophrenia compared to the general population (seeman, 2018), research indicates that suicidal behaviour increases during acute social crises. crucial predictive factors for suicide in women with schizophrenia include a history of sexual abuse, ipv, and the loss of children (carlborg et al., 2010). these traumatic events also have repercussions on women’s psychiatric symptoms, with depression and hopelessness identified as significant contributing risk factors to suicide (carlborg et al., 2010). in schizophrenia, the risk factors for suicide appear to be less associated with typical core symptoms of psychosis, such as delusions and hallucinations, and more linked to depressive symptoms, including agitation, hopelessness, and feelings of worthlessness (carlborg et al., 2010). consequently, as suicide risk is already high among people with schizophrenia, victimization exacerbates their situation, leading to an even higher likelihood of committing suicide. additionally, an increased likelihood of experiencing sexual and ipv during younger years was found in five studies (afe et al., 2016, 2017; darves-bornoz et al., 1995; leslie et al., 2023; yildirim et al., 2014). the vulnerability of younger women with schizophrenia may stem from the decline in social skills and cognition linked to the chronicity of the illness (afe et al., 2017). younger women also tend to be more dependent on their partner, increasing their risk of ipv, especially among women with smi (afe et al., 2017). regarding employment, unemployed or low-income women with schizophrenia were more likely to be victims of sexual and ipv (afe et al., 2016, 2017; darves-bornoz et al., 1995; khalifeh et al., 2015; leslie et al., 2023). as the study of afe et al. (2017) pointed out, individuals with schizophrenia are more likely to have a lower socioeconomic status due to the debilitating effect of the illness on their cognition, social skills, and ability to be productive. moreover, barriers still exist regarding employment and the improvement of the socioeconomic status of people with schizophrenia due to the ongoing stigma and discrimination (afe et al., 2017). thus, this becomes even more difficult for women with schizophrenia as gender barriers exist (e.g., men having better economic opportunities, more education, and more employment opportunities) (afe et al., 2017). given that employment offers substantial support, contributes to a dignified existence, and fosters financial independence, it is noteworthy that many women with schizophrenia lack jobs or sufficient income (afe et al., 2017). consequently, these women face an increased likelihood of experiencing violence, primarily attributable to their socioeconomic status and lower income in comparison to the general population (afe et al., 2017). these results suggest that younger women diagnosed with schizophrenia, particularly those with low income and/or unemployed status, face an elevated risk of becoming victims of sexual and ipv. this victimization, in turn, amplifies the risk of suicide and heightened psychopathology. the findings also suggest that ipv worsens the progression of schizophrenia, leading to an increase in symptoms and a higher risk of suicide. these findings underscore the need to enhance interventions that could better support women with 12 schizophrenia experiencing sexual violence and ipv. certainly, mental health professionals should routinely inquire about ipv among women with schizophrenia to identify potential victims. by making both direct and indirect inquiries about ipv, clinicians can better detect ipv and develop comprehensive therapy plans that include social interventions to support women with schizophrenia. additionally, clinicians need to be aware of the elevated prevalence of sexual and physical abuse in this population. they should thoroughly evaluate psychosocial, familial, and clinical histories collectively (kim et al., 2006). studies have shown that clinicians can identify ipv risk and address relationship dynamics, socioeconomic challenges, and pharmacological therapy effectively by giving proper attention to women's socio-demographic background, economic circumstances, and partners (afe et al., 2017). hence, the integration of regular violence screening and the establishment of a robust therapeutic rapport with clients offers health professionals a vital opportunity for intervention to prevent severe physical, psychological, and social harm to these women. this review also denotes how the selected articles assessed women in the same age range (between 30 and 40 years old) indicating scarce data for sexual and ipv among women with schizophrenia in younger and elderly populations. as a result, it is recommended that forthcoming studies take into account diverse populations, sexual diversity, and gender while adopting a non-binary perspective. lastly, the selected studies, published between 1995 and 2023, with a majority published after 2013 (n=5), suggest a recent emergence of reporting sexual and ipv incidences against women with schizophrenia. while most studies were cross-sectional, there is a need for qualitative and mixed-method studies to fully understand the experience of women with schizophrenia to prevent and protect them from sexual and ipv. overall, this scoping review reveals that more studies are needed to improve our knowledge of sexual and ipv against women with schizophrenia. study limitations this scoping review has some limitations to consider. to begin, only peer-reviewed articles published in scientific journals were included in this review, excluding grey literature. the authors decided to exclude grey literature to prioritize the most rigorous reviewed and established research. this helps in providing a clearer picture of the current state of knowledge by ensuring the quality and reliability of the articles. thus, this limited our ability to identify potential research and advance our understanding. moreover, the study selection criteria restricted this review to english and french, which prevented studies in other languages from being considered. furthermore, this research constrained its focus to adult women, omitting post-pubertal schizophrenia in children and young adolescents. lastly, the chosen articles lacked clear distinctions between sex and gender, with a majority frequently remaining ambiguous about whether they were addressing gender, sex, or both. as such, studies in other languages, the inclusion of grey literature, and the inclusion of a broader population could provide further insight into this subject. conclusion the aim of this scoping review was to identify and synthesize literature on sexual and ipv against women with schizophrenia. the studies included in this review revealed a higher prevalence of sexual abuse and ipv among women with schizophrenia relative to the general population. the findings indicate that younger women diagnosed with schizophrenia, especially those with low income and/or unemployed status, are at an increased risk of experiencing sexual and ipv. this victimization, subsequently, raises the likelihood of suicide and heightened psychopathology. these results underscore the necessity of fostering interdisciplinary collaboration among healthcare professionals, social workers, and policymakers to effectively tackle ipv against women diagnosed with schizophrenia. while the retained articles for this review were small, there is a need for further investigation. future research should explore current care setting interventions to prevent severe physical, psychological, and social harm, while also examining the impact of victimization on symptomatology as current results are mixed. 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(2021, march 9). violence against women. https://www.who.int/newsroom/fact-sheets/detail/violence-against-women world health organization. (2002). who multi-country study on women's health and domestic violence against women (no. who/fch/ gwh/02.2). world health organization. yildirim, m., yildirim, e. a., kaser, m., guduk, m., fistikci, n., cinar, o., & yuksel, s. (2014). the relationship between adulthood traumatic experiences and psychotic symptoms in female patients with schizophrenia. comprehensive psychiatry, 55(8), 1847–1854. https://doi.org/10.1016/j. comppsych.2014.08.049 bélisle et. al 15 violence against women with schizophrenia figure 1 summary of the search strategy 16 bélisle et. al figure 2 flowchart of study selection and screening process 17 violence against women with schizophrenia table 1 18 bélisle et. al table 1 (cont.) 5 graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university a conceptual model for addressing weight stigma and health: guiding practitioner conversations for weight health people don't care how much you know until they know how much you care. — attributed to theodore roosevelt people need support. every person faces adversity, and health is a universal concern – whether young or old, rich or poor, all contend with morbidity and mortality. compassionate individuals are empowered by a deep desire to promote the well-being of others. whether they work in medicine, health psychology, or public health, their passion for care sparks career interests and fuels professional diligence. however, how can healthcare practitioners (some researchers prefer practitioner to provider; scarff, 2021) from distinct training backgrounds and professional roles navigate the complexities of weight-related health and weight stigma? this paper reconciles promoting health behavior and reducing stigma for weight health by proposing a novel conceptual model for practitioners. the model resolves a dilemma faced by many practitioners: saying too much (e.g., prescriptive weight-related health advice exacerbating stigma) versus too little (e.g., ignoring insufficient health behavior engagement). to fully articulate the model, it is first necessary to review the evidence demonstrating the importance of weight-related health and discuss weight stigma as a barrier to health. weight health weight-related health is a principal public health concern globally (okunogbe et al., 2022; safaei et al., 2021). being of higher body weight due to an excess of adiposity large enough to cause reduced health or longevity – at least probabilistically over time – is linked to morbidity and mortality, is largely considered a complex lifestyle concern, and its consequences are associated with increased risk for a myriad of cardiometabolic diseases (allison et al., 2008; fruh, 2017; safaei et al., 2021). indeed, higher-than-optimal body weight has been linked to increased risk, or at least concomitant to, “... nearly every chronic condition, from diabetes, to dyslipidemia, to poor mental health. its impacts on risk of stroke and cardiovascular disease, certain cancers, and osteoarthritis are significant” (hruby & hu, 2015, p. 10). whether certain ranges of body weight (e.g., body mass index > 30; allison et al., 2008; katz, 2014) are to be medically considered a disease is irrelevant to the development of the model. the strength of evidence demonstrates that it is beyond a reasonable doubt that being of higher body weight due to excessive accumulation of adipose tissue is related to poorer cardiometabolic health and well-being (hruby & hu, 2015; pi-sunyer, 2009; robinson et al., 2020; visscher & seidell, 2001). although weight-related health and associated conditions are complex in their etiology and maintenance, consequences related to morbidity and mortality are considered largely preventable or reducible (fruh, 2017; hruby & hu, 2015). prominent health organizations educate practitioners and patients about the negative impacts of higher-than-optimal body weight. the world health organization, centers for disease control and prevention, and the colter k. clayton, ma department of psychology, university of mississippi, usa practitioners working in a variety of healthcare settings increasingly face a dilemma when speaking with patients about weight health. on one hand, prescriptive weight-related health advice can exacerbate stigma, while on the other, ignoring insufficient health behavior engagement limits health and increases the risk of other adverse weight-related health conditions. research has demonstrated that higher-than-optimal body weight is a correlate of morbidity and mortality, but has also demonstrated that weight stigma is pervasive, negatively impacting health, health behavior, and well-being. this article introduces a novel conceptual model to help practitioners initiate conversations about weight health by striving to support health behavior change in a way that deactivates and disempowers weight stigma. by advancing the acceptance principle from motivational interviewing and adapting its scope, the model focuses on destigmatizing attitudes and assumptions related to weight health to prevent or reduce generalized and internalized weight stigma. the model also focuses on limiting interpersonal stigma and its disruptive role in practitioner-patient communication by supporting personal autonomy for a lifestyle of health behavior. this article reports results from a rapid review and calls for research efforts to examine the potential causal role of active acceptance for reducing weight stigma. overall, the conceptual model simultaneously promotes health behavior and reduces weight stigma for weight health. keywords: weight stigma, weight health, health behavior, motivational interviewing, healthcare practitioner 6 weight and stigma national institutes of health use websites1* to publicly disseminate the latest research on risk factors and best-practice health strategies to educate practitioners and patients. healthcare practitioners know that weight loss (when needed) has a large impact on improving health through lowering risk for disease (e.g., type 2 diabetes, hypertension, dyslipidemia; haase et al., 2021) and is linked to improvement in current health conditions (pojednic et al., 2022). even modest amounts of weight loss (e.g., >5% of body weight) are associated with clinically significant improvements in cardiometabolic health and emotional well-being (fruh, 2017), and weight loss at higher levels can lead to further improvements (ryan & yockey, 2017). more engagement in health behaviors is needed; physical activity, eating a healthy diet, and obtaining quality sleep are vital for health. for example, in the united states, only about 1 in 4 adults meets physical activity guidelines, and engagement is even lower among those with lower incomes (elgaddal et al., 2020). practitioners also know that physical activity has health benefits independent of body weight. for example, among people with higher body weight, physical activity has demonstrated positive changes at the cellular level (e.g., improved enzyme function), along with improved metabolic function (e.g., increased insulin sensitivity), and better cardiovascular outcomes (e.g., decreased arterial stiffness; pojednic et al., 2022). thus, physiologic improvements observed with increased physical activity are observed despite starting weight and irrespective of whether weight loss occurs, and cardiorespiratory fitness is an indicator of metabolic health (ortega et al., 2013). given that health behaviors such as physical activity contribute to health, increased adherence and implementation are needed. weight stigma practitioners are increasingly becoming aware of how health stigma and discrimination limit social acceptance and opportunity, and how they exacerbate inequality, which are well-documented barriers to engagement in healthcare and health behaviors (hatzen1 *https://www.who.int/health-topics/obesity#tab=tab_1; https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight; https://www.cdc.gov/family-healthy-weight/ php/recognized-programs/index.html; https://www.cdc.gov/ obesity/php/about/obesity-strategies-what-can-be-done.html; https://www.niddk.nih.gov/health-information/weight-management/adult-overweight-obesity/health-risks buehler et al., 2013; stangl et al., 2019). weight stigma is a form of health stigma. it refers to reduced social status due to excess body weight, and weight-related negative attitudes are linked to discriminatory actions such as unfair treatment in healthcare (rubino et al., 2020). a landmark study at the turn of the century by pioneering weight stigma researchers introduced its negative impact on employment, education, and healthcare (puhl & brownell, 2001). subsequent research has solidified weight stigma as a major health issue: at least 1 in 2 adults experience stigma related to their weight, which is associated with less regular medical checkups, healthcare avoidance, and worse healthcare quality experiences (puhl et al., 2021). recent international research initiatives to address weight stigma have called for more actions from the medical community to promote the education and training of healthcare professionals to practice without participation in or perpetuation of weight stigma (puhl et al., 2021; puhl, 2023; rubino et al., 2020). healthcare practitioners are increasingly recognizing that weight stigma is not helpful or healthy. a major concern of weight stigma is its negative effect on health behaviors: decreased physical activity, decreased healthcare engagement, and paradoxically, even weight gain (tomiyama, 2014). weight stigma has negative impacts in laboratory and real-life contexts (major et al., 2014; panza et al., 2023; puhl & suh, 2015; rubino et al., 2020). for example, brief exposure to reading or watching weight stigma can elicit cardiovascular reactivity and increase overeating behavior (major et al., 2014; panza et al., 2023). the everyday consequences of weight stigma include maladaptive eating behaviors (e.g., binge eating), lower engagement in physical activity, and unhealthy weight gain (puhl & suh, 2015). dilemmas of weight health and stigma saying too much can exacerbate stigma. for example, some researchers have called for increased social pressures (e.g., societal shame) to help individuals become more aware of their weight and associated stigmatization (callahan, 2013), but subsequent stigma research did not support social pressure as a viable method to improve weight health (puhl et al., 2021). conversely, saying too little may condone poor health behaviors. the health at every size (haes) approach is a product of both academic research and social movements that challenge weight stigma, deprioritize weight and weight-related biomarkers of health, and 7 clayton promote bodily acceptance to improve health and well-being (bombak, 2014; penney & kirk, 2015). facilitating access to healthcare that is free of shame is a prominent virtue of this framework. however, while intending to reduce stigma, dismissing (whether deliberately or inadvertently) physical health recommendations may occur. people with higher weight report negative psychological reactions to receiving weight-related advice from healthcare practitioners (standen et al., 2024), which may explain why some groups reject and even criticize weight health recommendations as unethical (e.g., haes). self-affirmation theory describes how people maintain integrity to themselves (steele, 1988). in weight stigma research, this theory may explain why people may be motivated to maintain a positive selfview regarding their weight when perceiving weight stigma. for example, a healthcare professional recommending weight loss may evoke a patient’s efforts to maintain self-integrity, where healthcare recommendations related to body weight are perceived as attacks on personal identity; this may be a reason that recommendations can fail to produce motivation for change. thus, practitioners must simultaneously preserve patients’ self-integrity and recommend health behavior change. given the interacting complexities of weight-related health and stigma, practitioners face a daunting responsibility to care for patients. the dilemma practitioners face is two competing risks: over-alerting patients can be counterproductive, eliciting societal or personal shame and exacerbating the distress of stigma; conversely, under-alerting patients to weight-related health risks fails to promote positive health behavior change. a paradigm grounded in theory and evidence is needed to guide practitioners as they navigate the complexities of weight-related health. developing the whistle model research on the biopsychosocial factors of weight-related health and healthcare has led to theoretical and conceptual models that are comprehensive and often complex (marks, 2015; mccabe et al., 2023; michie et al., 2014; plotnikoff et al., 2007). however, such models are not specific to stigma, though one model of weight stigma has emphasized a vicious feedback loop of stigma and weight gain (tomiyama, 2014). thus, existing models fall short of offering a simple and practical framework to begin helpful discussions about weight health and stigma. the novel weight health through integrated stigma-reduction and lifestyle engagement (whistle) model serves as a guide for practitioners. in contrast to the traditional "sick" role of passive prescriptions, contemporary healthcare increasingly prioritizes enhancing patient agency to boost health outcomes through more effective health behavior (armstrong, 2014). however, healthcare practitioners may feel uncomfortable or incompetent in discussing weight with patients (pont et al., 2017). the whistle model aids practitioners as they practice attitudes of acceptance to reduce weight stigma when opening a conversation about weight-related health that facilitates the encouragement of health behavior change by using a patient-centered approach. health behavior change is facilitated through the atheoretical principles of motivational interviewing. at its core, motivational interviewing is an empirically supported, patient-centered approach to talking with people in a way that strengthens their own motivation and commitment for behavioral change (miller & rollnick, 2023). reflections and questions by practitioners help patients work through the natural ambivalence they experience when facing decisions about behavioral change. the proposed mechanism that has received the most empirical support is practitioners’ use of selectively reinforcing patients’ own motivational statements for behavior change (bischof et al., 2021). research on motivational interviewing as a favorable intervention for positive health behavior (e.g., physical activity) and weight-related health outcomes is mixed (amiri et al., 2022; frost et al., 2018; lundahl et al., 2013; makin et al., 2021; michalopoulou et al., 2022). however, motivational interviewing as an empirically supported way of effectively being in a helping relationship (e.g., practitioner engagement) and facilitating behavior change has received substantial empirical support across healthcare settings (bischof et al., 2021; lundahl et al., 2013; luty & iwanowicz, 2018; magill et al., 2018; miller & rollnick, 2023; rubak et al., 2005). while motivational interviewing principles broadly support behavioral change, they do not address the issue of stigma – particularly weight-related stigma – in weight-related health outcomes. the novel whistle model is a person-centered framework that tar8 weight and stigma gets weight health conversations and was derived from a component known as acceptance. the whistle model’s guiding principle of acceptance was based on a previous edition of the motivational interviewing approach created by miller & rollnick (2013) with four ‘a’s: absolute worth, accurate empathy, affirmation, and autonomy support. in the whistle model, the four ‘a’s function as fundamental assumptions, attitudes, and actions for practitioners working with patients and weight health concerns. thus, the whistile model provides a foundation to simultaneously reduce stigma and encourage health behavior change. in the whistle model, practitioners assume and adopt an attitude that each patient has inherent worth irrespective of weight, health, or behavior, and that each person is innately capable of behavioral change. actions of practitioner acceptance include expressing accurate empathy and communicating a genuine interest in understanding the patient’s experiences and situation (schumacher & madson, 2014). practitioners also provide affirmations and statements to help patients see their own strengths and resources and champion patients’ autonomy as they choose whether and how to make behavioral change. since patients with a history of weight stigma report being less heard and respected by their healthcare practitioner (puhl et al., 2021), the whistle model’s assumptions, attitudes, and actions function to reduce self-stigma, stigma in the practitioner-patient relationship, and prevent or reduce generalized weight stigma from interfering with healthcare discussions about weight health (see figure 1). weight stigma interferes with practitioner-patient communication through shameful language and impaired emotional engagement, which are associated with healthcare disengagement and avoidance (puhl, 2023). practitioners with higher weight stigmatizing attitudes report feeling less confident in offering weight health recommendations and less likely to use a person-centered approach when speaking with patients (bennett & puhl, 2024). on the other hand, within a motivational interviewing approach, patients who talk about plans for behavior change show better body weight outcomes over time (copeland et al., 2017). patients can feel simultaneously motivated to lose weight and feel bad (e.g., guilty) regarding their weight-related health (standen et al., 2024), highlighting the need for concurrent stigma reduction and health behavior encouragement. practitioners may be better equipped to work with weight health to deactivate stigma with acceptance-promoting statements. the whistle model helps practitioners to channel an atmosphere of acceptance to 1) prevent generalized social stigma and their own potentially stigmatizing attitude from entering the relationship, and 2) reduce self-stigmatizing beliefs among patients (though the patient acts as the mediator of this relationship; see figure 1). within this atmosphere, practicing acceptance moves generalized practitioner stigma and self-stigma further away from the patient to allow for increased patient self-efficacy, weight-related health information discussions, and encouragement of healthy lifestyle behavior. the figurative cloud represents the subjective, relational aspect in which practitioner-patient communication occurs. statements of accurate empathy increase connection and empower patients’ autonomy for making behavioral health changes (see table 1). supporting autonomy is intended to have the dual effect of further reducing stigma while promoting behavior change. practitioners risk eliciting ambivalent or negative psychological reactions as they offer weight-related advice, but a two-way discussion is a characteristic of patients feeling motivated to begin healthy behavior change (standen et al., 2024). practitioners using the whistle model who create an atmosphere for health behavior change, champion patient autonomy, and affirm the value and ability of healthy lifestyle behavior will likely negate the adverse impacts of stigma on health and well-being. the whistle model extends behavioral change frameworks. for example, motivational interviewing and self-determination theory (i.e., an empirical framework for enhancing behavior change) are conceptually related and aid practitioners in helping patients internalize their own motivation and ultimately foster volitional health behavior change (abildsnes et al., 2021). although these informed the development of the whistle model, this model uniquely highlights the necessity of averting weight stigma’s disrupting role in hampering practitioner-patient communication and provides a feasible template for accomplishing this task. it is also important to recognize that increasing sensitivity to perceived harm, such as weight stigma, may engender a sense of diminished perceived control among patients, which is a factor that has long been recognized as a facilitator of health behavior change 9 clayton (schwarzer & fuchs, 1996; strecher et al., 1986). conversely, while self-affirmation can be a barrier, it is also a catalyst for behavior change (cohen & sherman, 2014). indeed, research has demonstrated the value of affirmation interventions, which are associated with better health, including increased health behavior and even lowering body weight toward healthier ranges (epton et al., 2015; ferrer & cohen, 2019; logel & cohen, 2012). for example, self-affirmation is associated with greater acceptance of health information and stronger motivation for health behavior change when receiving health risk information (epton et al., 2015). discussion the whistle model is not a full-scale intervention but rather emphasizes an attitude of acceptance in which practitioners harmoniously attend to disarming stigma and facilitating health behavior for weight-related health. other researchers have developed a high-quality guide to foster practitioner-patient communication within a motivational interviewing approach to reduce stigma in weight health (see scherr et al., 2023, for a review). the whistle model adds to this research by focusing on attitudes and actions of acceptance, and its primary purpose is to initiate conversations about weight health and behavioral change within an attitude of acceptance to prevent and reduce stigma. beyond initial engagement and discussion about weight health using the whistle model, practitioners use methods and treatments congruent with their expertise, responsibility, and setting. more simply, a broad scope guideline to continue conversations is outlined within a brief action plan (bap), which is a person-centered approach to facilitate health behavioral change and has supporting evidence across many healthcare settings (jadotte et al., 2023). the whistle model’s biopsychosocial lens allows for a compassionate and health-focused approach to reduce stigma and empower patients to participate in healthy lifestyle behaviors. consistent with motivational interviewing principles, the whistle model does not imply endorsement of unhealthy behaviors but rather acts as a relational process in which an attitude of acceptance deactivates stigma while still facilitating health behavior change. as practitioners within the whistle model focus on empirically supported health behaviors in an atmosphere of acceptance that affirms one’s inherent value, defuses stigma, and supports autonomy for health behavior change, weight-related health is likely to improve. a call to healthcare practitioners psychological theories on behavior change are advancing the landscape of healthcare quality (hilton, 2023). healthcare practitioners across training backgrounds and treatment settings have a duty to promote weight health and well-being. mental health clinicians are even emerging as important, supplementary practitioners to weight-related health concerns (dandgey & patten, 2023; murray et al., 2021). given the rising adverse health consequences of higher body weight, inaction will have negative global impacts on health, well-being, and economic resources (okunogbe et al., 2022). although calls for systemic-based changes are increasing (and likely required) to effectuate lasting weight-related health improvements from a public health perspective (okunogbe et al., 2022; puhl & suh, 2015), practitioners maintain the responsibility to promote health behavior change. health psychology research has recognized weight-related health as a persistent public health concern despite decades of targeted resources and research (brownell, 2010). health psychologists have a duty to bilaterally support patients based on the advancing empirical literature across health sciences. just as weight stigma research is progressing, the data establishing the health benefits of healthy lifestyle behavior and the risks for morbidity and mortality related to higher body weight are also advancing. health psychologists are well-positioned to handle potentially conflicting goals related to stigma, behavior, and weight health. however, to maintain this position, health psychologists and related professionals must maintain fidelity to evidence demonstrating the negative impacts of higher body weight and strive to mitigate risks through facilitating health behavior. for example, contrary to haes, health psychologists cannot maintain weight-related neutrality when presented with opportunities to promote weight-related health. health behavior and weight-related health dialogue need not be removed nor disparaged to reduce weight-related stigma. promoting empirically supported health behaviors (e.g., physical activity) for weight-related health is vital for patients and a duty of practitioners. future research directions the whistle model has implications for at least three directions for research. first, there has been 10 weight and stigma promising research on self-affirmation as a weight-related health treatment (logel & cohen, 2012). more research should test whether self-affirmation interventions are effective for protecting patient self-identity in the context of receiving healthcare recommendations, reducing weight stigma, and facilitating health behavior changes congruent with weight health recommendations. relatedly, compounding stigmas represent a greater health concern (stangl et al., 2019), but research has only recently begun to investigate weight stigma and diversity, such as the intersectionality of weight stigma, race, and gender. experienced weight stigma is similar across racial and gender groups but internalized less among black and hispanic individuals relative to white individuals, and less among men relative to women (himmelstein et al., 2017; reece, 2019; wetzel & himmelstein, 2024). notably, lower self-compassion is associated with greater weight stigma across racial and socioeconomic backgrounds, which represents a potential target for reducing internalized weight stigma (puhl et al., 2020). second, the impact of technical aspects of the whistle model (i.e., acceptance statements and questions) should be empirically investigated to test the hypothesized effect of simultaneously reducing weight stigma and facilitating healthy lifestyle behavioral change (moizé et al., 2025). to operationalize the processes of the whistle model, researchers could determine whether a practitioner’s statement (or question) for initiating conversations about weight health is congruent with the four ‘a’s of acceptance. for example, 1 = congruent, 0 = partially congruent, and -1 = not congruent, with higher total scores reflecting higher adherence to the whistle model. table 1 provides appropriate statements, each of which is congruent with assumptions, attitudes, and actions of acceptance in the whistle model. a randomized controlled trial could be conducted to compare the weight stigma and behavioral outcomes of practitioners who use the whistle model to initiate conversations with patients compared to an active control, such as practitioners’ treatment as usual, which often involves blunt recommendations to reduce body weight that exacerbate stigma (standen et al., 2024). behavioral outcomes may be measured by any relevant health behavior metric (e.g., change in total minutes per week spent participating in physical activity). weight stigma outcomes may be assessed using existing validated weight stigma measures such as the perceived weight stigma scale (pwss; schafer & ferraro, 2011). third, researchers from disparate training backgrounds (e.g., medicine, public health, psychology, sociology) may consider joint initiatives to synthesize data across biopsychosocial health science domains to elucidate weight health and stigma interactions. results of such research would inform interventions to simultaneously reduce stigma and promote weight health and well-being. a major limitation is that extant literature on motivational interviewing has not examined its potential effectiveness (i.e., its potential causal role) for reducing weight stigma, as evidenced by a systematic rapid review (see appendix) using approach 3 by tricco et al. (2016). however, there are theoretical reasons that suggest that acceptance would be potentially effective for reducing stigma given that motivational interviewing is efficacious for behavioral change among people with substance use issues, who experience substance use stigma (el hayek et al., 2024; kulesza et al., 2013; magnan et al., 2024; miller & rollnick, 2023; yang et al., 2018). the only study to quantitatively correlate motivational interviewing and weight stigma showed that physician experience with motivational interviewing was associated with more use of person-first language and positive perceptions of patient adherence to treatment recommendations (bennett & puhl, 2024). although the whistle model’s foundation on patient acceptance and engagement lends itself well to reducing weight stigma in healthcare contexts (moizé et al., 2025), the empirical research previously outlined is a necessary next step to evaluate the potential efficacy of the whistle model. conclusion the whistle model is utilitarian, emphasizing action where health behavior promotion and an attitude of acceptance to reduce stigma occur concurrently. at its basic level, the whistle model is a unifying agent for practitioners and patients working together to improve weight-related health. practitioners must engage in accepting and collaborative conversations to increase health behavior, whether preventive or reactive, focusing on person-centered care to foster weight health. attitudes and actions demonstrated in an atmosphere of acceptance are likely to lead to reduced stigma and enhanced practitioner-patient 11 clayton communication. healthcare and mental health practitioners who encourage health behavior and discuss weight health may face criticism from colleagues or patients who favor reducing stigma over promoting weight-related health as campaigns against weight stigma become increasingly heard and promoted (e.g., haes). however, there is no need to campaign for avoiding conversations about health behavior and denigrate health science research for the destigmatization of weight. indeed, discussing the importance of fundamental health behavior (e.g., physical activity) may appear less popular, but it is more vital than ever. overall, the whistle model functions to increase patient-centered care by empowering practitioners to face the challenge of initiating weight-related health and health behavior change discussions in a way that deactivates the barriers of stigma. acknowledgements i sincerely thank dr. andrew h. hales for his professorship and writing mentorship. references abildsnes, e., elin andresen, n., storbaekken, s., beate samdal, g., mildestvedt, t., & meland, e. 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(2014). weight stigma is stressful. a review of evidence for the cyclic obesity/weightbased stigma model. appetite, 82, 8–15. https:// doi.org/10.1016/j.appet.2014.06.108 tricco, a. c., zarin, w., antony, j., hutton, b., moher, d., sherifali, d., & straus, s. e. (2016). an international survey and modified delphi approach revealed numerous rapid review methods. journal of clinical epidemiology, 70, 61–67. https://doi. org/10.1016/j.jclinepi.2015.08.012 visscher, t. l., & seidell, j. c. (2001). the public health impact of obesity. annual review of public health, 22, 355–375. https://doi.org/10.1146/ annurev.publhealth.22.1.355 wetzel, k. e., & himmelstein, m. s. (2024). weight stigma is uniquely tied to maladaptive eating across different racial, ethnic, and gender groups. appetite, 201, article 107604. https://doi. org/10.1016/j.appet.2024.107604 yang, l. h., wong, l. y., grivel, m. m., & hasin, d. s. (2017). stigma and substance use disorders: an international phenomenon. current opinion in psychiatry, 30(5), 378–388. https://doi. org/10.1097/yco.0000000000000351 16 weight and stigma figure 1. the weight health through integrated stigma-reduction and lifestyle engagement (whistle) model 17 clayton table 1. sample statements to initiate weight health conversations congruent with acceptance note. attuned readers may notice the conceptual overlap of the acceptance statements and even their near interchangeability. after each of these statements, an additional acknowledgement of patient autonomy may fit as well. for example, “and, of course, any changes (e.g., related to health, physical activity, eating) you choose to make would be completely up to you.” 18 weight and stigma appendix supporting table 1. search strategy for pubmed block 1: motivational interviewing block 2: stigma block 3: weight note. database was accessed 4/2/2025. no filters or date ranges were applied. the three blocks were connected with the boolean operator ‘and’. the search yielded five results. screening determined that no study examined the potential relationship between motivational interviewing and weight stigma. 19 clayton appendix supporting table 2. search strategy for scopus block 1: motivational interviewing block 2: stigma block 3: weight note. database was accessed 4/2/2025. no filters or date ranges were applied. the three blocks were connected with the boolean operator ‘and’. the search yielded five results. screening determined that no study examined the potential relationship between motivational interviewing and weight stigma. microsoft word manuscript 3_cl.docx graduate student journal of psychology (gsjp), volume 18, special issue 2022 (dis)embodiment in psychology and psychotherapy: a critical historical analysis and clinical implications camille mori department of psychology, university of calgary embodiment may refer to a centering and acknowledgement of the felt and physical body as an active agent in the experiencing, processing, and interpretation of one’s environment. in contrast, disembodiment decenters the body and internal processes. despite body-based perspectives and practices being present within psychology since its inception, the body has historically been marginalized within psychological theory and clinical practice. the present analysis aims to answer the question of why disembodiment is woven into psychological and psychotherapeutic practices by examining the historical roots of disembodiment in the west. beginning with philosophical foundations which have formed the tenets of western tradition, descartes’ mind-body dualism (i.e., a concept in which mind and body are distinct entities, often placing the mind in a dominant position over the body) and foucault’s notion of the docile body (i.e., the body as a subject to discipline and control) are discussed. these prominent philosophical roots are connected to dominant western institutions, in which dynamics of discipline and control are manifested. subsequently, philosophical underpinnings are present in the subject areas created within such institutions (i.e., psychology and psychotherapy). examining historical roots of embodiment can be viewed in relation to edward sampson’s (1996) seminal paper, which called for a more embodied psychology. critical to the employment of embodied practices in psychotherapy via increasingly popular cognitive-behavioral third-wave therapies (e.g., acceptance and commitment therapy [act], mindfulnessbased cognitive therapy [mbct]), a historical perspective brings to light deep roots of disembodiment that must be overcome to access a more embodied psychology. keywords. embodiment, foucault, docile bodies, psychotherapy, third-wave therapies psychotherapy developed as a western oral tradition and, consequently, has been imbibed with western philosophical values. mind-body dualism is one such philosophical stance that is intimately connected with psychological and psychotherapeutic practice, and with the contexts in which psychology and psychotherapy arose. descartes’ cartesian dualism (i.e., the concept in which mind and body are distinct and separate entities, often placing the mind in a dominant position over the body) permeates western medicine and health care, such that there are separate professions that specialize in either problems of the body or of the mind (i.e., physicians versus psychologists), with their respective professionals often governed under separate health care systems (i.e., public versus private). “mental” disorders are categorized in their own diagnostic manuals, such as the diagnostic and statistical manual (dsm-5), most often used in north america, or are categorized within their own diagnostic sections, such as in the international classification of diseases (icd-11). © 2022, graduate student journal of psychology, teachers college, columbia university. all rights reserved. graduate journal of psychology 18, pp-pp. mori graduate student journal of psychology health care professionals, their governing bodies and systems of reimbursement, and their classificatory tools are only a few examples of how dualistic thinking has been [c1]integrated into western conceptualizations of wellness. while efforts to integrate embodiment, a concept that centers the body as an active agent in experiencing and processing one’s environment, have been present since the beginnings of psychotherapy, divisions between mind and body are ever present and easily identifiable. an embodied psychology is yet unrealized, even two decades after edward sampson’s (1996) seminal paper argued for the establishment of embodiment in psychology and warned of the domination and oppressions that are perpetuated in a disembodied tradition. within current day psychotherapeutic theory and practice, some discussion has been put forth regarding ways to amend problematic dualistic practices (e.g., practices that may neglect important physical or internal aspects of a patient’s experience, or that may perpetuate stigma against non-observable conditions), yet embodiment in psychotherapy is, for the most part, afforded little discussion (leitan & murray, 2014). establishing embodiment in psychotherapy is no easy feat, as doing so is an attempt to upend deep roots of dualism and disembodiment. as such, an understanding of the historical roots through which psychology and psychotherapy inherited a disembodied tradition is crucial to successfully progress and integrate embodied practices and approaches. the current discussion arises at a time when third wave therapies, in which the body maintains a central role, are rising in presence and popularity (brown et al., 2011; kirmayer, 2015). for example, acceptance and commitment therapy (act), dialectical behavior therapy (dbt), and mindfulness-based cognitive therapy (mbct) are considered third-wave cognitive-behavioral approaches which use techniques such as meditation work, body scans, physical anchoring, or methods originally used for psychosomatic conditions (messer & kaslow, 2020). however, attempts to accommodate embodied methods in a historically disembodied tradition presents a danger of adopting and perpetuating superficial and inaccurate practices. superficial or inaccurate applications run the risk of violating ethical mandates of psychological practice, as ethical codes mandate competent provision of services (american psychological association [apa], 2017; canadian psychological association [cpa], 2017). as such, true integration of embodied practices for those therapies that rely on body-based techniques is integral to upholding ethical obligations of practice (kirmayer, 2015). with an understanding that forward progress necessarily begins with a critical look back, the present article will examine (dis)embodiment within and beyond the history of psychology and psychotherapy. the following will highlight the course from philosophical roots of dualism and mechanisms of control to the institutions in which psychology developed, and subsequently to the discipline and practice of psychology and psychotherapy. by understanding the historical extent of disembodiment in the field, solutions to a true integration of embodiment in psychotherapy arise. the present analysis was conducted via a literature review of primary resources, academic manuscripts, and books recovered from libraries and online databases (e.g., psycinfo, ebsco, embase) using related search terms (e.g., embodiment, disembodiment, thirdwave therapies, psychology, psychotherapy, dualism, foucault) and boolean operators. embodiment in psychotherapy multiple definitions of embodiment exist and span various disciplines and fields of study (krieger, 2005; ziemke, 2015). for the present discussion, a relevant definition of embodiment is an awareness of one’s internal experience, or “the body experienced from within,” (hartley, 2004, p.12); thus, felt and physical experiences are centered in the processing of one’s environment. thomas hanna (1970) is credited as introducing the (dis)embodiment in psychology and psychotherapy graduate student journal of psychology term “somatics” into the field of psychology, providing a name for body-based techniques, such as breathing exercises, that have been used by practitioners since the mid-1800s (hartley, 2004). of course, holistic approaches that acknowledge the integration of body and mind as inherent to wellness have existed long before then, through practices such as yoga, vipassana, and other meditative techniques (hartley, 2004; johnson, 1995). despite the historical significance of embodied healing practices, and efforts to maintain embodiment within psychology, body-based work has not held a consistent presence in mainstream psychotherapeutic practice throughout the 20th century. historical accounts most often refer to sigmund freud as the founder of psychotherapy (engel, 2008; smith, 1985; walker, 1957); however, young (2006) suggests another founding figure, dr. pierre janet (1859-1947), as “the first proper body psychotherapist” (p. 17). according to boadella (1997), freud’s psychoanalysis was derived from janet’s body-oriented work, yet freud moved away from a body-orientation, instead popularizing therapy mainly as a “talking cure” (young, 2006). wilhelm reich (18971957), who is also credited as an originator of body psychotherapy, held close ties to psychoanalysis through his research and clinical endeavors (totton, 2002). however, reich’s views led to his exclusion from psychoanalysis, marking yet another divide between embodied practice and psychotherapy (young, 2008). both janet and reich have maintained an established position in psychotherapy’s origin story, and their body-focused contributions continue to hold influence within less mainstream psychological research and practice (feldman, 2016; van der kolk, 1994). thus, when considering various historical perspectives, the origins of psychotherapy appear to be based within, rather than alongside, concepts of embodiment. how then has the body remained on the sidelines of psychotherapy? answering this question requires an in-depth look at western philosophical tradition as well as the interconnection between institutional practices and the development of psychotherapy. foucault as a philosophical foundation descartes’ philosophy is a foundation of western thought and scientific inquiry (olson, 1982), and dualistic thinking is still ever present in modern health care systems. in addition to descartes, michel foucault is another foundational philosopher whose ideas provide insight into cultural conceptualizations of the body. foucault wrote docile bodies (1977) as part of his seminal work, “discipline and punish: the birth of the prison,” which contributed to his popularity in north america (major-poetzl, 2017). a docile body, according to foucault, is one that is both precise in construction and malleable to discipline. it is dual in nature, insofar as it gains efficiency and power, as well as relinquishes power to the disciplinary body or authority that facilitates its construction. foucault provides the example of a soldier, representing a body which is both impeccably trained and wholly subjected to its trainer (e.g., a political/institutional authority). thus, a docile body is one that, while practiced and improved, achieves such efficiency via subjugation. beginning in the 18th century, foucault describes the methods by which control was exercised in order to create docile bodies. specifically, he introduces the scale of control, the object of control, and the mode of control. the scale of control refers to a focus on the body as manipulable parts, rather than as a whole or as an “indissociable unity” (foucault, 1977, p. 137). whether the reference is to a body as a populace, or a body as an individual, the scaling down to the individual body or, further, to parts of the body, is a method of discipline and control. the object of control refers to exercise as a method of control. in other words, exercise increases the efficiency of the reduced body. the mode of control mori graduate student journal of psychology refers to constant supervision and codification of activity as a method of discipline. in describing supervision and codification, foucault refers to the partitioning of time, space, and movement, again implying a reduction from whole to partial. of relevance to the current discussion, foucault implicates institutions, specifically the hospital and the school, as settings in which these methods of control have been exercised. the present thesis asserts that psychology and psychotherapy have adopted the ideologies foucault brought to light through his observation of institutions, as they themselves were created within those institutions. therefore, it is necessary to understand how methods of control were utilized in such institutional settings in order to better understand how they then manifested in psychological and psychotherapeutic research and practice. institutional roots: medicine and the academy foucault’s observations of mechanisms of control are evident in institutional practices and in the disciplines developed within them. foucault’s notion of a powerful and efficient, yet malleable and subjected, body is represented by the medical institutions of the 19th and 20th centuries, which were paradoxically both strengthened and controlled by the state. during this time period, medical systems and hospitals had gained a great deal of power in western society. however, the authority, power, and efficiency of medical institutions were only made possible through state financing (fox, 1993). the state relied on physicians to “care for the sick in order to make them productive and law-abiding…” (fox, 1993, p. 1219). thus, medical professionals were likewise in the authoritative position, strengthening the bodies of their patients, which served to further subject their patients to the law-abiding expectations of the state. yet another illustration of foucault’s subjected body is provided by berg and harterink (2004), who proposed that by focusing on controlling the hospital systems, as opposed to the individual practitioners, governing bodies ensured a broad scope of influence while allowing physicians to maintain their autonomy. as such, physicians were bestowed power while simultaneously relinquishing power to a governing body. ties between medical and academic institutions were well-established throughout the 20th century. in a paper outlining the history of the teaching hospital in the united states, burbridge (1957) stated it was “axiomatic that the medical college should be located in a university setting…” (p. 179). the mechanisms of control described by foucault, which were present within medical institutions, existed similarly in academic institutions. an abundance of scholarship has been dedicated to identifying the parallels between foucault’s discipline and punish and academia. in fact, foucault’s work “has arguably been the most frequently drawn upon in critical examinations of education” (morrissey, 2013, p. 797). to exemplify aspects of foucault’s philosophy relevant to the current discussion, the following will elucidate how the academic institution, and particularly its focus on a scientific methodology, engenders powerful yet subjugated bodies. examples of the scale, object and mode of control present in academic institutions are discussed. meyer (2006) suggests that the 20th century academic knowledge system “authorize[d] enormous control over humans, society, and nature” (p. xv). the empirically based education system served to “empower humans…as small gods, with legitimate purpose and comprehension.” yet, at the same time, the “rationalistic social sciences…provide[d] the needed supports for this explosion of what foucault called governmentality.” (meyer, 2006, p. xiv). in essence, the institution which empowered human knowledge and productivity also served to strengthen the institution and its ability to exercise control over those residing in the academic institution, and consequently over society more broadly. thus, foucault’s governing authority and powerful yet subjected body were in (dis)embodiment in psychology and psychotherapy graduate student journal of psychology one way manifested in the academic institution and its human constituents. foucault’s scale, object, and mode of control became evident when significant shifts in academia occurred in the early 20th century, which formed the basis for the current academic institutional system (goldin & katz, 1999). specifically, the late 19th and early 20th century witnessed the development of research into a core foundation of academic practice (etzkowitz, 2001). the use of scale, in which control is exercised by breaking down the subject of control into component parts, has constituted a basis for factious debate within the realms of scientific inquiry and research methodology (lee & wallerstein, 2010). however, these discussions center around the related term of reductionism rather than scalability. the scale of control (i.e., the reduction of constructs into more operative components in order to harness knowledge), is “often justified by reference to the methodological ideal of parsimony” and the “prerogative of scientific abstraction” (sayer, 2010, p. 6, 12). that reductionist philosophy and practices are argued to be elemental to the scientific research endeavour exemplifies how a scale of control is interwoven into the very foundations of academic research. furthermore, while qualitative methods have more recently gained ground in psychological research, such methods that aim to take a relatively more holistic and contextual approach have remained on the sidelines of academic research (henwood & pidgeon, 1992; madill & gough, 2008; mason, 2017). foucault’s object of control is evident in the practice of publication. the emphasis on research publication is such a prevailing characteristic in academia that the term “publish or perish” is a common colloquial aphorism in the research world. the origins of the term dates back to the early 1930s, demonstrating the historical presence of a culture of productivity in academia (coolidge, 1932; rawat & meena, 2014). the efficiency required for prolific publication is analogous to foucault’s object of control, where economy and efficiency are prioritized. foucault’s (1977) assertion that “the only truly important ceremony is that of exercise” (p. 137) is apt when viewing publication as an exercise through which power is both gained by the individual researcher, and relinquished to a broader academic institution. supervision and codification as modes of control are also conspicuous in academic institutions. put succinctly by morrissey (2013), supervision was evident in the 20th century institution and could “be seen in the managerial practices of performance evaluation and efforts to frame, regulate and optimize academic life” (p. 799). morrissey (2013) argues that, within academic institutions, “productions must be coded, ascribed value and quantified,” in order to “govern the academic subject” (p. 799). while many examples exist, the ones provided herein demonstrate how foucault’s concept of a docile body and the scale, object, and mode of control was evident in 20th century conceptions of research institutions. manifestations of foucault’s philosophy within 19th and 20th century medical and academic institutions may appear distinct from discussing embodiment in psychotherapy; however, the present argument asserts that an understanding of the body in psychotherapy is necessarily grounded in foucault’s observations of western culture and its institutions. two points are proffered to substantiate this claim. first, in foucault’s exposition of docile bodies, not only did he direct a spotlight on the hospital and the school as relevant locales of his philosophy, his literal and metaphorical employ of the body evidences his philosophy’s relevance to the body itself. second, areas of research and practice are a function of the context in which they are created (jovchelovitch, 2019). knowledge of the context in which psychotherapy developed allows for a more thorough mori graduate student journal of psychology understanding of how the body was conceptualized in psychology and psychotherapy. in other words, foucault’s designation of academic and medical institutions as domains of control, may suggest that those methods of control are inevitably manifested in the areas of inquiry and practice developed within those institutions. academic and medical institutions were essential to the development of psychology and psychotherapy; as such, the following will discuss how the methods of control present in those institutions also emerged in psychotherapy and, subsequently, in psychotherapy’s relation to the body. methods of control manifested: the founding of psychology and psychotherapy psychology and psychotherapy have been closely related to academic and medical institutions since their formation. hartley (2004) asserts that “modern psychology’s roots grew out of the ground of the biological and dualistic medical model of nineteenthcentury psychiatry” (p. 14). freud earned his medical degree and worked in hospital as a medical doctor in theodore meynert’s psychiatric clinic (walker, 1957). both pierre janet and wilhelm reich were medical doctors and spent time employed in hospitals (hart, 1983; sharaf, 1983). freud, janet, and reich were professors, whose research and ideas were facilitated by various academic institutions, including the university of vienna, the sorbonne, and the university of oslo. thus, key figures in the development of psychotherapy were embedded within major academic and medical institutions of their time. wilhelm wundt, who is famously known for creating the psychology laboratory (harper, 1950), is a critical figure to acknowledge when drawing the link between psychology and institution. “evidence of a rapid process of institutionalization” (danziger, 1990, p. 32) could be witnessed in the operations and output of wundt’s psychological laboratory, which has been recognized as an exemplar of institution due to the social structure and division of labour adopted within it. specifically, danziger states that “the division of labor that was spontaneously adopted in wundt’s laboratory was none other than the well-known division between the roles of ‘experimenter’ and ‘subject’” (danziger, 1990, p. 30). the division between the actor and the acted-upon, as a tenet of institution, was present in various forms within medicine, academia, and subsequently within psychology and psychotherapy. medical doctors were powerful actors in society who acted upon the body of patients. in so doing, they facilitated both the power and subjugation of the patient. within the research tradition of academic institutions, the researcher adopted the role of objective observer, while the participant was quite literally a “subject” of investigation. to provide an abstraction of the researcher-participant dynamic as it relates to a tradition of institutional control, the research subject’s participation in the experiment facilitated the power of the individual in society insofar as the research was meant to bestow power through knowledge upon society’s citizens. at the same time, the experimental participant was passively subjected to whatever rules were laid out by the researcher. notably, this division of labor between experimenter and subject served to establish psychology within the academic research institution. psychotherapy did not deviate from this tradition; it maintained the distinct relationship between the observer and the observed. thus, the methods of control central to a historical institutional structure were maintained and reflected in the interactions that were taking place at an individual level. the body in psychology and psychotherapy the necessary path has been traced from embedded systems of control in 18th and 19th century western culture, to 19th and 20th century medical and academic research institutions, to the founding of psychology and psychotherapy. the following is a discussion of how these embedded methods of control were consequently manifested in conceptualizations of the body in psychology, psychotherapy, and their major (dis)embodiment in psychology and psychotherapy graduate student journal of psychology developments. here, a focus becomes the micro-level dynamic that arises in the therapeutic context, in which interand intra-personal interactions occur between and within bodies in space. examples of how these dynamics existed in psychology and psychotherapy are provided. the interand intra-personal relationship to the body in psychotherapy the psychotherapeutic relationship, in its founding days, is often discussed in terms of the power differential between therapist and patient. by nature of the psychotherapeutic context, in which an objective and neutral therapist provides aid to a patient, the therapist is placed in a position of control (gannon, 1982; whitebook, 1999). in the early days of psychotherapy, therapists may have utilized their power to “gain a privileged post within the ferment of the patient’s mind, and thus more ably leverage his own suggestions to the patient…while retaining his position of utter aloofness” (engel, 2008, p. 10). dr. jerome frank, a professor of psychiatry in the 1950s, described the treatment setting as providing cues that encouraged the patient’s dependence on the therapist, with the implication being that healing cannot occur without allowing control to be exercised over oneself by an external authority (frank, 1959). thus, similarities are present between the therapistpatient relationship, a historically established physician-patient relationship, and foucault’s observation of a body as an object that is acted upon, with a powerful entity that subjects the body while simultaneously facilitating its power. reflecting broader social systems of control, as well as the mainstream interpersonal therapeutic dynamic, the intrapersonal dynamic between an individual and their own body in psychotherapy displayed a similar relationship, whereby the body was something to be controlled, acted upon, and subjected to the authoritative self. in western society, the body has historically been conceptualized as “a repository of sin,” “a disgusting sexual object,” “something to be perfected and controlled through diet and exercise,” “something to be medicated or fixed by the medical profession,” and “an object of scientific research by biology and neuroscience” (young, 2006, p. 21). the body in psychotherapy was treated similarly and was considered something that holds “baser impulses to be sublimated by freudian analysis” (young, 2006). thus, foucault’s docile bodies are directly represented in the way that the body was, and often still is treated, both in society and in psychotherapy. in other words, foucault’s philosophy detailing a facilitation of power and simultaneous subjugation of the body is represented in how the body has often become an object to be acted upon as a means to an individual’s power and efficiency. the body in psychotherapeutic modalities the conceptualization of the body as an object of control has been woven into the roots of mainstream psychotherapy. as such, major movements within psychology and psychotherapy inherited the body’s marginalized position. beginning in the 1800s, behaviorism and cognitivism represent major movements in psychology and therapeutic intervention. these traditions evidence the body’s lack of autonomy. the body is treated not as a source of knowledge through which insight into one’s emotional experience could be gained, or a means through which healing could occur, but as an object which could be submitted to a strict training protocol in order to undo maladaptive and observable habits and behaviors. humanistic traditions, such as emotion-focused therapy (eft), align more closely with an embodied perspective; yet; they evidence a disembodied tradition via historical and current rejection of aspects of their practice. in the case of eft, the underlying theory of the approach also contains elements of a dualistic approach. behavioral therapy. in the behaviorist tradition, “feelings…were simply irrelevant to mental health” (engel, 2008, p. 88). if feelings, by definition, are felt mori graduate student journal of psychology experiences, indifference towards feelings implies an indifference towards that which facilitates and processes the felt experience (i.e., the physical body). in contrast to a more phenomenological and subjective approach, which was, for a time, present in humanistic psychology, behaviorism “was an oddly cold approach to psychology: one which elevated observable behaviors to the exclusion of all other aspects of human existence” (engel, 2008, p. 83). as embodiment is closely related to a subjective, inwardly-felt experience, to exclude the subjective experience from psychology in favor of a purely observable approach consequently excluded embodiment from the approach altogether. behaviorism was applied to therapy via behavior therapies in the 1950s, which brought a similar “body-as-object” approach to therapy as it had brought to research. reminiscent of foucault, behaviorist methods facilitated the healing of the individual through the individual’s subjection to a highly precise and measured regime. engel (2008) described behavior therapy, which: “used rewards, punishments, aversions, and conditioning to teach or train subjects to behave differently than they had in the past. behavioral therapists utterly rejected traditional psychotherapy as useless, preferring instead to focus on the very observable and measurable changes wrought through operant conditioning” (p. 83). the principles underlying behaviorist methods reflect the dynamics of control which contribute to powerful yet docile bodies. as with foucault’s methods of control, behaviorism operated on a scale of control which broke down human functioning into smaller and more manageable components, or “basic units.” specifically, watson stated that “the basic unit of learning is the conditioned reflex” (watson, 1957, p. x). the level of reduction enacted upon human behavior thus lent itself to an exercise of sorts, through which associations between reflex and response could be systematically strengthened (tomic, 1993). the emphasis on observable and measurable change is akin to the supervision and codification observed by foucault. while an emphasis on the body is observed in the behaviorist tradition, it is characterized by subjecting the body to rational observations and, thus, exemplifies a disembodied tradition based on dualism and efforts to control. in sum, the rejection of felt, internal processes in behaviorism, coupled with the therapeutic techniques reflective of the modes of control underlying a disembodied western tradition, placed the body in a subjugated position in behaviorist therapies. one could argue that behaviorism did not hierarchize the mind over body, as the “black box” of consciousness was essentially circumvented in the behaviorist approach. rather than concerning itself with mental processes, the focus remained solely on observable behavior (tomic, 1993). in fact, watson asserted that “all psychology except behaviorism is dualistic” (watson, 1957, p. 4). however, to treat the body in a way that reduces it to observable behaviors by an external authority serves to place it in an inferior position to the observer. furthermore, a focus on observable behavior contradicts the definition of embodiment, which, as stated earlier, is “the body experienced from within” (hartley, 2004, p. 12). even while behaviorism did not concern itself with unobservable mental or internal processes, the entire behaviorist enterprise was highly rationalized, objective, and empirical characteristics representative of the cultural and systemic context in which it was created. thus, to claim that behaviorism was not dualistic fails to recognize how behaviorism was created upon a western philosophical foundation that favored the mind above body, and that facilitated dynamics of control reflecting that hierarchical order. cognitive therapy. while cognitive-behavioral approaches to therapy assumed a dominant position beginning in the 1980s, cognitive therapy was originally developed as an independent form in the mid-1900s. it arose, in part, out of dissatisfaction with (dis)embodiment in psychology and psychotherapy graduate student journal of psychology behaviorist approaches, which were criticized as being overly simplistic and unable to address more complex human problems (newman et al., 2017). cognitive therapy was based on the premise that healing could occur if clients were taught to think in more rational and adaptive ways, as opposed to responding in an emotional or “neurotic” manner (engel, 2008). rational emotive therapy (ret) was an early form of cognitive therapy founded by albert ellis, a trained psychoanalyst who diverged from the psychoanalytic tradition due to what he perceived to be a lack of theory and efficacy (ellis & bernard, 1985). marginalization of the body in psychotherapy is evident in the cognitive tradition, which favored cognitions and thought over felt, emotional experiences; in other words, it privileged mental processes with little heed to the body or physical processing. similar to behavior therapies, conceptualizing the emotional and felt experience as either inconsequential or as something to be mastered by cognition, undermined the body’s role as an equal player or potential agent of change in the healing process. through a comparison of cognitive therapy and more mindfulness-based approaches, fennell and segal (2011) provide an example of disembodiment with a cognitive tradition. specifically, they refer to elements of cognitive therapy as representing “a shift of gear… from mindful embodiment to lecture mode” (p. 132). cognitive therapy’s emphasis on rationality and cognition as a way to exercise behavioral change reflected a dualist conceptualization of the mind-body relationship (leitan & murray, 2014), which points to certain philosophical foundations of cognitive therapy. specifically, situating the body in an inferior position was in alignment with the hierarchy put in place by dualist philosophical roots. the dualism present in cognitive therapy is parallel to the dualism present in western society and the institutions present within it, which favored rationality, empiricism, and objectivism. foucault’s methods of control, present in these institutions, were also present in cognitive therapy and served to maintain a dynamic of control which subjugated the body. while the scale of control in behaviorism was reflected in breaking down behavior into component parts, cognitive therapy’s “units” of control were thoughts and cognitions. ellis’ scaling down of cognitions resulted in the identification of a list of precise irrational thoughts (capuzzi & stauffer, 2016). in cognitive therapy, thoughts were the subject that held the power to change the “operations of the ‘body’ (i.e., behavior)” (leitan & murray, 2014, p. 3). the use of exercise and codification as the object and modes of control was clearly present in cognitive therapies, which introduced the use of homework and worksheet exercises to psychotherapy (ellis, 1962). while no doubt providing benefit to clients (broder, 2000), the habit of engaging in cognitive exercises and codifying the process in cognitive therapy favoured a highly intellectualized and rationalized processing. humanistic therapy. when discussing the therapeutic relationship, one cannot forgo discussing the humanistic movement in psychology and carl rogers’ personcentered therapy. rogers, credited as one of the founders of humanistic psychology, wrote extensively on nondirective psychotherapy throughout the 1950s and onward (orlov, 1992). in direct contrast to the hierarchical relational dynamic described above, “clientcentered therapy required the therapist to reduce his role in the therapeutic relationship to one of sympathetic and nonjudgmental listener” (engel, 2008, p. 76). in rogers’ own words, the therapist-client relationship in the humanistic tradition was one in which the therapist approached the client “not as a scientist to an object of study, not as a physician expecting to diagnose and cure, but as a person to a person” (rogers, 1989, p. 409). in addition to this relational shift brought forth by humanistic therapy, embracing a mori graduate student journal of psychology subjective and phenomenological perspective was also present (moreira, 2012). this perspective represented a greater importance being placed on the subjective lived experience and the felt body, rather than the more traditional objective, empirical viewpoint. despite some discrepancies between phenomenology and a truly embodied perspective (sampson, 1996), the phenomenological perspective takes a step closer to embodiment, and requires one to “set aside not only the ways in which the natural sciences approach the body, but also the ways in which we have tacitly taken over naturalscientific assumptions into our everyday understanding of embodiment” (behnke, 2011). innovations in humanistic psychology can be attributed to its democratic and phenomenological approach, which directly contrasted the western philosophical and institutional roots that formed the foundation of a disembodied psychological tradition. this contradiction did not go unnoticed, as engel (2008) pointed out that “client-centered therapy seemed to contradict rogers’ roots in a psychology department within a school of education” (p. 80). however, that which placed humanistic psychology on a mantle of innovation may have simultaneously been what contributed to its dismissal, as its lack of objective empiricism has it considered by some as “a detour in the history of american therapy, more than a milestone” (engel, 2008, p. 82). humanistic psychology still holds great influence, perhaps in part due to rogers’ “move away from a clinical phenomenological approach in the 1980s” (moreira, 2012, p. 51). while humanistic therapies have no doubt made a lasting and continuing impact on psychological practice, somatically-based methods associated with humanistic psychology, such as alexander techniques, rolfing, and the feldenkrais method (moss & shane, 1999; posadzki et al., 2010; taylor, 1999), to name a few, remain on the sidelines of therapeutic practice (hartley, 2004). emotion-focused therapy. emotion-focused therapy (eft) is a popular therapy based in the humanistic tradition (greenberg, 2011; greenman & johnson, 2013). developed by leslie greenberg and colleagues in the 1980s, eft views emotion as fundamental to the self and to the healing process (greenberg, 2010, 2011). unlike behaviorist traditions, which rejected the importance of felt experiences, eft considers embodied emotional shifts as a catalyst for change. in a clinical synthesis of eft written by leslie greenberg (2010), several references to embodiment are made. greenberg asserts “bad feelings can be transformed by…the evocation of meaningfully embodied experience” and “enduring emotional change occurs…not through the process of insight or understanding alone” (p. 37) as “emotional awareness involves feeling the feeling, not talking about it” (p. 35). efts dialectical constructionist stance, in which reason and emotion are integrated, serves to position the body and mind equally as collaborators rather than hierarchically, and thus stands in opposition to a dualist or disembodied perspective (greenberg, 2011). the therapist-client relationship in eft aligns with humanistic methodologies, eschewing the traditional dynamics of control through a client-centered gestalt-style therapy (greenberg, 2010, 2014). the embodied perspective in eft is present in descriptions of its clinical application, but less so in explanations of the modality’s theoretical basis. in describing the theoretical underpinnings of eft, greenberg (2010) refers to emotions as a “brain phenomenon” (p. 33). albeit different from “thought,” greenberg asserts that the emotional brain houses neural networks that effect emotional responses. the language used in greenberg’s theoretical explanation is reminiscent of cognitivist language (richards, 2010), describing emotion memories as “units stored in memory networks” (greenberg, 2010, p. 33). this perspective is differentiated from body-based perspectives, in which emotion memories are not only stored in cognitive networks, but are imprinted in the body and are re(dis)embodiment in psychology and psychotherapy graduate student journal of psychology experienced in real time (van der kolk, 2015). while the role of the felt physical experience is not lost upon the clinical application of eft, its theoretical foundations do not reflect the embodied perspective central to its practice. even so, embodied practices in eft make it a unique psychotherapeutic modality in the landscape of past and current therapeutic methods. the evidence supporting eft as an effective modality contributes to its popularity and establishment in the field. despite evidence to show it may be a modality equal to, and in some respects, surpassing outcomes of cognitive-behavioral therapy (cbt; greenberg, 2010; watson et al., 2003), eft nonetheless trails behind the scope and influence of cbt. cbt’s broader impact in western psychotherapy can arguably be due to a relatively larger evidence base in comparison to eft and other therapies; however, a greater number of studies dedicated to a modality does not imply the relative empirical soundness of that modality (leichsenring & steinart, 2017). in a “cbt-centric” era (leichsenring & steinart, 2017; roy-byrne, 2017) arising from a historical tradition of dualistic practices and disembodiment, the incorporation of embodiment in eft, foreign to western practices, may contribute to its trailing role behind cbt. simultaneously, the adherence of eft to cognitively-based theoretical underpinnings may facilitate its place in mainstream psychotherapeutic practice. looking to the future: clinical implications major developments within psychotherapy throughout the 19th and 20th century, including aspects of behavior therapy, cognitive therapy, as well as the reception of humanistic methods, can be viewed from an embodiment lens as characterizing a “disownment” of the body and maintaining the body as an inferior and subjugated object (young, 2006). why and how this occurred can be explained in relation to the philosophical and institutional traditions out of which psychotherapy developed. these traditions are present within various aspects of early and present-day psychotherapy, namely, within a persisting dynamic which maintains the client as a subjugated body in the therapeutic context, as well as in relation to the client’s own mind and cognitions. however, developments have taken place in psychotherapy such that a new third wave of cognitivebehavioral therapies are gaining in popularity and widespread use. the origins of third wave cbt approaches can be traced back to the mid-1990s, with the early 2000s marking a more official designation of third-wave approaches, most often including acceptance and commitment therapy (act), dialectical behavior therapy (dbt), and mindfulnessbased cognitive therapy (mbct) (messer & kaslow, 2020). given the predominance of cognitive and behavioral approaches in western therapy, adoption of meditation and mindfulness-based practices in third-wave cognitive therapies (mbct in particular) represents a significant shift in general practice due to adoption of an embodied perspective. meditation and mindfulness practices are historically rich and deeply embodied practices (hartley, 2004; mruk & hartzell, 2006); mcbt itself was drawn from mindfulness-based stress reduction (mbsr), a method originally developed for psychosomatic conditions (messer & kaslow, 2020). in clinical practice, techniques which encourage clients to use mindfulness techniques, somatic anchoring points (i.e., focusing on one’s breath, feeling one’s feet on the ground), and body scanning are now commonly used alongside traditional cbt techniques (aloneftis, 2017; barlow et al., 2017; hayes & hofmann, 2017). the significance of adopting third wave practices and embodied techniques in mainstream psychotherapy lies in the contrast between their underlying philosophy and epistemology, and those underlying the culture and institution of traditional western mori graduate student journal of psychology psychotherapeutic practices. in virtbauer and shaw’s (2017) discussion of epistemological, methodological, and ethical issues of mindfulness in western psychology, they state that “…a mindful science is in stark contrast to the cartesian dualism of mind… which has shaped much of modern western scientific epistemology” (p. 41). however, the authors also reflect on the opportunity to integrate contrasting approaches. widespread acceptance of third wave therapies and mindfulness techniques presents a fruitful opportunity for diversity in psychotherapeutic practice, but also presents a danger of superficial application. students in clinical training programs as well as seasoned clinicians may be asked to apply techniques without an understanding of how the history of their field and context of their academic training engenders a perspective incompatible with one necessary to employ embodied perspectives in their practice. in a study exploring medical and psychology students’ experiences in learning mindfulness, solhaug and colleagues (2016) found that, while students identified embodiment as key to mindfulness practice, their acknowledgement of core tenets of mindfulness, such as non-striving and acceptance was often at odds with “instrumental aims of improvement and control” (p. 842). the authors point out “a gap between the original intention of mindfulness… and western society’s drive for instrumental[ity]” (p. 847). important to a mandate of best practice in psychological practice, the philosophical and epistemological discrepancies between embodied practices and western healing traditions may impact the quality and efficacy of service delivery (kirmayer, 2015). integrated approaches and the adoption of an embodied perspective in psychotherapy provide exciting avenues of inquiry and practice. how then do clinicians, researchers, and trainees explore these avenues while avoiding the pitfalls of superficial application? through the present discussion, i hope to engage in one method proposed by virtbauer and shaw (2017), which is to reflect on our scientific history and foundations so as to avoid “naïvely assum[ing] that the concept and practice of traditional mindfulness can be received without questioning the mindfulness of the receiver (i.e., western science)” (p. 42). researchers have identified the differences between waves of therapy as philosophical rather than empirical, necessitating philosophy of science as a required subject of training for therapists (hayes & hofmann, 2017). another method is the utilization of cross-disciplinary collaborative approaches, in which researchers and practitioners may share experience, knowledge, and practice. even within academic campuses, experts in various disciplines are close in proximity, but far in integrative practices. maintaining disciplines, methods of practice, and specialized experts in silos can be viewed as a vestige from a philosophical system which scales down from whole to partial, resulting in the reduction of a broad system of inquiry and human curiosity to component parts which rarely integrate. if psychotherapy is to make successful progress towards a credible use of embodied practices, learning from individuals and immersing in disciplines whose practices are rooted in alternative epistemologies (e.g., somatic practitioners, movement and fine arts disciplines) is necessary. in fact, the radical crossing of established disciplinary boundaries may, in of itself, build the bridges necessary to undo a tradition of disembodiment and forge a more embodied psychotherapy (glenberg, 2010; slife, 2021). discussion this work provides a critical historical analysis regarding an embodied perspective, which has typically been neglected in psychology and psychotherapy. this discussion also reviews the prevalent dynamics in the field, which presently focus on the power and (dis)embodiment in psychology and psychotherapy graduate student journal of psychology control exercised over the body. in relaying a historical account, i return to the philosophical roots upon which western tradition is founded upon, which include dualism and, importantly, foucault’s observations of control and the creation of the docile body. foucault identified institutions, namely, the school and the hospital, as locales where these dynamics of control are exercised and perpetuated. predicated on the notion that disciplines are influenced by the context and environment within which they are created, psychology and psychotherapy were necessarily influenced by the medical and academic institutions within which they were founded and developed, and through which deeply rooted systems of mind-body hierarchy and control over the body have existed. important to note is that disembodiment in psychotherapy has not gone unnoticed by scholars in the field. edward sampson constitutes a primary voice in the call for a more embodied psychology through his work titled “establishing embodiment in psychology” (sampson, 1996). in it, he argues that dominant western traditions have impeded an embodied perspective. he argued that even contemporary discourses, such as “more inclusive discourses of social constructionism” (p. 602) maintained a body-as-object tradition and have failed to incorporate a truly embodied perspective. what has been discovered in examining the history of the body in psychology, reflects sampson’s assertion that “if there is one dominant message that has been carried for many centuries in the western tradition’s relationship to the body, it centers on the ideas of… control” (sampson, 1996, p. 612). while sampson makes mention of the historical roots of disembodiment in psychology, providing a comprehensive discussion of historical foundations was beyond the scope of his paper. thus, the present discussion addresses this gap by taking a critical look at the roots of disembodiment in psychology and psychotherapy. a critical examination of psychology and psychotherapy through a historical lens is crucial as it provides insight into the present practices and future directions of psychology and psychotherapy. regarding the ways in which the body has been treated in medicine and academia, referencing foucault is not a novel undertaking; however, an application of his philosophical theories to psychological and psychotherapeutic practices is unique. furthermore, an understanding of the ways in which the body has been dealt with in psychology and psychotherapy is critical at our current juncture, given a growing trend in the field to incorporate mindfulness and other body-based practices. exploring the historical perspective in order to more thoughtfully and effectively move the field forward is best described through the work of sampson (1996), in which he states that “if social relations of domination are indeed somaticized… and as my idea of embodiment also recommends, we will need to be certain that our transformative practices are themselves as embodied as are the oppressions we hope to undo” (p.621). in other words, to overcome a deeply embedded tradition of disembodiment requires an awareness of the depth to which disembodiment is rooted in history, the ways in which disembodiment manifests in our current ways of being, and an equally substantive reification of embodiment. limitations the discussion presented herein must also be considered in light of limitations to the present analysis, which may guide future areas of inquiry. first, definitions and conceptualizations of embodiment and the mind-body relationship vary both within and outside of psychology (leitan & murray, 2014; smith, 2017); thus, other conceptualizations may yield alternative considerations. second, while the current exploration focuses on traditions of disembodiment in psychology and psychotherapy’s history and current practice, embodied and somatic practices have still been present in mori graduate student journal of psychology various forms within psychology. the examination of (dis)embodiment in psychology may benefit from future research which aims to explore ways in which the body has indeed been present throughout the course of psychology’s history. in turning to the philosophical foundations upon which the present analysis is based, there are other western philosophical traditions which may provide additional insight into historical roots which have shaped the body’s presence in current western practices (babbitt, 2014). further exploration of other major philosophical influences may guide a broader understanding of embodiment in the west. importantly, such a focus on western philosophies and practices neglects to consider non-western philosophical traditions and embodied practices, which may align with, or run counter to, traditions of embodiment attended to in the present analysis. advancing this area of research would involve extending current inquiry to other disciplines, as well as to other populations and cultural contexts. acknowledgments the author declares no conflict of interest. the author received no financial support for the research, authorship, and/or publication of this article. the author would like to acknowledge and thank dr. michaela mara for initial feedback and guidance on the manuscript, and dr. melanie kloetzel for the teachings in her course dance 481: cross cultural currents: theorizing dancing bodies (2016), in which she introduced foucault’s concept of the docile body and its widespread relevance to the structures in which we live and the hierarchies we embody. correspondence to this article should be addressed to camille mori, department of psychology, university of calgary, 2500 university of dr. nw, calgary, ab t2n 1n4, canada. email: cmmori@ucalgary.ca references aloneftis, r. 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(2015). what's that thing called embodiment? avant: trends in interdisciplinary studies, 6(2-3), 161-174. 5 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university resilience and psychological distress in genetic testing for alzheimer's disease the landscape of preventative genetic testing is continuously expanding, providing insights into the likelihood of developing or transmitting genetic disorders. this form of testing holds apparent significance: offering the advantage of foreknowledge about genetic diseases prior to the manifestation of symptoms, facilitating the diagnosis of various conditions, and receiving information pertaining to the potential transmission of genetic disorders to offspring (khoury et al., 2006). within alzheimer's disease and related dementias, a focal point of investigation lies in genetic testing. advanced technology is now available to analyze genetic makeup, facilitating the identification of specific genes associated with the onset of alzheimer's disease. consequently, some individuals are interested in procuring their genetic results (cutler & hodgson, 2003). as genetic testing advances and refines, its accessibility is anticipated to expand, granting individuals the choice of accessing information about their susceptibility to alzheimer's disease and related dementias. ethical considerations stemming from the acquisition of potential symptomatology knowledge encompass issues of hereditary transmission, lifestyle adjustments, and future life planning (roberts et al., 2003). alongside the benefits of genetic testing, there are potential ramifications for those who opt to acquire genetic information, notably an increase in psychological distress. psychological distress is characterized by a spectrum of stress-related symptoms encompassing anxiety, tension, and depression, significantly impacting overall well-being (gooding et al., 2006). in the context of discovering that one is a carrier of an alzheimer’s disease gene, individuals may commonly be confronted with uncertainties regarding the timing and potential outcomes of their condition, thus intensifying psychological distress (galluzzi et al., 2022). given that alzheimer's disease and related dementias involve irreversible brain degeneration and lack definitive curative treatments, the absence of viable long-term remedies could lead to distress among individuals experiencing cognitive impairment or a dementia diagnosis (cutler & hodgson, 2003). therefore, receiving genetic information about alzheimer's disease has the potential to induce substantial psychological distress (bookherimer & burggren, 2009). moreover, chronic stress has been shown to exert a detrimental impact on alzheimer's disease itself. research suggests that sustained stress can accelerate the progression of alzheimer’s disease, leading to increased neurodegeneration and the worsening of cognitive and behavioral symptoms in affected individuals (justice, 2018). this complex interplay between stress and alzheimer’s disease underscores the need for comprehensive interventions aimed at addressing both the psychological well-being of patients and the biological factors contributing to disease progression. though the psychological impact of receiving a diagnosis for an incurable disease is apparent, the doalicia burgei department of psychology, tiffin university the relationship between resilience and psychological distress resulting from genetic testing for alzheimer’s disease among non-cognitively impaired individuals is examined in this study. preventative genetic testing determines the likelihood of developing or passing on genetic disorders. however, receiving genetic information, especially regarding incurable diseases like alzheimer’s disease, can lead to significant psychological distress. resilience, the ability to cope with adversity and recover quickly, is considered a protective factor against psychological distress. the purpose of this study is to investigate whether higher levels of resilience are associated with lower psychological distress from genetic testing for alzheimer’s disease and to determine if having a familial history of alzheimer’s disease influences this relationship. an online cross-sectional survey was conducted among 181 non-cognitively impaired participants (43.6% male; 54.1% female; mage=38.1 [13.9]) using the impact of genetic testing for alzheimer’s disease (igt-ad) scale and the brief resilience scale (brs), along with a question about family history of alzheimer’s disease. the results indicated a significant negative correlation between resilience and psychological distress, suggesting that individuals with higher resilience experienced lower distress related to genetic testing. however, family history did not mediate the relationship, meaning the protective effect of resilience was consistent regardless of familial risk. these findings have implications for developing targeted support services and resilience-based interventions to help individuals cope with the emotional impact of genetic testing for alzheimer’s disease. further research could explore other potential protective factors and examine the long-term impact of genetic testing results on psychological well-being and behavior. keywords: resilience, psychological distress, genetic testing, alzheimer’s disease 6 burgei main of potentially protective factors remains less explored. resilience is a pivotal protective factor against psychological distress (garmezy, 1991). resilience, characterized by the ability to withstand or recover quickly from distress, has an established inverse correlation with psychological distress (yasien et al., 2016). norman garmezy introduced the resilience theory to understand how individuals who face adversities and risk exposure can develop normally and become healthy adults (garmezy, 1991). this theory postulates that resilience entails rebounding from emotional distress and maintaining adaptive behavior despite threats and adversities to an individual's well-being. resilience has been shown to impact the adjustment to genetic testing results with hereditary diseases, including cancers (ho et al., 2010). psychological distress from genetic testing is impacted by the severity of the disease, perceived risk, ability to control the disease, and availability of treatments (oliveri et al., 2018). analogous to cancer, alzheimer's disease significantly affects quality of life and psychosocial well-being and often necessitates long-term care or interventions (oliveri et al., 2018). hence, further exploration is required to unravel the interplay between resilience and psychological distress from genetic testing, particularly in alzheimer's disease. moreover, the influence of resilience on psychological distress may not be uniform across all individuals. family history, which signifies whether an individual has a familial predisposition to alzheimer's disease, has the potential to influence this relationship. a family history of a disease, particularly one with a genetic component like alzheimer's disease, can significantly heighten psychological distress (liu & cao, 2014). it leads to increased awareness of one's susceptibility, fostering stress and anxiety, as individuals become more concerned about their own risk and the possibility of transmitting the condition to their descendants (roberts et al., 2003). furthermore, family history can impose a perceived genetic "inheritance burden" on individuals, leading to guilt and concern about implications for their loved ones or future generations (james et al., 2006). while family history can increase the risk of developing alzheimer's disease (liu & cao, 2014), its role in the context of resilience and psychological distress remains underexplored. an understanding of the psychological impact of genetic testing, particularly in the alzheimer's context, is beneficial in identifying individuals at heightened risk of psychological distress and in devising additional coping strategies (chung et al., 2009). resilience-based interventions aimed at strengthening an individual's resilience, thereby mitigating distress, and at promoting emotional well-being hold the potential to significantly enhance the quality of life for individuals afflicted by neurocognitive disorders. however, more information is needed to understand how to effectively introduce resilience interventions (wang et al., 2021), specifically in the context of receiving genetic testing results. purpose the purpose of this study is to examine the relationship between resilience and psychological distress from genetic testing for alzheimer’s disease among non-cognitively impaired individuals, hereafter referred to as ‘unimpaired.’ drawing from resilience theory, which posits that protective factors mitigate the adverse consequences of risk exposure (garmezy, 1992), it is hypothesized that individuals with higher levels of resilience will experience lower levels of psychological distress when considering genetic testing for alzheimer's disease. this association rests on the premise that individuals exhibiting higher resilience levels will experience lower levels of emotional and behavioral challenges, such as depression, anxiety, and stress (yasien et al., 2016), compared to their counterparts with lower resilience levels. furthermore, family history is hypothesized to mediate the interplay between resilience and psychological distress. instances of psychological distress, including anxiety, depression, and disease-specific distress, tend to intensify in the presence of a family history of particular diseases (liu & cao, 2014). family history is projected to influence the strength of the relationship of resilience as a positive adaptation to psychological distress, given that a familial history of alzheimer's disease is likely to amplify the psychological distress experienced by participants contemplating genetic testing for the disease. the intent of the study is to answer two key research questions: 1. do variations in the impact of genetic testing for alzheimer's disease (igt-ad) scores relate to levels of resilience among unimpaired partici pants? 2. does the presence of a family history of alzhei mer’s disease influence or mediate this relationship? 7 resilience and psychological distress this study aims to recruit participants to complete a survey consisting of the igt-ad survey, brief resilience scale, and a query regarding a family history of alzheimer’s disease. the igt-ad (appendix 1) was created to evaluate the nature of genetic information and examine the impact of alzheimer’s disease risk assessment (chung et al., 2009). the survey will measure the adverse effects of participants receiving genetic information about alzheimer’s disease. the brief resilience scale (appendix 2) will assess the perceived ability to bounce back or recover from stress (smith et al., 2008). the variables, psychological distress from alzheimer's disease genetic testing and resilience, will be assessed for a relationship and will determine if family history impacts the relationship. the findings hold significant implications for discerning susceptibility to psychological distress related to genetic testing and understanding the role of resilience in counteracting these psychological effects. method participant recruitment and selection to address the research question, a cross-sectional survey was conducted online, leveraging the benefits of prompt participant data collection without the need for in-person administration, which aligns with the study’s focus on obtaining a snapshot of characteristics at a specific moment. this research project underwent rigorous ethical review and received institutional review board (irb) approval from tiffin university, ensuring the protection and well-being of all participants involved. prior to involvement in the study, participants were required to complete an informed consent which provided comprehensive information about the research objectives, procedures, potential risks, benefits, and confidentiality measures. due to the convenience of online data collection, the internet survey platform, prolific, was used for participant recruitment, with the study population of interest being cognitively unimpaired individuals. the survey obtained a study sample of participants who are not cognitively impaired or experiencing memory concerns through exclusion criteria. participants who answered “yes” to the initial question regarding memory concerns and cognitive impairment: “are you currently experiencing cognitive impairment or concerns with your memory and thinking?”, were disqualified from the study. the survey was a convenience sample as the prolific platform fills study places on a first-come, first-served basis and was distributed to all available participants. participants were pre-screened for english as their primary language, and an inclusion criterion was implemented to obtain participants only from the united states. sample size determination a power analysis was conducted using g*power to determine the appropriate sample size for the expected statistical analyses. for multiple regression (f2=.15, 80% power, α=.05) a minimum sample size of 82 and 68 participants, respectively, is required to yield meaningful results. the study aimed to recruit approximately 200 eligible participants to complete the survey, accounting for the number of participants deemed ineligible due to the initial question regarding memory concerns or cognitive impairment and their incomplete survey completion. a total of 231 participants initiated involvement in the study, and 50 participants were disqualified from the study due to the inclusion criteria. the sample size consisted of 181 responses with an average survey completion time of three minutes. participants who completed the entirety of the survey were rewarded $0.40 as an appreciation of their time and effort. participant demographics a total of 251 participants were presented with the survey, 181 met the inclusion criteria and completed the entirety of the survey. the sociodemographic characteristics are reported in table 1. the sample consisted of 98 females (54.1%), 79 males (43.6%), and four non-binary participants (2.2%). participants’ ages range from 19 to 73 years, with a mean age of 38.1 years (sd = 13.9). regarding educational attainment, 1 participant (0.6%) had some high school education, 23 participants (12.7%) had completed high school or equivalent, 63 participants (34.8%) had some college education, 75 participants (41.4%) held a bachelor’s degree, and 19 participants (10.5%) held a graduate or professional degree. survey design the survey consisted of a one-group design with a two-variable comparison of psychological distress from alzheimer’s disease genetic testing and resilience. google forms was used to generate a survey consisting of the preliminary question regarding current cognitive impairment, two embedded scales, a question regarding family history of alzheimer’s 8 burgei disease: “do you have a history of alzheimer’s disease in your family?” (questionnaire 1), and demographic questions (questionnaire 1). the study items were piloted among five participants to determine the appropriateness and consistency of the items. description of scales impact of genetic testing for alzheimer’s disease scale. the first scale, impact of genetic testing for alzheimer’s disease (igt-ad; appendix 1), assessed the dependent variable, psychological distress from receiving alzheimer’s disease genetic testing (chung et al., 2009). the igt-ad scale was developed to accurately assess the psychological distress associated with genetic testing for alzheimer's disease. while existing risk assessment scales predominantly focus on measuring depression and anxiety (chung et al., 2009), the igt-ad scale was formulated to gauge the psychological impact of genetic susceptibility to alzheimer's disease, incorporating insights from other genetic testing impact assessment scales (cella et al., 2002). this instrument is designed for clinical and research applications, providing a concise self-report measure of the psychological impact of genetic susceptibility to alzheimer's disease (chung et al., 2009). this 16-item scale used a 4-point response scale where 0 was “strongly disagree,” and 5 was “strongly agree.” the total score ranges from 0-80, with higher scores reflecting greater psychological distress related to alzheimer’s disease genetic testing (chung et al., 2009). in their study, chung et al. (2009) reported a mean of 16.9 with a standard deviation of 9.9, serving as a reference point for interpretation, along with a cronbach’s α of 0.82 for the scale. the igt-ad was assessed for construct validity by comparing the final scale to other established psychometric scales, including the impact of event scale (ies), the center for epidemiologic studies depression scale (ces-d), and the beck anxiety inventory (bai). using spearman’s correlations, the final scale was positively correlated with all the psychometric scales indicating convergent validity (chung et al., 2009). the assessment results suggest that the igt-ad is a valid and reliable scale that may be a more useful and sensitive tool in measuring psychological distress specific to alzheimer’s disease genetic testing than other generalized mood scales. brief resilience scale. the second scale, the 6-item brief resilience scale (brs; appendix 2), was used to measure the independent variable, resilience, or the perceived ability to bounce back or recover from stress (smith et al., 2008). this 6-item scale used a 5-point response scale where 0 was “strongly disagree,” and 5 was “strongly agree.” the total score ranges from 0-30, with higher scores reflecting greater resilience (m=21.18-23.88, sd=4.08-5.1; smith et al., 2018). smith et al. (2018) reported cronbach’s α of 0.80-0.91 for the scale. the brs was assessed for convergent validity and was positively correlated with resilience measures, including optimism, social support, and life purpose, and was negatively correlated with pessimism and negative interactions (smith et al., 2008). the assessment results indicate that brs is an adequate measure of resilience with good internal consistency and test-retest reliability. reliability and validity in the current dataset to ensure the reliability and validity of the measurement instruments in the current dataset, an analysis of internal consistency was conducted using cronbach's alpha. the values for cronbach's alpha in our dataset, demonstrating a high level of internal consistency (α= .82 for igt-ad and α= .94 for brs), were found to be consistent with previous research (chung et al., 2009; smith et al., 2018), affirming the instruments' sustained reliability. additionally, the content validity of the scales, which assess the intended constructs, was confirmed as the items were adapted from previous studies with established validity. data screening and preliminary assumptions statistical analyses were performed using the spss 28.0 statistical software. the data met the assumptions for multiple regression analysis: (a) one continuous independent variable (igt-ad total scores), one continuous dependent variable (brs total scores), and one dichotomous mediator variable (family history) , (b) independent observations, (c) a linear relationship exists between the independent and dependent variables, (d) homoscedasticity is present, (e) no multicollinearity, (f) no outliers, and (g) the residuals are normally distributed. a durbin-watson statistic was conducted to support the independence of residuals (dw = 1.743). standardized residuals indicated approximately normally distributed errors, as did the normal p-p plot of standardized residuals. tests for multicollinearity showed no concern (brs total scores, tolerance = .994, vif = 1.006; family history, tolerance = .994, vif =1.006). in order to explore the potential mediating effect 9 resilience and psychological distress of family history on the relationship between psychological distress and resilience, a mediator analysis using regression was applied. in the mediator analysis, psychological distress and resilience are defined as the dependent and independent variables, respectively, while family history is defined as the mediator to determine if family history impacts the relationship. the process macro model 4 for spss was utilized to apply a bias-correct non-parametric bootstrapping technique with 5000 resamples to estimate family history’s direct, indirect, and total effects (preacher & hayes, 2008). all assumptions for the mediator analysis using regression analysis were met. results descriptive statistics the survey's descriptive statistics are reported in table 2. the sample contained 52 participants with a family history of alzheimer's disease (28.7%) and 129 participants without (71.3%). no family history was coded as 0, and family history was reported as 1 with a reported mean of .287 (sd = .454). the total scores of the igt-ad scale ranged from 1 to 72, with a mean score of 34.3 (sd = 11.8), indicating moderate psychological distress related to alzheimer's disease genetic testing for the sample. the total score of the brs scale ranged from 6 to 30, with a mean score of 19.8 (sd = 5.4), indicating a moderately resilient sample. statistical analyses multiple regression analysis a multiple regression analysis was performed to investigate the relationship between psychological distress from alzheimer’s disease-related genetic testing (igt-ad scores) and resilience (brs scores). the model, incorporating brs scores as the independent variable and igt-ad scores as the dependent variable, yielded a significant negative association (figure 1). the multiple correlation coefficient (r) was 0.415, indicating a moderate correlation between the predicted and observed values of igt-ad scores and the predictor variable. the regression model, involving brs scores, accounted for 17.22% of the variance in igt-ad scores (r² = .172, f(2,175) = 16.057, p < 0.001). the unstandardized coefficient for brs scores was -0.829 (p < 0.001), indicating that, for each unit increase in brs scores, igt-ad scores decreased by 0.829 units. covariate analysis to assess the potential influence of covariates on the relationship between brs and igt-ad scores an analysis of the covariates, including age, gender, and education was conducted. education level emerged as a significant predictor (b = 1.963, se = 0.892, β = 0.151, t = 2.202, p = .029), suggesting that individuals with higher education levels experienced higher psychological distress. the results of this analysis revealed that after controlling for these covariates, the relationship between brs and igt-ad scores remained statistically significant (f(22,153) = 1.877, p = .015, η² = .212)). mediator analysis the mediator analysis results are reported in table 3. the analysis of family history revealed a non-significant effect on igt-ad scores (p = .163), suggesting family history did not significantly influence the scores. the interaction term between brs scores and family history did not significantly contribute to the variance in igt-ad scores (r² = 0.011, f(1, 175) = 2.326, p = 0.129), suggesting that the relationship between brs scores and igt-ad scores were not influenced by the presence of family history. bootstrap analysis further supported the regression results. discussion the present study investigated the relationship between resilience and psychological distress resulting from genetic testing for alzheimer's disease among unimpaired individuals. the findings indicated a significant negative correlation between resilience and psychological distress, indicating that higher levels of resilience were associated with lower levels of distress related to genetic testing for alzheimer's disease, irrespective of age and gender. these results support previous research that resilience can act as a protective factor against psychological distress in the context of genetic testing for hereditary diseases (ho et al., 2010). the negative correlation between resilience and psychological distress suggests that individuals with higher resilience may cope more effectively with the potential implications of genetic testing for alzheimer's disease. resilience allows individuals to adapt positively to challenging situations and adversities (garmezy, 1991), which may translate into reduced distress when faced with the possibility of developing alzheimer's disease. higher levels of resilience may enable individuals to maintain emotional well-being despite the perceived threat of the disease and the uncertainty associated with genetic testing results (yasien et al., 2016). 10 burgei the results also showed that family history did not significantly mediate the relationship between resilience and psychological distress. this suggests that individuals with higher resilience may be better equipped to cope with the emotional impact of genetic testing, regardless of their family history. while a family history of alzheimer's disease can increase the risk of developing the condition (liu & cao, 2014), it did not significantly impact how resilience influenced the psychological distress associated with genetic testing for the disease. the development and use of the igt-ad scale were essential in measuring the psychological impact of genetic susceptibility to alzheimer's disease (chung et al., 2009). previous scales primarily targeted depression and anxiety, but the igt-ad scale provides a more specific and sensitive measure for assessing distress specifically related to alzheimer's disease genetic testing. using validated and reliable measures, such as the igt-ad and the brs, strengthens the study's validity and supports the generalizability of the findings to other populations undergoing genetic testing for hereditary diseases. the present study contributes to the existing literature by focusing on unimpaired individuals' psychological distress related to genetic testing for alzheimer's disease. understanding the factors that influence individuals' responses to genetic testing is crucial, as it can help identify those at higher risk of experiencing distress and guide the development of tailored interventions. the results suggest that resilience-based interventions may be beneficial for individuals undergoing genetic testing for alzheimer's disease, as they may help mitigate the psychological distress associated with receiving test results (wang et al., 2021). limitations the present study had some limitations that should be acknowledged. the sample consisted of a convenience sample of unimpaired individuals recruited online, limiting the generalizability of the findings to the broader population. future research could aim to recruit a more diverse and representative sample to increase external validity. the study's cross-sectional design does not allow for causal inferences, and future longitudinal studies can better examine the relationship between resilience and psychological distress over time. it is crucial to acknowledge that the igt-ad and brs scales were not counterbalanced in this study, thereby introducing the possibility of order effects influencing participants' responses. self-report measures are subject to response biases, and participants may have provided socially desirable responses, leading to potential measurement errors. another potential limitation arises from the reliance on participant-reported family history of alzheimer's disease. this information could be subject to variations in accuracy, as it depends on participants' knowledge and the extent of their inquiries within their families. some participants may have inquired about alzheimer's disease in only a few generations, while others may have gone further back in their family tree. for future research, adopting more standardized and comprehensive methods for assessing family history may enhance the accuracy of this variable. implications and future research the study's findings have several implications for clinical practice and future research. first, identifying individuals at higher risk of psychological distress related to genetic testing can inform the development of targeted support and counseling services to help individuals cope with the emotional impact of test results. healthcare providers should consider incorporating resilience-based interventions as part of pre-and post-genetic counseling for alzheimer's disease and other hereditary conditions. such interventions may help individuals develop coping strategies and enhance their emotional well-being in the face of potential risk ultimately aiding in the reduction of stress that can contribute to the accelerated progression and neurodegeneration of alzheimer's disease (justice, 2018). while the present study did not explicitly assess the temporal aspect of psychological distress, it is essential to acknowledge that distress may vary over time. genetic testing results can trigger acute stress reactions, followed by an adjustment period. for some individuals, this psychological distress may be temporary, while for others, it may extend into a more prolonged and chronic experience. future research could delve into the dynamics of psychological distress over time in relation to genetic testing results, examining the factors influencing its duration and intensity. future research should explore other potentially protective factors, such as social support, coping strategies, and personality traits, to gain a comprehensive understanding of the factors that influence psychological distress related to genetic testing for alzheimer's disease. longitudinal studies can also provide insights 11 resilience and psychological distress into how resilience evolves over time in response to receiving genetic testing results and the progression of alzheimer's disease. additionally, examining the long-term impact of genetic testing results on psychological well-being and behavior, especially in those with a family history of alzheimer's disease, can offer valuable information for personalized interventions. conclusion in conclusion, the present study adds to the growing body of literature on psychological distress related to genetic testing for alzheimer's disease by examining the role of resilience as a protective factor. the findings highlight the importance of resilience in coping with the potential emotional impact of receiving genetic testing results and suggest that resilience-based interventions may be beneficial in supporting individuals undergoing genetic testing for alzheimer's disease. healthcare providers should consider incorporating resilience-based strategies in genetic 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(2016). relationship between psychological distress and resilience in rescue workers. saudi medical journal, 37(7), 778-782. https://doi.org/10.15537/ smj.2016.7.15004 burgei 13 resilience and psychological distress table 1 sociodemographic characteristics of the participants 14 burgei table 2 survey descriptive statistics 15 resilience and psychological distress table 3 mediator analysis 16 burgei figure 1 scatterplot of brs and igt-ad total scores 17 resilience and psychological distress figure 2 normality distribution of igt-ad and brs total scores 18 burgei appendix 1 the reveal impact of genetic testing in alzheimer’s disease scale (igt-ad) the questions below are about specific responses you may have about receiving your alzheimer’s disease genetic test results. please evaluate your response to receiving your results and answer every question in this section. indicate whether you strongly disagree, disagree, agree, or strongly agree with each statement, by selecting the corresponding response. 19 resilience and psychological distress note. items 4, 5, 14, and 15 are reverse scored. to score, add the responses varying from 1-5 for all sixteen items, giving a range from 0-80. 20 burgei appendix 2 brief resilience scale (brs) note. items 2, 4, and 6 are reverse scored. to score, add the responses varying from 1-5 for all six items, giving a range from 6-30. 21 resilience and psychological distress questionnaire 1 family history and demographic questions 63 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university can induced awe reduce anti-gay prejudice in heterosexual adults and does the need for closure moderate this effect? pankaj gupta & iain hamlin school of psychology, college of health, psychology, and social care, university of derby despite decades of struggle, prejudice based on sexual orientation continues to be commonplace (bartos et al., 2014; pirlott & cook, 2018). homosexual people face rejection at three levels– the socio-political level (heterosexism), the cultural level (sexual stigma) and the individual level (anti-gay prejudice (agp) or sexual prejudice; herek, 2007). on a socio-political level, as of december 2020, 70 countries worldwide still criminalised homosexuality and in 11 of those countries, homosexual behaviour could warrant a death penalty (international lesbian, gay, bisexual, trans, and intersex association, 2020). on a cultural level, a major contributor to stigmatization of homosexuality has been the ‘scientific’ rationalization given by the psychology and psychiatry disciplines for treating homosexuality as a mental disorder (drescher, 2015). the american psychiatric association (1987) completely removed homosexuality as a mental disorder as late as 1987, in its revised third edition of the diagnostic and statistical manual of mental disorders, and the world health organisation (1990) removed homosexuality from its international classification of diseases in 1990. on an interpersonal level, homosexuals continue to battle various forms of harmful prejudicial behaviors like verbal harassment, physical assault, sexual assault, social avoidance, and social distancing (huebner et al., 2004). sexual prejudice was the cause for 17% of hate crimes committed in 2019 in the united states (federal bureau of investigation, 2019). despite the ethical obligation that the discipline of psychology has, to find effective ways of reducing sexual prejudice, this field of research continues to be very small (case & stewart, 2010). interventions to reduce anti-gay prejudice according to a meta-analytic review of interventions to reduce sexual prejudice (bartos et al., 2014), only education and contact with gay people have shown a reasonable medium sized effect. education is a rational confrontational intervention that can sometimes work and sometimes backfire (cramwinckel et al., 2021) because prejudice has underlying emotions that are often resistant to rational argument (dovidio et al., 2004) and those who identify strongly with their ingroup are likely to feel that their ingroup is being made to look guilty with the educational intervention and to respond with increased hostility towards the outgroup (doosje et al., 1998). the general findings of intergroup contact research are more promising (pettigrew & tropp, 2000; 2008). however, many psychologists (e.g., mckeown & dixon, 2017; vezzali & stathi, 2020) caution against its real-world applicability because the idealized interactions that psychologists study are very different from actual interactions in real‐life settings (paluck & green, 2009). other limitations of intergroup contact interventions are: 1) the effects of contact vary significantly across difwith sexual prejudice continuing to be widely prevalent and seriously harmful, there is a need to find ways to reduce anti-gay prejudice (agp). this online experimental study examined if a novel intervention, induced awe, can reduce agp; if those high in need for closure (nfc) show higher agp; and if nfc moderates the effect of awe on agp. in total, 154 heterosexual adults completed the need for closure scale (roets & van hiel, 2011) before being randomly assigned to one of three emotion inducement interventions – 1) watching a 4.43 min long video of the target emotion, awe, 2) watching the comparison emotion, amusement, or 3) watching a neutral emotion as a control. post intervention, the participants completed the explicit measures homosexuality attitudes scale (has; kite & deaux, 1986). data were analysed using a 2 (nfc) x 3 (emotion type) independent factorial anova. none of the three hypotheses were supported since there were no main effects of awe or nfc on agp, and no interaction effect of awe and nfc on agp. key implications of these results were 1) awe inducement does not change prejudicial attitudes at an explicit level (dale et al., 2020), 2) factors beyond nfc, like right wing authoritarianism (rwa)and social dominance orientation (sdo), may influence the effectiveness of awe in reducing prejudice, and 3) questions were raised about certain boundaries for awe’s effectiveness. methodological modifications suggested for future research include using implicit measures or veiled elicitation methods for authentic measurement of agp, employing more potent awe elicitors, and assessing the mediating role of rwa and sdo on the effect of nfc on agp. keywords: anti-gay prejudice, induced awe, need for closure, need for closure scale, homosexuality attitudes scale, sexual prejudice 64 ferent types of contact positive or negative (vezzali & stathi, 2020); 2) such effects lack generalizability, since most studies have been done with people under the age of 25 and the effects of contact are not measured for longer than a day (paluck and green, 2009); and, 3) the model hopes to psychologically rehabilitate dominant bigots (mckeown & dixon, 2017). allport’s (1954) intergroup contact hypothesis, said that four conditions must be met for intergroup contact to effectively reduce prejudice: equal status, common goals, intergroup cooperation and support of authorities, and laws and customs. while many subsequent studies have shown that even when all four of the conditions are not met there is still a reduction in prejudice seen (pettigrew & tropp, 2000), many critics have shown that in real life, intergroup contact can increase prejudice instead of decreasing it (mckeown & dixon, 2017; graf et al., 2014). another less researched prejudice reducing intervention is elicitation of emotions like empathy toward a discriminated group (paluck & green, 2009). however, its effect on reducing sexual prejudicial attitudes has only shown modest results (bartos et al., 2014). there is a need for psychologists to test other forms of interventions for reducing agp. awe awe is an emotional response to exceptionally vast stimuli and events, like the beauty and vastness of nature, certain forms of art, ability, perfection, and supernatural events, that defies one’s accustomed frame of reference in some domain, transcends one’s current understanding (shiota et al., 2007), and requires an accommodation/adjustment to existing mental structures (keltner & haidt, 2003). awe is a unique emotion that has shown widespread effects on increasing an individual’s prosocial behavior (piff et al., 2015), as well as on reducing conviction about one’s ideological attitudes (stancato & keltner, 2021). experience of positive awe has two kinds of effects. one type is where awe changes the patterns of sociality with reduced focus on self and increased feeling of being small or insignificant (bai et al., 2017; stellar et al., 2018), thereby leading us to see ourselves as a small part of a greater whole, more connected to humanity, including out-group members (shiota et al., 2007). the second type of effect of awe relates to how its experience is cognitively destabilizing and triggers the need for accommodation (rudd et al. 2012; valdesolo et al., 2016). experiencing awe-inspiring phenomena involves challenging one’s current mental structures (keltner & haidt, 2003), and searching for new knowledge structures to make sense of new experiences, leading to schema change (shiota et al., 2007). although dale et al. (2020) did not find support for a schema change with regard to negative racial attitudes toward african americans, stancato and keltner (2021), across three experimental studies, did find robust support for it as a result of experiencing induced awe. stancato and keltner (2021) tested the effects of experimentally induced awe on reducing conviction about one’s ideological attitudes related to racism and found that induced awe led to uncertainty and ambivalence regarding one’s attitudes towards ideologically opponent outgroups and that in turn promoted reduced dogmatism and increased perceptions of social cohesion. there are many theoretical positions (for example allport, 1954; adorno et al., 1950; sidanius et al., 2004), that suggest that many kinds of prejudice, like racism, sexism, and sexual prejudice, share similar characteristics (aosved et al., 2009). so, theoretically if inducing awe can reduce racially prejudicial attitudes, it should be effective in reducing sexually prejudicial attitudes as well. however, no one has tested this effect yet. this study’s first objective was to test the effect of inducing awe on the reduction of agp in heterosexual adults. need for closure in his seminal work ‘the nature of prejudice’, allport (1954) theorized that individuals with a prejudice-prone personality think of anything and everything in a prejudicial way. they have a motivated general way of thinking, that does not discriminate between different outgroups and holds prejudice against all kinds of targeted groups. a more contemporary theory that also supports allport’s (1954) theory of prejudiced personality is the need for closure (nfc) theory posited by kruglanski and webster (1996; also see kruglanski & fishman, 2009) which explains the individual differences behind prejudicial thinking. therefore, nfc is a cognitive style that predicts prejudicial attitudes (onraet et al., 2011; roets & van hiel, 2011). nfc has been defined as the desire for "an answer on a given topic, any answer, compared to confusion and ambiguity" (webster & kruglanski, 1994, p. 1049) with two underlying tendencies – seizing (seeking quick and definite answers sourced through easily accessible information) and freezing (freezing upon those gupta & hamlin 65 can induced awe reduce anti-gay prejudice? lending credence to the idea that nfc’s effects on racial prejudice and sexual prejudice would be similar. one evolutionary function of awe is to generate a need for accommodation and updating of current mental frameworks, and to make sense of new information that cannot be assimilated in current mental structures (griskevicius et al., 2010) – needs people are generally motivated to satisfy (fiedler, 2001). the other function of awe is to increase the prosocial tendencies in people via a sense of ‘small self’ seeing oneself as less important in the grand scheme of things (piff et al., 2015). when faced with situations and people that defy conventions and norms, like homosexuals, people with high nfc (vs. low nfc) have a greater and more urgent need for cognitive accommodation (dhont et al., 2011; van hiel & mervielde, 2002). since awe is known to increase prosocial tendencies, we expected the experience of awe to help resolve this heightened need for accommodation in favour of reduced anti-gay bias. although dispositional tendencies to experience awe are negatively associated with nfc (shiota et al., 2007), awe can be induced in individuals who are or aren’t predisposed to experiencing it, and its effects can last up to a week or longer after the experience (anderson et al., 2018; takano & nomura, 2020). by combining findings from the awe, nfc, and sexual prejudice literatures, we expected that nfc would play a moderating role in the effect of awe on agp, in such a way that people high in nfc would respond to experience of awe with a greater reduction in agp. to overcome prior study limitations of most studies being correlational, conducted in the united states and among college students, this study was designed to be experimental, conducted among heterosexual adults in the age range of 18 to 87 years, with participants from many countries (including the united kingdom, canada, united states, europe, and india). this study’s aim was to explore a new line of research related to the use of a novel emotional stimulus, awe, to reduce agp, especially among high nfc/prejudice-prone people, which has not been conducted to date. hypotheses h1: people who have awe elicited within them will report a larger decrease in anti-gay prejudice than people who experience amusement or neutral emotion. h2: people high in need for closure will show higher anti-gay prejudice than people low in answers and guarding them against any contradictory information). individuals high in dispositional nfc desire order and structure in their lives, predictable knowledge that is stable across circumstances, and swift and firm decisions. they are uncomfortable with ambiguity and are closed-minded, unwilling to have their knowledge challenged (webster & kruglanski, 1994). nfc theory explains why people with high dispositional nfc experience discomfort with situations and people that seem to deviate from expectations and norms, and therefore hold negative attitudes toward a wide variety of marginalized groups (roets & van hiel, 2011), including homosexuals (soenens et al., 2005). in three belgian studies, van hiel et al. (2004) found support for a structural equation model in which nfc had a positive effect on racism which was fully mediated by right wing authoritarianism (rwa) but only partially by social dominance orientation (sdo). similarly, baldner and pierro (2019) found a significant positive correlation between nfc and prejudice against immigrants in italy and in the united states. soenens et al. (2005) conducted a study in belgium with 393 psychology students, examining the relationship between different identity styles and measures of conservatism, and racial and sexual prejudice. as a part of that study, they found that nfc positively correlated with other measures of conservatism (rwa and sdo) and prejudice (racism and anti-gay prejudice). the second objective of this study was to find support for the idea that individuals high in nfc display higher agp. moderating role of nfc on the effect of awe on anti-gay prejudice while allport (1954) posited that prejudice reducing interventions, like intergroup contact, don’t work on prejudice-prone personalities because of the rigidity of their attitudes, contemporary researchers (dhont et al., 2011; hodson, 2008) found evidence to the contrary. dhont et al. (2011) conducted a series of five studies among flemish belgian students and adults testing if nfc moderates the relation between intergroup contact and prejudice toward muslim immigrants. the results consistently showed that intergroup contact was more strongly associated with reduced levels of racial prejudice among people high in nfc compared to people low in nfc. aosved et al. (2009) found strong correlation between the constructs of racism, sexual prejudice, sexism, ageism, classism, and religious intolerance, 66 gupta & hamlin need for closure. h3: there will be an interactive effect of induced emotion and need for closure on anti-gay prejudice, such that the relatively beneficial effects of awe induction (relative to amusement and neutral emotion induction) on anti-gay prejudice should be greater for those high in need for closure than those low in need for closure. method design this was an online experimental study with data collected via qualtrics. this experimental study had an independent measures 2 x 3 factorial design. iv1 ‘emotion type’ was a three level, between-subjects factor where awe, amusement, and neutral emotion types were induced by using three different 4.43-minute-long video stimuli. iv2 ‘nfc’ was a measured factor, split at the time of analysis into two levels – high nfc (above median) and low nfc (below median). the dv was the anti-gay prejudice score. overall, we aimed to examine 1) the effects of a 4.43 min. awe video (vs. 4.43 min. ‘amusement video’ – a comparison positive emotion, and a 4.43 min. ‘neutral emotion’ video – as control) on agp, 2) the effect of nfc on agp, 3) the interaction effect of induced emotion type and nfc on agp. participants the g*power estimate for the number of participants required for this study was 158 (power 0.8, effect size 0.25, alpha error probability 0.05). a total of 159 self-identified heterosexual adults were recruited for this online study – 90 (57%) through survey circle (a research participant recruitment website), 57 (36%) through social media platforms (facebook, linkedin, and whatsapp groups of family and friends), and 12 (7%) though the research participation scheme (rps) and the msc. psychology student community at university of derby. participants recruited through survey circle and rps received points for participating in this study, which counted towards their research credit. no other participants received any incentives. individuals who were not fluent in english, were <18 years of age, or did not self-identify as heterosexual were excluded from this study. five outlier cases, with z-scores higher than +/2.58, were removed from the analysis to improve the conditions of normality in the data set. remaining participants (n = 154) ranged in age from 18 to 87 (m = 35, sd = 14.5) and 71% were female and 29% were male. the participant data had a strong skew towards younger age groups with modal age of 23 years and 50% of respondents being under 30 years of age. the sample was geographically heterogeneous, having 50 (32.5%) respondents from the united kingdom, 42 (27.3%) from india, 21 (13.6%) from canada, 16 (10.4%) from europe, 13 (8.4%) from the united states, and 12 (7.8%) from other countries. materials the materials used in this study were a qualtrics account to host the survey, spss to conduct the planned analysis and student onedrive to store the participant data. the experiment stimuli used were three previously validated videos, all related to nature, and all edited to the same duration of 4.43 min. awe video stimulus https://www.youtube.com/ watch?v=rup_p2g8sac previously used by piff et al. (2015), consisted of nature clips from the bbc’s planet earth series with grand, awe-inspiring shots of scenic vistas, mountains, plains, forests, and canyons. amusement video stimulus https://youtu.be/osqoyz2cigu, captured amusing moments from the daily life of antarctic penguins, and had been previously used by yichao et al. (2021). the neutral emotion type video stimulus https://www.youtube.com/watch?v=8yfkdjtlozc, was a short documentary about goby fish, previously validated and used by valdesolo et al. (2016) and found to be devoid of strong emotional responses. measures nfc was measured with the 15-item short version (roets & van hiel, 2011) of the nfc scale (webster & kruglanski, 1994; revised by roets & van hiel, 2007). sample items included “i don’t like to go into a situation without knowing what i can expect from it” and “i would quickly become impatient and irritated if i would not find a solution to a problem immediately.” respondents completed the items on a 6-point scale from 1 (completely disagree) to 6 (completely agree), and responses across items were averaged such that higher scores would indicate higher levels of nfc. this study obtained a cronbach’s alpha of .84. for this version of the nfc scale, roets and van hiel (2011) obtained cronbach’s alpha of .87, demonstrating good internal consistency. homosexuality attitudes scale (has; kite & deaux, 1986) consists of 21 items assessing people’s stereotypes, misconceptions, and anxieties about 67 homosexuals. sample items include “homosexuals should be forced to have psychological treatment” and “if i were a parent, i could accept my son or daughter being gay”. respondents rate each item on a 5-point likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. the scale provides a unidimensional factor representing attitudes toward gay individuals and reported high internal consistency (α >.93) and good test-retest reliability (r = .71). cronbach’s alpha for this study was .95. a higher score on has represents a more favourable evaluation of homosexuals. the has has previously been utilized as a measurement to assess beliefs about homosexuals in several studies, for example, keiller (2010). procedure this study was approved by the ethics review panel at the university of derby. subsequently, participants were recruited using a variety of methods including survey circle, social media and university of derby student platforms (details in participants section above). the study was posted on these platforms using the participant invitation, which included the digital url and qr code for the qualtrics webpage where the study was hosted. those interested in taking part in the study were invited to click on the url or scan the qr code to access the virtual participant information sheet which provided the details about the research aims and overview, and what they would be required to do if they decided to participate in the study. the participant information sheet also stated that participation in the study was completely voluntary, anonymized, that there was an option to ‘opt out’ of the study anytime during or up to two weeks after their participation in the study, prior to the data analysis taking place, and that participants would be provided with a unique identifier code in order to withdraw. there was no reward or monetary benefit for participation, except those recruited via the rps and survey circle who received points in the respective research participation schemes. there were no attempts to deceive the participants. participants were informed of the approximate length of the study (15-20 minutes). this was followed by the gdpr regulations and privacy notice. once the candidates had thoroughly read the information sheet and the privacy notice, they were asked to provide their consent in an informed consent form. the consent form had a box the participant had to tick before continuing, confirming their informed consent. participants were then directed to the next section asking the following demographics – age, gender, and country of residence. after completing the demographic section, they were directed to the first task which was responding to the nfc short version scale. upon completion of this task, using qualtrics randomizer, they were randomly allocated to one of three groups – awe/amusement/neutral – and were asked to view the corresponding 4.43-minute-long emotion eliciting stimuli video. participants were not able to fast forward or speed up the video at any stage and needed to watch the video in full at regular speed. after participants finished viewing the emotion eliciting stimulus video they were asked to report the intensity of their current emotions out of 14 options “fear,” “anger,” “sadness,” “pride,” “awe,” “peacefulness,” “excitement,” “happiness,” “boredom,” “anxiety,” “love,” “surprise,” “amusement,” and “disgust” (1 = not at all; 7 = extremely). this emotional manipulation check has been previously used by piff et al. (2015) and rudd et al. (2012). the last task for the participants was to respond to the has measuring their attitudes toward homosexual individuals. has was administered only once, after the experimental intervention, in line with previous studies using experimental manipulation of awe, for example, stellar et al. (2018), and yichao et al. (2021). once the final task was completed, all participants were taken to the debrief page and provided reconsent to their data being used by the research team, which concluded their participation in the study. the debrief informed them of the next steps in the study, clearly stating till which point they could withdraw. to do this, participants were going to be asked to provide their unique identification code and state to the researchers that they are no longer interested in participating in the study. they were also informed that upon request they will be able to access the final research paper if desired. lastly, contact details of the researchers were provided to welcome the opportunity to ask any questions. analytic strategy data imported from qualtrics study were analyzed using spss. outliers (z-scores greater than +/2.58) were removed. before conducting a 2 x 3 factorial anova, the data from remaining participants were checked for parametric assumptions. the dependent variable (agp) data were at interval level. can induced awe reduce anti-gay prejudice? 68 gupta & hamlin since there were many groups in the 2 x 3 design of this study, and because normality of residuals rather than normality of variables is important in anova (kozak & piepho, 2018), the residuals for agp were examined for normality, which showed a deviation from normality. subsequently, a log 10 transformation was done on the agp reflected data, and their residuals showed a normal distribution. normality was also checked after splitting the data into each of the six (2 nfc levels x 3 emotion types) iv combinations, each of which also showed a normal distribution. homogeneity of variance was checked with a levene’s test. a 2 (nfc level) x 3 (emotion type) factorial independent measures anova was then conducted. apart from the main analysis, a manipulation check was done to find if the awe stimulus generated higher mean levels of awe emotion as compared to the amusement stimulus and the neutral emotion stimulus, by conducting a one-way anova. normality and homogeneity of variance assumptions were checked before conducting the one-way anova. results five univariate outlier cases with z-scores greater than +/2.58 were removed from the initial data set of 159 participants – with 3 from agp data (z = -3.00, -3.68, -3.00) and 2 from nfc score data (z = -2.71, -2.99), leaving a sample of 154 respondents for analysis. the descriptive and normality test statistics are given in table 1. manipulation check to determine whether the awe video stimulus elicited a higher level of awe emotion as compared to the amusement video and the neutral emotion video, an emotion manipulation check was done using a one-way anova. the data were screened for normality assumptions before performing an anova. histograms and q-q plots showed a normal distribution. inspection of box plots did not reveal any outliers. the z-scores for skewness of awe levels for awe, amusement, and neutral stimuli were –1.67, 1.36 and 0.15 respectively. the z-scores for kurtosis of awe levels for awe, amusement, and neutral stimuli were 1.62, -1.17 and –2.09 respectively all within the acceptable +/2.58 range for a sample size of 154. the k-s and s-w tests being significant suggested the distribution deviated from normal, but anova has been found to be robust enough to account for such small anomalies (field, 2013). levene’s statistic was not significant (p = .34), so homogeneity of variance was assumed. the descriptive and normality test statistics of data analysed using spss are given in table 2. a one-way anova was used to examine the effect of the three different emotion stimuli on the level of awe elicited. the results revealed that there was a statistically significant difference in the mean level of awe elicited between at least two groups (f(2, 151) = 8.35, p = .001). tukey’s hsd test for multiple comparisons found that the mean level of awe elicited was significantly different between awe stimulus and amusement stimulus (p = 0.001, 95% ci = [.63, 2.50]), as well as between awe stimulus and neutral stimulus (p = .015, 95% ci = [.18, 2.06]). awe video stimulus generated more awe as compared to amusement or neutral video stimuli. assumptions check based on the rationale given in the analytic strategy earlier, the residuals for agp were examined for normality. while the zkurtosis (.51/.39 = 1.31) was in the desirable range of +/2.58, the zskewness (-1.22/.19 = -6.42), histogram and q-q plots showed the residuals of agp were not normally distributed. thereafter, a log 10 transformation was done on the agp reflected data and its residuals were examined for normality which showed acceptable zskewness (.49/.19 = -2.50) and zkurtosis (1.00/.389 = 2.57) of between +/2.58 and close to normal histogram and q-q plots. skewness and kurtosis were then checked for the residuals of agp log 10 transformed reflected data for all six levels of iv conditions (3 emotion types x 2 nfc levels) separately. this too produced zskewness and zkurtosis scores between acceptable limits of +/2.58. while the residuals of log 10 transformed agp reflected data met the requirements of normality for conducting an anova, the levene’s statistic was significant, p = .014, showing that homogeneity of variance cannot be assumed, and the results should be interpreted with caution (field, 2013). main analysis results of the factorial anova revealed that, contrary to h1, there was no significant main effect of emotion type on agp (f(2, 148) = 0.06, p = .94, ηp2 = .001). in contrast with h2, there was no significant main effect of nfc on agp (f(1, 148) = 2.01, p = .16, ηp2 = .013). in contrast with h3, there was no significant interaction effect between nfc and emotion type on agp (f(2,148) = 0.47, p = .62, ηp2 = .006). for all groups, ηp2 values suggested a small effect size. 69 discussion in this study we examined if induced awe (compared to amusement or neutral emotions) reduces agp, if high nfc (vs. low nfc) leads to higher agp, and if nfc moderates the effect of awe on agp. the results did not support the first hypothesis since participants in the awe condition did not differ in their reduction of agp, from those in the amusement or neutral emotion conditions. the second hypothesis was also not supported since participants with high nfc did not significantly differ in their agp scores from those with low nfc. also, the results did not support the third hypothesis since no interaction effect of induced awe and nfc was found on agp. the finding that an awe-inducing intervention did not reduce agp stands in contrast with the findings of stancato and keltner (2021) who found that induced awe (using similar stimuli as the present study) reduced conviction in attitudes towards racial outgroups. one point of difference between the two studies pertains to the demographic skew in the respective samples. stancato and keltner (2021) recruited their sample entirely from amazon turk whose respondent pool had a male skew (54% male), older age skew (70% aged >30 years) and had only 22.3% represented by student respondents (levay et al., 2016). in contrast, the present study had a female skew (71% female), younger age skew (50% aged < 30 years and modal age = 23 years), and a student skew (64% students). multiple studies have shown that women are less sexually prejudiced than men, and this difference is especially large among college students (kite & whitley, 1996). younger people, especially students who volunteer to participate in sexuality-related research, also have more sexual experiences and less restrictive values than their peers (wiederman, 1999). college students express less prejudice than an average individual (judd et al., 1995) and are more aware of modern social proscription against the expression of prejudice (crandall & eshleman, 2003). college students have had more exposure to some form of diversity or antibias training (mccauley et al., 2000). this demographic skew of the sample could help explain the present study’s significantly more favourable attitudinal responses to homosexuality than expected. the results pertaining to the first hypothesis were however in line with dale et al. (2020), who did not find a significant effect of induced awe on reduction of negative stereotypical attitudes toward african americans. dale et al. (2020) posited that individuals may not perceive the effects of induced awe beyond the emotion itself, and the attitudinal shifts that are expected to happen in response to the experience of awe are likely to be outside of conscious awareness thereby impacting only implicit attitudes and not explicit attitudes. since both dale et al. (2020) and this study used a prejudice scale measuring explicit attitudes, this may have led to insignificant effects of induced awe on prejudice reduction in both studies. using scales measuring explicit attitudes could have also led to inauthentic measurement of prejudice in both cases. specific to this study, another drawback of using an explicit scale for measuring agp is the assumption that people will explicitly express their prejudice, which does not always happen, because of social desirability reasons (steffens, 2005). crandall and eshleman’s (2003) ‘justification-suppression model’ for prejudice expression posits that because of suppression by social norms people do not directly express their genuine prejudices. when it comes to prejudice, what is felt and what is reported are two different things. implicit measures like the implicit association test (iat) are rarely used in sexual prejudice research, but may provide more accurate results (banse et al., 2001). in an experiment, banse et al. (2001) conducted among 79 german students, attitudes towards gays and lesbians were tested using both an explicit scale and an iat adapted from greenwald et al. (1998). this study found that participants faked explicit attitudes (which were very positive) but could not fake implicit attitudes (which were relatively negative). in another study, coffman et al. (2016) found that widely used explicit measures of anti-gay sentiments produce significant underestimation in existing surveys because of social desirability, even when responses are private and anonymized. coffman et al. (2016) conducted an experiment where 2,516 u.s. participants were randomly assigned to either a “best practices method” that was computer-based and provided privacy and anonymity, or to a veiled elicitation method that provided even more anonymity since it did not allow inference of any answer to any individual but could be used to accurately estimate statistics about the population. the results showed that the veiled method increased the rates of anti-gay sentiment substantially. respondents were 67% more likely to express disapproval of an openly gay manager at work and 71% more likely to say it is okay can induced awe reduce anti-gay prejudice? 70 gupta & hamlin to discriminate against lesbian, gay, or bisexual individuals. this could explain why attitudes towards homosexuals, as assessed with an explicit questionnaire in this study, showed higher than expected favourable results. this study’s findings could also imply that the nature of awe-inducing stimuli used in this study might not have been potent enough or directly relevant to the domain of effecting changes in sexual prejudicial attitudes. according to shiota et al. (2007), approximately half of all awe experiences arise in response to awe-inspiring virtuous or magnanimous actions of people of high stature and the next largest category of awe elicitors is nature. our elicitors of awe were quite mild and included images only in the domain of nature. this raises the questions of whether more intense elicitors of awe (like in-vivo or virtual reality experiences of awe through immersion in nature) or awe elicitors that were more directly related to the domain of prejudice (like speeches of inspiring public figures or virtuous individuals within a community) could be more effective in reduction of sexual prejudice. the finding that nfc did not have a causal effect on agp is contrary to soenen et al. (2005), who found a significant correlation between these two constructs. a point of difference between these studies that could explain the unexpected results for the second hypothesis, is that the present study was done online, while soenen et al.’s (2005) studies were conducted in-person. according to krosnick (1991), some respondents take a shortcut to providing answers in a self-report questionnaire engaging in ‘satisficing’ behaviours like response non-differentiation, random responding, and speeding. these ‘satisficing’ behaviours are more prominent in online studies because of the ease of responding and lack of a sense of accountability because there is no supervision (heerwegh & loosveldt, 2008). it is possible that due to the online mode of conducting this study, the respondents showed higher ‘satisficing’ behaviours in their responses that led to measurement errors for agp (fricker et al., 2005). another reason for nfc not showing a main effect on agp could be related to the individual differences in sdo and rwa levels for the participants. soenen et al. (2005) found that homophobia had a stronger correlation with rwa than with sdo, and van hiel et al. (2004) found a positive effect of nfc on racial prejudice that was fully mediated by rwa but not sdo. a practical implication of van hiel et al.’s (2004) findings is that the interventions aimed at reducing nfc could potentially reduce racial (and other forms of) prejudice by reducing the rwa levels, but would not be successful in reducing sdo levels; therefore, their impact would be substantial in individuals with high rwa but not significant in those with high sdo. while the present study’s scope did not include the measurement of rwa and sdo levels in participants, it is possible that more participants with high nfc in this study had high sdo levels (and not high rwa levels), which is probably why nfc did not show the expected effect on agp. the finding that there was no interaction effect of awe and nfc on agp was contrary to dhont et al. (2011), where they found that nfc moderates the relationship between intergroup contact and racial prejudice. this contradiction could be because inter-group contact and awe work differently as prejudice-reducing interventions while awe is a self-transcendent positive emotion that works through self-diminishment and humility (shiota et al., 2007), intergroup contact works through reducing negative emotions of anxiety and fear about outgroups (pettigrew & tropp, 2008). alternatively, it could be because racial prejudice has a higher correlation with nfc than sexual prejudice does with nfc (soenen et al., 2005). the results of this study had several implications. first, these results showed that the inducement of awe does not result in sexual prejudicial attitude changes at an explicit level (dale et al., 2020). second, these results suggested that factors beyond nfc (like rwa and sdo) may influence the effectiveness of awe-based interventions in reducing prejudice. and lastly, the nonsignificant results raised questions about the conditions under which awe might be effective in reducing sexual prejudice. limitations this study had the following limitations. firstly, like most research on sexual prejudice (bartos et al., 2014) this study too used a standardised self-report sexual prejudice scale measuring explicit attitudes towards homosexuals. as discussed above, this could have led to inauthentic reporting of agp. dasgupta and hunsinger (2008) noted that limited resources are the main reasons for performing online research on convenience samples, as was the case with the present study too. the second limitation of this study was employing a convenience sample that heavily skewed the 71 can induced awe reduce anti-gay prejudice? demographics in favour of younger female students who, as discussed earlier, are less sexually prejudiced than the general population. thirdly, this study used an online delivery mode that could have led to measurement errors. fourthly, this study used a mild elicitor of awe in the domain of nature, not directly related to the domain of prejudice reduction. lastly, this study did not consider the mediating roles that rwa and sdo could play on the effect of nfc on agp. future research should consider making the following methodological modifications. first, use implicit measures like the iat used by banse et al. (2001) or veiled elicitation methods used by coffman et al. (2016) to achieve a more ‘authentic’ assessment of agp. second, recruit a purposive sample to achieve more representative quotas for age, gender, and occupation to diminish the sampling bias (bethlehem & stoop, 2007). third, conduct the study in an in-person laboratory setting instead of online to minimize measurement errors. fourth, either use more potent elicitors of awe like an in-vivo or a virtual reality experience of awe in nature, or use awe stimuli like awe-inspiring speeches of virtuous individuals of stature, which would be in the domain of prejudice reduction. fifth, measure the rwa and sdo levels in participants and assess the meditation effects of rwa and sdo variables on the impact of nfc on agp. conclusion in conclusion, this experimental study aimed to test if high nfc individuals show higher anti-gay prejudice, if induced awe can reduce anti-gay prejudice, and if it can do so more in prejudice prone (high nfc) individuals. while the results did not support any of the hypotheses, this study’s findings contribute to the ongoing debate about whether and under what conditions prejudice can be reduced via induced awe in high nfc individuals. while some studies have shown awe to change prejudicial attitudes at an explicit level, some, including this study, have suggested that it does so only at an implicit level. some studies have shown that mild awe elicitors like awe-inspiring nature videos are effective in attitude change, while some others including this study, posit that more potent elicitors of awe are required. some studies have found that high nfc is linked to high levels of sexual prejudice, whereas some others have found that this relationship is more strongly mediated by rwa and not so much by sdo. the potential for this line of research continues to hold. future research with suitable methodological changes is recommended. such suggested changes are: using implicit measures or veiled elicitation methods for authentic measurement of agp, employing more potent elicitors of awe, assessing the mediating role of rwa and sdo on the effect of induced awe on sexual prejudice reduction, recruiting a purposive sample that is more representative of the general population, and conducting an in-person study instead of an online study to reduce measurement errors. references adorno, t. w., frenkel-brunswik, e., levinson, d. j., & sanford, r. n. 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(2021). the effect of awe on natural risk-taking prefer-ences: the role of need for closure. current psychology. 1-15. https://doi.org/10.1007/s12144-021-01758-9. 75 can induced awe reduce anti-gay prejudice? table 1 anti-gay prejudice (agp) scores across emotion stimulus and need for closure (nfc) 76 table 2 elicited awe scores across emotion stimulus gupta & hamlin 4040 teaching with purpose: how calling buffers burnout’s impact on teacher behaviors alexsis h. davis, catrina notari, & jessica j. sim department of psychology, elmhurst university research consistently demonstrates that burnout is related to more counterproductive work behaviors (cwbs) and fewer organizational citizenship behaviors (ocbs). nonetheless, there is limited research on the relationship between calling orientation (a sense of purpose and passion for one’s work) and the behavioral outcomes of burnout, particularly within the context of teachers in the united states. the current cross-sectional study seeks to address this gap by investigating whether teachers’ sense of calling moderates the relationship between burnout and both cwbs and ocbs. a total of 108 kindergarten to 12th grade (k-12) teachers were recruited via prolific to participate in an online survey. participants answered questions about their calling orientation, burnout levels, cwbs, and ocbs. we hypothesized that burnout would be positively associated with cwbs and negatively associated with ocbs, and that a strong calling orientation would buffer these relationships. the survey results supported the prediction that teachers experiencing high levels of overall burnout were more likely to engage in cwbs. importantly, teachers with a strong sense of calling were less likely to engage in cwbs, even when experiencing reduced personal accomplishment. contrary to expectations, overall burnout was not associated with ocbs, nor did it interact with calling orientation to predict ocbs. the findings suggest that fostering a sense of calling could help minimize cwbs and enhance teachers’ commitment to their work. future research should explore how teacher recognition, professional development opportunities, and interventions that promote purpose or meaning can further support teacher well-being and reduce cwbs. keywords: burnout, calling orientation, counterproductive work behaviors, organizational citizenship behaviors, teaching burnout is a pervasive issue in the workplace and a key topic in industrial-organizational psychology (maslach et al., 2001). burnout is detrimental to individual well-being and costly for businesses, with organizations losing $120 to $190 billion usd annually due to burnout and employee stress (weiss, 2020). to address this issue, the present research explores whether a calling orientation—a sense of purpose and passion for one’s work (wrzesniewski et al., 1997)—buffers the effects of high levels of burnout prevalent among teachers (marken & agrawal, 2022). despite extensive research on burnout, a notable gap remains in the literature regarding the moderating role of calling orientation in the relationship between burnout and engagement in counterproductive work behaviors (cwbs) and organizational citizenship behaviors (ocbs)— actions that harm and benefit an organization, respectively (schnake, 1991; spector et al., 2006). by understanding this relationship, organizations, and educational institutions can better tailor interventions to mitigate the consequences of burnout and foster more resilient and engaged workers. burnout and its consequences burnout is a multidimensional concept comprised of emotional exhaustion, depersonalization, and reduced personal accomplishment (maslach et al., 2001). emotional exhaustion refers to feelings of being overextended and drained of one’s emotional and physical resources. the second dimension of burnout is depersonalization, which refers to negative, callous, and detached behaviors. the last dimension of burnout is reduced personal accomplishment, which is a sense of reduced self-efficacy or accomplishment. all three dimensions are responses to prolonged exposure to job stressors (maslach & leiter, 2008). employees who are burned out are more likely to engage in counterproductive work behaviors (cwbs) and less likely to engage in organizational citizenship behaviors (ocbs; turek, 2020). cwbs are a set of actions or conscious decisions intended to harm the organization and/or the organization’s stakeholders (spector et al., 2006). these include abuse, production deviance, sabotage, theft, and withdrawal. in the context of teaching, examples of teacher cwbs could include absenteeism, misusing resources, plagiarism, and overall lack of caring for their students. cwbs are costly to organizations and hurt morale. given that cwbs and burnout are strongly linked (liang & hsieh, 2007), it is crucial for organizations to prevent burnout among their employees as this may not only reduce cwbs but may also increase ocbs (turek, 2020). ocbs and cwbs are often viewed as opposites, as cwbs hurt the organization while ocbs benefit it (dalal, 2005). therefore, it is advantageous for organizations to encourage ocbs, as these behaviors benefit the organization without incurring additional costs. graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 41 davis, notari, & sim ocbs are defined as behaviors that are not formally required by a particular job but are desired by the organization, such as punctuality, helping others on work-related issues, and volunteering (schnake, 1991). these behaviors can be directed toward the organization or coworkers (spector et al., 2010). in the context of teaching, ocbs are vital not only to the educational institution but also to its students. examples of teacher ocbs include volunteering for extracurricular activities or paying for their own school supplies. despite not being part of the job description, these behaviors are typically expected from those in the teaching profession (litvinov, 2023). however, research indicates that burnout reduces engagement in ocbs (turek, 2020). combating teacher burnout teachers are burning out at an increased rate (pressley, 2021). widely used to understand teacher burnout, the job demands-resources model argues that burnout occurs when the demands of the job outweigh the available resources (bakker & demerouti, 2014; van droogenbroeck et al., 2021). common sources of stress include teaching unmotivated students, maintaining classroom discipline, confronting time pressures and workload demands, exposure to significant changes, evaluations by others, difficult relationships with colleagues, administration or management, and poor working conditions (kyriacou, 2001). reports suggest that teachers in the united states experience reduced autonomy in the classroom, along with declining levels of support from administrators and school districts (walker, 2016). the growing emphasis on standardized testing, coupled with recent political scrutiny of curricula, has further limited teachers’ ability to make decisions about classroom management and instructional strategies (heubeck, 2023; stanford, 2023). research suggests that teachers can combat burnout by reducing job demands and increasing job resources. one way to do this is through job crafting (wrzesniewski & dutton, 2001), which allows teachers to customize their work environment to align with their skills, preferences, and values. this proactive approach helps buffer against burnout by promoting autonomy, fostering resilience, and enabling teachers to navigate challenges while preserving their sense of meaning and purpose (van wingerden & poell, 2019). another approach is through perceived organizational support (eisenberger et al., 1986). the negative effects of burnout are mitigated when employees perceive that their organization values their contributions and prioritizes their well-being (turek, 2020). this support can come from various sources, such as the school district or administration, through measures such as open communication channels and formal recognition programs (e.g., hsieh et al., 2022). teacher calling orientation given the documented decrease in autonomy and organizational support, we examine the role of personal resources in alleviating the negative effects of burnout. specifically, the current research investigates teachers’ sense of calling as a potential protective factor against burnout. teaching is one of the top three professions at high risk for burnout alongside human services and health care (maslach & goldberg, 1998). notably, the common thread among these jobs is that they are socially valuable and fueled by workers’ fulfillment. socially valuable and fulfilling jobs are the two most important requirements for a calling orientation (wrzesniewski et al., 1997). a calling is work that people feel true passion for and that brings a sense of fulfillment. calling orientation refers to someone who feels called to do the work they do. in contrast to a calling, individuals can view their work as a job or career (wrzesniewski et al., 1997). a job provides financial support and is based on necessity rather than passion. as such, it is not considered a major part of their life. although a career could involve some passion for one’s work, the main goal is to advance within the field. teaching is often thought of as a calling position due to its social value and potential to bring a deep sense of fulfillment. however, a calling orientation can be a double-edged sword. people who are driven by a passion for their work often encounter occupational hazards. for teachers, these occupational hazards may be physical or psychological, including workplace violence, disease transmission, and false accusations (berlanda et al., 2019). furthermore, teachers are often not well-compensated. nevertheless, teachers commonly enter the profession because they feel a calling to inspire and shape young minds rather than being motivated by the expected payout (national society of high school scholars, 2020). due to these conditions, passion can lead to increased rates of burnout (vallerand et al., 2003). since teaching is an occupation at high risk for burnout— leading to more cwbs and fewer 42 calling on burnout, cwb, and ocb ocbs— it is critical to explore these relationships. one key objective of education is to develop knowledgeable individuals who can contribute to society. faced with rising teacher shortages (schmitt & decourcy, 2022) and high turnover (carver-thomas & darling-hammond, 2017), schools may hire unqualified teachers, increase class sizes, or cut programs, harming student learning. therefore, school administrators should nurture and recognize teachers’ sense of calling, as this ultimately benefits the workplace. even when burned out, teachers with a strong sense of calling are less likely to engage in cwbs. present research interestingly, much of the work on the behavioral outcomes of teacher burnout has been conducted outside of the united states (e.g., kassandrinou et al., 2023). for example, a study conducted with both private and public school teachers in pakistan found correlations between the different dimensions of burnout and cwbs (makhdoom et al, 2019). however, the applicability of these findings may be limited, as teachers in the united states work longer hours than teachers in other countries, are paid less than their college-educated counterparts, and have experienced a steady and steep decline in wages over the past three decades (schmitt & decourcy, 2022). furthermore, there is little existing literature on the impact of teacher’s calling orientation. two separate studies conducted in china suggest that calling orientation may be a protective factor against burnout for university teachers (lian et al., 2021) as well as for kindergarten, primary, secondary, and high school teachers (zhao et al., 2022). however, neither of these studies directly examined cwbs or ocbs. the present research aims to bridge this research gap by examining the impact of calling orientation on the behavioral outcomes of burnout among teachers in the united states. teachers are subjected to numerous stressors in their jobs, which contribute to their high burnout rate (maslach et al., 2001). as described above, employees who experience burnout are more likely to engage in cwbs and less likely to engage in ocbs (turek, 2020). to address this issue, the current study explores whether teachers’ level of calling orientation moderates the impact of burnout (duffy et al., 2016). specifically, we hypothesize that calling orientation helps buffer educators from the negative effects of burnout. in the current study, we surveyed teachers across the united states to assess their calling orientation, burnout, and engagement in cwbs and ocbs, using a self-report survey with a cross-sectional design. consistent with past research, we predict that teacher burnout will be associated with more cwbs and fewer ocbs, particularly among teachers with a low calling orientation. in contrast, we predict that teachers with a high calling orientation will be protected from the negative effects of burnout, which will result in fewer cwbs and more ocbs. in summary, we expect higher levels of burnout to be positively associated with counterproductive work behaviors (cwbs) and negatively associated with organizational citizenship behaviors (ocbs). additionally, we propose that calling orientation will interact with burnout to predict both cwbs and ocbs. method participants participants were recruited from prolific, an online research platform known for providing higher-quality data and more diverse participant samples compared to other common recruitment methods, such as amazon’s mechanical turk (tang et al., 2022). prolific participants typically outperform those on other platforms in terms of comprehension, attention, and honesty (peer et al., 2017). prolific’s pre-screeners ensured that participants were kindergarten to 12th grade (k-12) teachers in the united states. the final sample consisted of 108 teachers (38% male, 58.3% female, and 3.7% non-binary). participants ranged in age from 23 to 78 years old (m = 38.38, sd = 11.64). the sample consisted of 83.3% white or european-american, 5.6% hispanic, latinx, or spanish origin, 3.7% black or african-american, 3.7% asian or asian-american, 0.9% native american or alaska native, 0.9% native hawaiian or other pacific islander, and 1.9% other. participants’ length of tenure ranged from 1 year to 37 years (m = 10.04 years, sd = 6.76). procedure after providing informed consent, participants completed four measures through a qualtrics survey: calling orientation, burnout, counterproductive work behaviors, and organizational citizenship behaviors, followed by demographic questions on age, gender, race/ethnicity, and tenure. the measures were presented in a fixed order, with items randomized within each scale. partic43 davis, notari, & sim ipants were compensated two dollars for their time. measures calling orientation to determine each teacher’s level of calling, participants completed dik et al.’s (2012) brief calling scale. this scale consists of four questions that ask participants if they have found their calling or if they are searching for their calling. since we were interested in the general presence or search for a calling, we chose the brief calling scale, which also helped minimize participant fatigue (dik et al., 2012). sample items include, “i have a calling to a particular kind of work,” and “i am trying to figure out my calling in my career (reverse coded).” participants rated their agreement with each statement on a 1 (not at all true of me) to 5 (totally true of me) likert scale. the four items were averaged to determine participants’ overall level of calling (α =.79). burnout to measure burnout, participants completed the maslach burnout inventory-educator survey. the maslach burnout inventory has been validated and shown to be reliable across a wide range of settings and populations (maslach et al., 1997). the 22-item inventory measures the three dimensions of burnout. sample items include, “i feel emotionally drained by my work” and “i feel very energetic (reverse coded).” participants responded to each statement using a 0 (never) to 6 (every day) likert scale. the 22 items were averaged to determine participants’ overall level of burnout (α = .93). we also calculated the scores for the three dimensions of burnout. emotional exhaustion. we computed the average score across the nine corresponding items to determine participants’ level of emotional exhaustion (α = .95). depersonalization. we computed the average score across the five corresponding items to determine participants’ level of depersonalization (α = .76). reduced personal accomplishment. we computed the average score across the eight corresponding items to determine participants’ level of reduced personal accomplishment (α= .86). counterproductive work behaviors to measure engagement in cwbs, participants completed the 10-item counterproductive work behaviors checklist, which includes an equal number of organizationand person-focused items (spector et al., 2010). the short form was selected to reduce time and response burden, while also aligning with the ocb measure. sample items include, “ignored someone at work” and “came to work late without permission.” participants responded to each statement using a 1 (never) to 5 (every day) likert scale. the 10 items were averaged to determine participants’ level of engagement in cwbs (α = .79). organizational citizenship behaviors to measure engagement in ocbs, participants completed the 10-item organizational citizenship behaviors checklist (spector et al., 2010). the short form is parallel in structure to the cwb measure and was also chosen to minimize participant fatigue. sample items include, “volunteered for extra work assignments” and “lent a compassionate ear when someone at work had a work problem.” participants responded to each statement using a 1 (never) to 5 (every day) likert scale. the 10 items were averaged to determine participants’ level of engagement in ocbs (α = .88). demographics participants provided demographic information at the end of the survey, including age, gender, race/ethnicity, and tenure in their current teaching position. age was reported in years using a free-response field. gender was reported in response to the question, “what is your gender?” with four options: male, female, non-binary, and other (with a request to specify). race/ethnicity was reported in response to the question, “what is your race/ethnicity?” with the following options: white or european-american, black or african-american, asian or asian-american, hispanic, latinx or spanish origin, native american or alaska native, native hawaiian or other pacific islander, and other (with a request to specify). tenure was reported in response to the question, “how many years have you worked in this role?” with a free-response field. analytical approach responses were analyzed using separate multiple linear regressions for cwbs and ocbs. multiple linear regression analyses were conducted to assess the strength and direction of continuous predictor variables (american psychological association, 2018). specifically, calling was examined as a moderator of the relationship between burnout and both cwbs and ocbs. each set of behaviors was predicted from mean-centered burnout, mean-centered calling, and their interaction, with significant interactions followed up with simple slopes analyses at high and low levels of calling. additionally, exploratory analyses were performed to examine the role of each of 44 calling on burnout, cwb, and ocb the three dimensions of burnout on cwbs and ocbs (bernhard, 2006; van droogenbroeck et al., 2021). results descriptive statistics and the interrelations among all the study variables are presented in table 1. counterproductive work behavior overall burnout the variables accounted for 17% of the variance in cwbs (r2 = .17, f(3,104) = 6.98, p < .001). as predicted, burnout was associated with more cwbs (b = .12, t(104) = 2.60, p = .01). however, calling was not associated with cwbs (b = -.07, t(104) = -1.38, p = .17). additionally, the interaction between burnout and calling was not significant (b = -.06, t(104) = -1.46, p = .15), which might suggest that calling orientation does not moderate the effect of burnout on cwbs. for exploratory purposes, we repeated the same analysis with each of the three dimensions of burnout. emotional exhaustion. the variables accounted for 12% of the variance in cwbs (r2 = .12, f(3,104) = 4.21, p < .01). emotional exhaustion was not associated with cwbs (b = .04, t(104) = 1.41, p = .16). however, calling was associated with fewer cwbs (b = -.12, t(104) = -2.40 p = .02). the interaction between emotional exhaustion and calling was not significant (b = .001, t(104) = .05, p = .96), which indicates that the effect of calling on cwbs is not dependent on levels of emotional exhaustion. depersonalization. the variables accounted for 19% of the variance in cwbs (r2 = .19, f(3,104) = 8.34, p < .001). depersonalization was associated with more cwbs (b = .10, t(104) = 2.95, p < .01). additionally, calling was associated with fewer cwbs (b = -.10, t(104) = -2.20, p = .03). however, the interaction between depersonalization and calling was not significant (b = -.05, t(104) = -1.56, p = .12), which suggests that calling orientation does not moderate the effect of depersonalization on cwbs. reduced personal accomplishment. the variables accounted for 17% of the variance in cwbs (r2 = .17, f(3,104) = 6.94, p < .001). reduced personal accomplishment was not associated with cwbs (b = .07, t(104) = 1.27, p = .21). however, calling was associated with fewer cwbs (b = -.11, t(104) = -2.16, p = .03). additionally, the interaction between reduced personal accomplishment and calling was significant (b = -.11, t(104) = -2.27, p = .03). simple slopes for the relationship between reduced personal accomplishment and cwbs were tested at low (one standard deviation below the mean) and high (one standard deviation above the mean) levels of calling. at low levels of calling, there was a positive relationship between reduced personal accomplishment and cwbs (b = .17, t(104) = 2.67, p = .009). however, at high levels of calling the relationship was no longer significant (b = -.04, t(104) = -.54, p = .59). the results demonstrate that high levels of calling may buffer against the negative effects of reduced levels of personal accomplishment on cwbs (see figure 1). organizational citizenship behaviors overall burnout the model did not account for significant variance in ocbs (r2 = .04, f(3,104) = 1.54, p = .21). contrary to predictions, the results indicated that burnout was not associated with ocbs (b = .01, t(104) = .13, p = .90). similarly, the relationship between calling and ocbs did not reach conventional levels of statistical significance (b = .16, t(104) = 1.83, p = .07). the interaction between burnout and calling was also not significant (b = -.03, t(104) = -.43, p = .67), which might suggest that calling orientation does not moderate the effect of burnout on ocbs. for exploratory purposes, we repeated the same analysis with each of the three dimensions of burnout. emotional exhaustion. the model did not account for significant variance in ocbs (r2 = .06, f(3,104) = 2.05, p = .12). emotional exhaustion was not associated with ocbs (b = .07, t(104) = 1.28, p = .21). however, calling was associated with more ocbs (b = .21, t(104) = 2.48, p = .02). the interaction between emotional exhaustion and calling was not significant (b = -.02, t(104) = -.37, p = .71), which indicates that the effect of calling on ocbs is not dependent on the level of emotional exhaustion. depersonalization. the variables accounted for 8% of the variance in ocbs (r2 = .08, f(3,104) = 2.97, p = .04). depersonalization was not associated with ocbs (b = .06, t(104) = 1.11, p = .27). however, calling was associated with more ocbs (b = .20, t(104) = 2.60, p = .01). the interaction between depersonalization and calling did not reach conventional levels of significance (b = -.10, t(104) = -1.71, p = .09), which indicates that the effect of calling on ocbs is not dependent on the level of depersonalization. reduced personal accomplishment. the vari45 davis, notari, & sim ables accounted for 14% of the variance in ocbs (r2= .14, f(3,104) = 5.61, p < .01). reduced personal accomplishment was associated with fewer ocbs (b = -.28, t(104) = -3.41, p < .001). however, calling was not associated with ocbs (b = -.003, t(104) = -.04, p = .97). additionally, the interaction between reduced personal accomplishment and calling was not significant (b = .002, t(104) = .03, p = .98), which suggests that calling orientation does not moderate the effect of reduced personal accomplishment on ocbs. discussion while there is extensive research on burnout, cwbs, ocbs, and calling orientation separately, there is little research that integrates the four concepts, especially in samples of american teachers. the current study investigated the relationship between calling, burnout, cwbs, and ocbs among k-12 teachers. consistent with predictions, teachers who experience greater overall burnout engaged in more cwbs. this effect may be explained by levels of depersonalization, as teachers who felt more depersonalized engaged in more cwbs. contrary to predictions, overall burnout was not associated with ocbs, although exploratory analyses revealed a significant relationship between reduced personal accomplishment and ocbs. although not explicitly hypothesized, exploratory analyses also revealed that calling was associated with more ocbs when the dimensions of emotional exhaustion or depersonalization were analyzed in place of overall burnout. although we did not find strong evidence for the moderating effect of calling on the relationship between overall burnout and cwbs and ocbs, exploratory analyses of the three burnout dimensions provided partial support for this moderating relationship, particularly between reduced personal accomplishment and cwbs. at low levels of calling, reduced personal accomplishment was associated with more cwbs. however, at high levels of calling, the relationship was no longer significant. the results suggest that even when faced with feelings of incompetence or a lack of achievement and productivity, having a calling orientation can act as a buffer against the negative effects on cwbs. stated simply, individuals who are deeply committed to their profession are less likely to exhibit behaviors that harm their organization and its stakeholders even during times of self-doubt or feelings of inadequacy. these findings highlight the potential protective role of calling orientation in mitigating the adverse effects of reduced personal accomplishment, ultimately fostering a more positive and productive work environment among educators. limitations and future directions we did not find strong support for our predictions, which may be due to several limitations that future research could address. first, some of the established measures used were short versions, and both the ocb and cwb scales were domain-general, rather than specifically designed for educators (e.g., many items assessed behaviors towards coworkers rather than students). future research could develop more domain-specific scales to better capture counterproductive and extra-role behaviors in teaching, directed at both students as well as coworkers. additionally, using the full-length versions of these scales may provide more nuanced insights. second, we combined different types of educators to achieve an adequate sample size. as a result, the findings may have masked challenges that are unique to specific contexts (e.g., school districts, grade levels, teacher education levels). future research could include interviews with teachers to gather more qualitative insights into their work environments, offering richer data beyond what a survey alone can provide. third, our sample size was limited by the constraints of the prolific platform, which had a small pool of active k-12 teachers. future research could employ snowball sampling to recruit a larger and more representative sample of teachers. this approach could also improve generalizability, as financially stable educators may be less likely to participate in online crowdsourcing platforms offering low monetary incentives. additionally, the sample may have excluded teachers who left the profession due to extreme burnout, potentially introducing bias by omitting the perspectives of those most affected. finally, the current study used a cross-sectional design, limiting the ability to draw causal conclusions. additionally, all our measures relied on self-report, which could introduce common method bias and may have been influenced by social desirability. future research could address this limitation by incorporating ratings from supervisors or peers alongside self-report data. a longitudinal approach would also be valuable to examine how burnout and a sense of calling evolve over time, and 46 calling on burnout, cwb, and ocb to assess their long-term effects on ocbs and cwbs. theoretical implications in the current research, we focus on calling orientation, particularly among educators. the findings have the potential to inform multiple areas of research, with several opportunities for future studies on this topic, given the gap in the literature. teaching is often intertwined with a sense of calling, which is associated with deep passion and internal motivation. while some research exists on the positive effects of calling orientation for teachers, most of these studies have been conducted outside the united states (lian et al., 2021; zhao et al., 2022). the present study highlights the relationship between reduced personal accomplishment, calling, and cwbs. specifically, teachers who experience a strong sense of calling may be less likely to engage in cwbs, even when faced with a sense of reduced personal accomplishment. at the same time, past research suggests that such passion can be exploited by organizations or supervisors, potentially leading to increased workloads and higher burnout (kim et al., 2020). therefore, we encourage researchers to examine both the beneficial and detrimental effects of a calling orientation (e.g., cardador & caza, 2012). future research could explore similar relationships in other calling-oriented professions and further investigate the interplay between calling orientation, burnout, and engagement in cwbs and ocbs. practical implications teachers regularly report being underpaid, overworked, and underappreciated. educational institutions may attempt to address teacher burnout by identifying the stressors or reducing the strains of teaching (e.g., stress management workshops or fitness programs). as mentioned earlier, the job demands-resources model can be used to explain teacher burnout. to reduce cwbs and promote ocbs, organizations may attempt to balance the job demands and/or job resources. however, the demands and resources may not always be amenable to change. for instance, the covid-19 pandemic presented a formidable challenge for educators, and teacher pay in the united states continues to remain low (marken & agrawal, 2022). the current study introduces an alternative way for organizations to minimize the negative effects of burnout on the workplace by focusing on personal resources. to foster a calling orientation, administrators could invest in teacher recognition or professional development opportunities to actively engage teachers in their profession, or they could introduce interventions that focus on developing a teacher’s sense of purpose and meaning (e.g., hackman & oldham, 1976). our results suggest that educators with a strong sense of calling are less likely to engage in cwbs, even when experiencing feelings of reduced personal accomplishment. therefore, it is crucial to foster educators’ sense of calling to minimize engagement in cwbs and promote sustained engagement and commitment to their work. together, these strategies would help teachers reconnect with their sense of purpose in the profession, while also supporting their physical, mental, and emotional well-being. building on these findings, fostering a sense of calling in educators could strengthen their resilience and long-term commitment to the teaching profession. connecting teachers to their sense of purpose may also improve the overall school climate and culture. even in the face of burnout, teachers with a strong sense of calling are more likely to maintain professionalism and avoid behaviors that could disrupt students and staff. more practically, reigniting this passion could help reduce teacher attrition and further boost workplace engagement. conclusion research indicates that teachers face numerous stressors and are increasingly experiencing burnout (pressley, 2021). this study found that teachers’ sense of calling appeared to act as a buffer, mitigating the negative effects of reduced personal accomplishment on cwbs. these results suggest that a calling orientation may serve as a protective mechanism against burnout, emphasizing the importance of nurturing teachers’ sense of purpose. these insights not only benefit student outcomes but also contribute to the overall well-being of educational institutions. references american psychological association. 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(2022). teacher career calling reduces burnout: the mediation effects of work engagement and psychological capital. frontiers in psychology, 13, 1-8. https://doi. org/10.3389/fpsyg.2022.988467 50 note. *p < .05. **p < .01. calling on burnout, cwb, and ocb table 1 descriptive statistics and correlations for study variables 51 figure 1 moderating effect of calling on the relationship between reduced personal accomplishment and counterproductive work behaviors davis, notari, & sim 87 "where did all the lesbians go?" a content analysis of the sense of community within lesbian spaces on tiktok danielle shinbine1, meredith r. maroney2, emily c. coombs1&4, douglas, r. maisey1, and alayna fender3 1werklund school of education, university of calgary, canada 2department of counseling and school psychology, university of massachusetts boston, boston, ma, usa 3university of british columbia, vancouver, bc , canada 4faculty of education department of educational psychology, canada as physical lesbian spaces continue to diminish, platforms like tiktok have become essential for queer women seeking community. this study uses deductive content analysis, guided by mcmillan and chavis’ (1986) sense of community framework, to examine how membership, influence, fulfillment of needs, and shared emotional connection are expressed in these digital spaces. by analyzing the top 100 comments on two videos from 11 popular lesbian tiktok creators, whose followers range from 340 thousand to 9 million, the research explores how a sense of community is fostered online. a total of 22 videos were analyzed, with comments coded into key themes. the findings reveal how users express solidarity through mutual support and validation, often rooted in shared language and collective experiences unique to lesbian identity. commenters navigate issues such as relationships and societal marginalization, fostering a sense of belonging. however, tensions emerge as users grapple with inclusivity and representation, particularly around race, gender identity, and the evolving definition of lesbian identity. these discussions highlight both the unifying aspects of digital lesbian spaces and the challenges of ensuring diverse voices are heard. this research underscores tiktok’s evolving role in shaping lesbian identity and community, spotlighting both opportunities and challenges for fostering belonging. keywords: lesbian, tiktok, social media, community graduate student journal of psychology spring 2025 vol. 24 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university a sense of community is a critical component in facilitating well-being in lesbian, gay, bisexual, transgender, and queer + (lgbtq+) individuals (mclaren., 2009; meyer & frost, 2013). research in the past 20 years has highlighted the lgbtq+ community's ability to create a sense of community in virtual spaces (cavalcante, 2018; gorkemli, 2012; gross, 2003). most recently, the social media platform “tiktok” has appeared to resonate with the lgbtq+ community as a whole (hiebert & kortes-miller, 2023; simpson & seeman, 2020), and subgroups within the larger community, including the lesbian community (gray, 2018; hanmer, 2013). however, research examining how this subset of the lgbtq+ community uses social media to build a sense of community online is sparse and virtually nonexistent when examining tiktok. due to previous research establishing the importance of a sense of community for lgbtq+ individuals, as well as research indicating that the community as a whole can benefit from virtual spaces that produce an online sense of community, the present study aimed to identify how a sense of community is created by lesbians on tiktok. it has been well documented that the lgbtq+ community experiences higher frequencies of discrimination and victimization due to their lgbtq+ identity, contributing to higher frequencies of mental health concerns (hendricks & testa, 2012; meyer, 2003). resilience factors, such as a sense of community, have been identified as a buffer against these outcomes for the community (frost & meyer, 2012; mclaren et al., 2013) as well as enhance protective factors, such as social support and self-esteem (doyle & molix, 2014; petruzzella et al., 2019). a sense of community has been defined as “a feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members' needs will be met through their commitment to be together,” (mcmillan & chavis, 1986, p. 9). fostering a sense of community is important for lgbtq+ people, as it serves as an access point for both tangible and intangible resources (apa task force on psychological practice with sexual minority persons, 2021; de lira & de morais, 2018). connection to the lgbtq+ community and its culture also serves as a mechanism to facilitate identity development, with individuals claiming that the community’s support results in stronger identity development (closson & comeau, 2021; parmenter et al., 2020). however, the impact of a sense of community appears to vary depending on one’s sexual identity, with bisexual people reporting feeling a reduced sense of belonging when compared to lesbian and gay individuals, which may speak to experiencing biphobia within the larger lgbtq+ 88 where did all the lesbians go? community (kertzner et al., 2009; lambe et al., 2017), and suggests that the impact of a sense of community may vary across different sexual and gender identities. lesbians have actively contributed to facilitating community connectedness in the larger lgbtq+ community, specifically regarding their role in the contribution of blood donations amidst the hivaids epidemic during the 1980s (hutchison, 2015). although there is less research on lesbian and queer women, some research has found that a sense of community provides a buffer against adverse mental health outcomes and enhances protective factors for the lesbian community (busby et al., 2020; mclaren, 2009; mclaren & castillo, 2021; zimmerman et al., 2015). spaces exclusive to lesbians have been valued by the community, with lesbian bars being a cornerstone of lesbian culture and a facilitator of community connectedness (faderman, 1991). these spaces serve a dual purpose of being a place for in-person connection and the flourishing of lesbian identities while also providing a safe environment against potential discrimination from the larger community (brown-saracino, 2019; corteen, 2002; hankin, 2002; hartless, 2018). there has been a concerning trend of a diminishment of lesbian-specific spaces for the community to meet. in 2021, almost 200 lesbian bars shut down, with 20 remaining (compton, 2021). reasoning for these closures may speak to various changes, such as the covid-19 pandemic (rieger, 2020) and the undermining of women-specific spaces in the interest of appearing non-trans-exclusionary (stryker & bettcher, 2016). this is concerning when considering that lesbian bars have historically had either the lowest or second-lowest prevalence rate of all lgbtq+ bars, second only to bars catering to lgbtq+ poc (mattson, 2019). these closures leave the lesbian community to either gather in unwelcoming heterosexual spaces or try to integrate into lgbtq+ spaces dominated by white, cisgender gay men, with a recent study examining that the remaining 15 owners of lesbian or lgbtq+ bar in the usa do not prioritize female-only spaces (mattson, 2020). there is a sense of loss associated with this decrease in lesbian-specific spaces, with multiple documentaries and memorials being created by the community to represent this mourning (brown-saracino, 2020; clements, 2019; denny, 2015). moreover, physical spaces that facilitate a sense of community, such as lgbtq+ bars, have experienced high closure rates due to the covid-19 shutdown of businesses (mattson, 2023). the covid-19 pandemic’s impact on lgbtq+ spaces cannot be understated. scrogg and colleagues' (2020) examination of the impact of social distancing guidelines on lgbtq+ emerging adults revealed that the guidelines resulted in lower levels of hope and community connectedness as well as higher alcohol use. the pandemic also had a unique impact on lgbtq+ youth, as many noted that they were restricted to staying in home environments deemed unsafe to express their lgbtq+ identity (fish et al., 2020). these numbers have started to rebound as more lesbian bars reopen (glassman-hughes, 2023; hoeffer, 2023); however, they have not recovered to their numbers before the pandemic (mattson, 2023). these reductions of spaces for lesbians are concerning, as this loss of a sense of community leads lgbtq+ individuals to be more vulnerable to detrimental mental health outcomes as a result of minority stress due to being unable to benefit from the protective factors and buffers that a sense of community provides. the need and benefit of establishing spaces that form a sense of community online has been an endeavour that the lgbtq+ community has historically been invested in, with gross (2003) noting lgbtq+ individuals were pioneers in utilizing the internet to find community. for example, drag performers have utilized social media to replace in-person performances to combat isolation (rieger, 2020). virtual spaces which bring a sense of community have also been established in response to large-scale discrimination, as illustrated by one study which examined the impact of a virtual forum facilitating open discussion for lgbtq+ students following the 2016 orlando mass shooting, an event that has been understood as an lgbtq+ hate crime (jackson, 2017). students from this study noted that the form helped them receive support, disclose their distress associated with the event, and emotionally process the event. these attempts to connect online speak to the resilience and adaptability of the community, as well as the inherent importance of a sense of community. research indicates that lgbtq+ individuals use social media in several ways, including obtaining romantic connections and friendships (miller, 2015), accessing resources (mcinroy et al., 2019), 89 shinbine et al. and existing in accepting spaces they may not have in their offline lives (higa et al., 2014). in particular, online gay and lesbian associations have been cited as a source of activism, support, and a way to facilitate an online sense of community (gorkemli, 2012). there is a small body of research examining this phenomenon of internet usage in lesbian communities. however, these findings are promising, as multiple studies state that lesbians also find this sense of community online (gray, 2018; hanmer, 2013). burke’s (2000) study notes that personal advertisements online in the lesbian community facilitate connection and community engagement. burke suggests that the internet may be unique for lesbian community engagement, as this space may feel safer than a traditional lesbian bar. in recent research, lesbian social media content creators note that their audiences feel more connected and represented when the creators discuss their lesbian identity in their content (ladegaard, 2023). in recent years, “tiktok,” a social media application focused on video sharing, has gained increased usage (unni & weinstein, 2020) and has been identified as a space for lgbtq+ individuals to feel connected with their community (simpson & semaan, 2020). lgbtq+ youth note that during the covid-19 pandemic, tiktok was a powerful tool for managing family relations, facilitating lgbtq+ identity development and community belongingness, and sharing resources (hiebert & kortes-miller, 2023). similar to other online gay and lesbian communities, tiktok appears to have the potential to be a space for activism, possibly through its lgbtq+ oriented content being an inspiration for users to consider a future where discrimination against the community is eliminated (duguay, 2023). explorations on how lesbian and queer women use the platform are minimal; however, there is a small body of research suggesting that the platform can be used for identity expression and activism for this group, particularly through the presence of “sapphic pop” on the platform (mcewan, 2023) and the community label of “lesbian tiktok”. for the purposes of this study, "lesbian tiktok" is operationally defined as content and interactions on tiktok that specifically focus on lesbian identities, experiences, and issues, including videos created by and for lesbian individuals that promote community engagement, support, and activism. methods researcher reflexivity statement the research team was composed of several individuals with various backgrounds and experiences with the study’s subject matter. the first author identifies as a white, pansexual demigirl who was a first-year master’s student during the data collection process and served as a coder. the second author is a white, lesbian, cisgender woman who was an assistant professor and provided consultation and support with the methods and writing process. the third author identifies as a lesbian autistic woman, was also a first-year master’s student during the data collection and served as the first auditor of the project. the fourth author identifies as a queer indigenous person, was also a first-year master’s student, and served as a second coder. the final author is a white queer woman who was a social media consultant at the time of data collection. our team consisted of members with varying degrees of involvement with social media, with some members being frequent users of lgbtq+ tiktok in particular and others being more passive consumers of lgbtq+ social media in general. these varying engagement levels allowed the team to consult and review the data from multiple vantage points. we approached this study with a shared interest in the importance of a sense of community for lesbians, specifically exploring how social media can play a role in facilitating this sense of community. the research team extensively discussed how our experience with social media and the lgbtq+ community would impact the study. despite all researchers sharing an lgbtq+ identity, their experience with social media varied, specifically with tiktok. due to their first-hand experience of being lgbtq+ and engaging in social media, as well as their previous work examining the lgbtq+ community’s experience with social media, the first author approached the study with the belief that social media can function as a way for lesbians to obtain a sense of community. however, they also acknowledged that social media can also be a space for lgbtq+ content creators to experience discrimination from other users, which they remained cognizant of throughout the coding process. data sources the research team collected the top 100 comments on two videos from 11 popular lesbian tiktok content creators. these accounts predominantly featured 90 where did all the lesbians go? individual creators; however, two accounts featured lesbian couples who shared ownership of the account. during data collection, these videos had a subscriber range of 340 thousand to 9 million. there were no pre-established relationships between commenters, content creators, or the research team. however, one member was familiar with the content creators through their usage of tiktok, which helped inform the coding team of current events on the platform and provided context to certain comment sections. procedure prior to any data collection, the team received an exemption from the research ethics board for analyzing the comments due to all data being publicly available. the team’s criteria for the video was that (1) the video was made within the last year prior to analysis (from february 2022 to february 2023), and (2) the video directly addressed lesbian/queer women's experiences. the third author (primary auditor) then selected fifteen lesbian tiktok content creators by cross-referencing four online articles that listed popular lesbian influencers for review. then, the auditor looked up the creators to determine if their content met the aforementioned criteria. four creators from the original list were excluded from the analyses because their content did not meet the criteria or their account was removed from the platform, resulting in a final list of eleven content creators who produced content that met the study’s criteria. following this review, we identified a maximum of two videos from each content creator. in situations where more than two videos from the creator fit the criteria, the videos with the most comments were selected, based on rationale that these videos had the most user engagement. this resulted in a final 22 videos being analyzed by the coding team. we then extracted the top 100 comments pre-sorted by tiktok with comments with the most likes or responses using apify's tiktok comments scraper software program. the program scraped comments from tiktok videos, including comment text, user id, timestamp, number of replies, replies content, and number of likes. in instances where videos had fewer than 100 comments, all comments were extracted and analyzed on nvivo, a qualitative data analysis software. neither the content creators nor commenters were engaged at any point in the selection and collection process. analysis guiding theory the purpose of this study was to better understand how a sense of community is demonstrated on lesbian tiktok. while different theoretical models exist for conceptualizing community, we selected mcmillan and chavis’ (1986) sense of community framework due to its longstanding application in both offline and digital spaces. their model, which identifies four key components—membership, influence, integration and fulfillment of needs, and shared emotional connection—provided a structured foundation for analyzing community building in an online context. this framework has been widely applied to digital communities, including social media, online support groups, and virtual activism spaces, demonstrating its adaptability to non-traditional, technology-mediated interactions (blanchard, 2008; obst et al., 2002). prior research has shown that mcmillan and chavis’ model effectively captures how users express belonging and influence within online platforms, making it particularly relevant for examining tiktok’s role in fostering community among lesbian users (chen et al., 2013). the model's emphasis on shared emotional connection is especially applicable in digital spaces, where community members rely on text, video content, and interactive comment sections to build social bonds and validate identities (oh et al., 2014). recognizing the unique affordances of tiktok, including its algorithm-driven engagement and participatory culture, we adapted mcmillan and chavis’ framework to analyze how community manifests in this dynamic online space. the coding team conducted a close reading of mcmillan and chavis’ original article (1989), carefully aligning its four core components with observable user behaviours on tiktok. through a series of three iterative discussions, the research team refined the codebook to ensure that the framework adequately captured the nuances of online interaction, identity expression, and community-building behaviours specific to lesbian tiktok. deductive content analysis deductive content analysis (neuendorf, 2017) is a type of content analysis in which the coding framework originates from a theory, operationalizing the theory within the coding process (hsieh & shannon, 2005). deductive content analysis’ utility for the present study resides in its ability to analyze data on a previous91 shinbine et al. ly identified framework (elo & kyngäs, 2008). initially, the first auditor created a codebook of 22 potential subthemes based on mcmillan and chavis’ (1986) sense of community framework and a preliminary review of the data. during the coding process, the first auditor and two coders engaged in discussions to refine the definitions and applicability of the subthemes. through this iterative process, two additional subthemes emerged that were not fully captured by the original 22 subthemes. specifically, the team identified a need to differentiate between explicit expressions of identity affirmation and implicit forms of community validation, leading to the addition of the subthemes “identity affirmation” and “community rituals.” the final codebook consisted of 24 subthemes, reflecting a more nuanced representation of how users engaged with the content. additionally, comments where the intended meaning could not be determined—either due to language barriers or ambiguity in context—were categorized under a 25th code titled “unknown.” this ensured that un-codable data was systematically accounted for without forcing interpretations that could misrepresent user intent. after establishing the codebook and coding the videos, it was decided that comments could be coded two to five times to capture the nuances of the established subthemes. the two coders were then assigned different comment sections to code independently. in this process, the coders also used memoing to document and reflect on the process during each coding session, which helped inform several discussion points. upon finishing the coding, the auditor and two coders met to discuss the findings and the process, informing the initial results. methodological integrity perspective management in data collection was established through ongoing discussions between the coding team about how their own identities and perspectives may influence the analysis, maintaining awareness of these perspectives throughout the process. as recommended by levitt and colleagues (2018), we utilized memoing and engaged in extensive conversations before and during the analysis process. these conversations included establishing agreement on the codebook between the two coders and the auditor before analysis and reviewing all coding by the first auditor to ensure the codes aligned with the subthemes. while a formal interrater reliability check (e.g., cohen’s kappa) was not conducted, the research team took multiple steps to ensure coding consistency through these discussions and ongoing reflection. the second author, who served as a consultant, also suggested restructuring the findings. given the constructivist paradigm of this study, which emphasizes the co-construction of knowledge and subjective meaning-making, these changes significantly modified the results section to reduce the emphasis on the frequency of each subtheme. instead, they emphasized how the most common subthemes manifested in the comments. this restructuring was discussed extensively by the research team and was agreed upon as being best aligned with the study’s goal of better understanding how a sense of community is presented in lesbian tiktok content creators’ comment sections. results through the results, we identified codes aligning with each of the original four tenets established by mcmillan and chavis’ (1986) theory of a sense of community: membership, shared emotional connection, influence and integration, and fulfillment of needs. all subthemes in our codebook guided by this theory were identified in some capacity, with prominence varying greatly between subthemes. a total of 2,070 comments were coded. however, we elected to explain the most salient subthemes from each theme to illustrate better how commenters experienced more prominent subthemes of a sense of community. membership membership was exhibited through commenters' sense of belonging within the lesbian tiktok community and expressed feelings of belongingness. specific methods that commenters expressed this theme included users disclosing their own experiences, their investment in current events relevant to the lesbian community, and noting that they felt accepted by content creators and fellow commenters. to illustrate this, we selected three of the most salient subthemes that arose through our analysis: an investment of the self, shared importance of events and tasks, and emotional safety. investment the subtheme of investment of the self was presented through users expressing personal sentiments regarding their lesbian identity and lived experiences. in comments with this subtheme, users often provided insight into their own experiences of being a lesbian 92 where did all the lesbians go? and mentioned their struggles with coming out. these conversations were often extensions of the video content itself, with users contributing their narratives and similarities to the lesbian experiences that the videos highlighted as well as their attraction to the content creators. for example, one user mentioned their previous same-sex attraction before coming out with the comment, “haha! my friend and i would play house at 10yrs & my mom caught us kissing like parents do. she freaked! i didn’t get to play with her anymore after.” (averycyrusv1, reference 16). overall, this sub-theme reflected the relationship between user and creator experiences and their vulnerability in expressing these experiences online. this subtheme occurred 196 times and was found in 9.47% of all comments. shared importance of events and tasks the subtheme of shared importance of events and tasks was demonstrated through users expressing their sentiments regarding current topics of interest regarding popular topics amongst the lesbian community both on and off tiktok. relationship speculation was highlighted as an important topic for users. in particular, one creator, speculated to be in a relationship with another popular creator in the videos extracted during the analysis, resulted in many users discussing this rumoured relationship in their comment sections. this discussion was also had on the other content creator’s videos, with one user stating “it’s my favourite drama show....jojo, if u see this… we need u to stop for the sake of all lesbians...u know the lesbians are lesbianing too hard when king princess says so” (kingprincessofficial69v1) on a video that referenced this situation. this overlap of discussion across videos demonstrates how prevalent the shared importance of events and tasks relevant to the community is expressed throughout multiple creators’ videos. in total, the shared importance of events and tasks was mentioned in comments 132 times, making up 6.38% of comments. emotional safety emotional safety refers to the security that users felt and expressed within the comment sections explicitly. emotional safety consisted of the overt disclosure of the users in the comment sections feeling secure and a space for inclusion, which helped facilitate moments of investment by disclosing their personal experiences. one user expressed their adoration for a creator being a safe space for them by saying, “you’re such a safe person i love this.” another comment also addressed how they appreciated that a creator made a video about going no contact with family due to their lesbian identity as the content itself became a space to alleviate their isolation in the matter. they expressed this gratitude with the following comment: “i always have felt so uncomfortable about this topic and alone. this helps so much.” this sub-theme described the level of security that users felt when engaging with creators and other users on the platform. this subtheme often overlapped with the previous two subthemes, yet was distinct in that it facilitated users expressing themselves. in particular, emotional safety was intertwined with the level of comfort and vulnerability users stated when expressing their connection with creators and their content on tiktok. this sub-theme occurred 130 times, accounting for 6.28% of all comments. influence the key component of influence refers to the degree to which community members are able to impact and shape the community's decisions, activities, and outcomes. it reflects the extent of individual and collective power and control within the community. in the current dataset, influence was represented by members extrapolating their own lesbian/queer woman identity from the video content in the form of comments, expressing their own opinions and views within the context of the video, and meshing into the larger lesbian tiktok community by expressing the same sentiment as a larger theme of comments on the video. by doing this, users expressed personal sentiment and conformity to the video’s messages. the three most common themes identified included consensual validation, personal stake, and conformity. consensual validation the subtheme of consensual validation was displayed through members expressing validation or approval of the creator, which was not predatory in nature. some of these comments spoke to the physical appearance of the creator, such as “you look so cute, avery! hope you are doing well,” and “you are like a female young ralph macchio in the best way possible.” additionally, consensual validation was illustrated by the praise of users for the content creators’ relationships, with some comments stating, “you are a stunning beautiful gorgeous couple and very jealous off you both ,” and “all my love to you, you’re a beautiful soul with a beautiful partner. .” consensual validation in this 93 shinbine et al. context appeared to speak to approval of the “fit” of the couple, as well as their attractiveness to the commenters. consensual validation was identified 290 times, encompassing 14.01% of all comments. personal stake users depicted the subtheme of personal stake by expressing personal opinions of their investment and attraction to creators. one user expressed their attraction on a video with a creator mentioning that they would “spoil” the viewer if they were in a romantic relationship with them by stating, “i’m not spoiled, but i’d definitely get spoiled by you.” additionally, the deep commitment to the tiktok creators' lives was illustrated by the quote: “the courage you have shown has been such an inspiration to so many of us! life after no contact can be beautiful! thank you for proving that.” personal stake was also illustrated by creators expressing their own opinions regarding lesbian tiktok creator “drama.” one specific example of this iteration of personal stake was through the quote of one commenter who felt sympathy for one of the creators amidst the drama, stating: “it’s not funny she’s trying her best hopefully you don’t take this offensively but some things get hard so remember if you we’re in the situation and someone thought it was funny you wouldn’t be very thankful about that so just remember what you say can hurt someone but if they were to say to you you would really be hurt also don’t take this offensively i’m sorry just supporting” another user retorted to this comment with their personal opinion, stating, “no. you don’t get out of a two year relationship and go date someone else the week after….. i don’t care if you’re hurting, you don’t do that.” overall, users felt that they were valid in expressing their personal stake in the content creators’ lives through the comment sections of their videos. this subtheme was enlightening, as it demonstrated the vulnerability the community held in expressing their opinions associated with content creators on a public platform. this subtheme was seen 175 times, which reflected 8.45% of all comments. conformity the subtheme of conformity was often coded with the phenomenon of “atting(@)” oneself by saying, “this is totally me,” or “me.” these comments would include commenters announcing their conformity with the video’s content, suggesting that the video was a representation of themselves and their views. other comments would feature their conformity to the opinions within the comment section, with several members expressing similar sentiments. one example of this was a video containing a lesbian couple who falsely teased a pregnancy announcement to reaffirm their childfree status, with multiple commenters reaffirming the video by stating “you tell em!! your entitled your privacy and your own life outside of social media!” and “i understand where you’re coming from in wanting to be apart of their journey and we’ve all come to enjoy that yes...but everyone deserves privacy too.” overall, conformity was illustrated through the consensus of opinion displayed in each comment section and occurred 196 times, representing 9.47% of all comments. integration and fulfillment of needs the key component of integration and fulfillment of needs refers to the extent to which individuals feel a sense of belonging and connection within a community and the degree to which their social and psychological needs are met within that community. although the sub-themes of integration and fulfillment of needs were less prominent than the sub-themes exhibited throughout the other four themes, all sub-themes occurred at least once. this theme manifested through commenters expressing how the content has helped them become well-versed in topics relevant to the lesbian tiktok community and users expressing willingness to provide and accept support from other users or the creators in the comment sections. the three sub-themes that will be explained further include group and individual competence, need fulfillment, and mutual aid. group and individual competence this sub-theme encompasses commenters knowing relevant community-specific information. in the comment sections, group and individual competence were shown through users responding to current tiktok drama. for example, several users shared their knowledge and opinions associated with a relevant tiktok lesbian influencer couple who was experiencing controversy by saying “i mean the last 24 hours alone is enough to fill the 2022 drama quota. period.” and “i think they lesbian’d a little too close to the sun.” additionally, commenters also expressed that the content they consumed helped them maintain their insight of relevant news for the community on tiktok, with another commenter saying, “this is 94 where did all the lesbians go? pretty accurate and needed because i am in my mid20s and so busy with work to get the tea.” these comments highlight the inherent desire for users to stay connected to culturally relevant events, such as influencer drama, as well as express their opinions surrounding these recent events. this subtheme was identified 99 times, making up 4.78% of all comments. need fulfillment the sub-theme of need fulfillment was exhibited, with commenters expressing how the content consumed benefited them. examples include expressions of what content engagement means to the commenter, such as “i’m following u because im inspired and that’s it.. idc about your marriage or relationship.” users also expressed gratitude for the content, as one user said, “i always have felt so uncomfortable about this topic and alone. this helps so much. thank you.” lastly, some comments specifically mentioned how the creators’ video will benefit the user in real life, with one comment stating, “coming out soon and needed this reminder that it will get better .” this sub-theme helped demonstrate the utility of creator videos in validating and fulfilling emotional needs. needs fulfillment was coded in 33 comments, or 1.59% of the total comments analyzed. mutual aid lastly, the sub-theme of mutual aid featured commenters who were both willing to receive and provide help to other group members. some of this aid manifested in the form of emotional support offered by other members, with one commenter expressing, “i’m a 40-year-old mother with three kids. i have a grandchild on the way. i am a part of the community. please do not hesitate to message me about anything.” a noteworthy interaction was when one creator voiced their desire to help a commenter when they requested a video on tips to come out, saying, “i would love to talk about this more, i’ll pin your comment in a video soon .” other commenters expressed their need for aid, “i need tips. my whole biological and foster family are toxic, but i always end up talking to them again. but i can’t keep doing this to myself.” these comments highlighted the community’s ability to provide and accept support, as well as their comfort of doing so in the comment sections. mutual aid was seen in 14 comments, equating to 0.68% of comments analyzed. shared emotional connection the key component of shared emotional connection refers to the degree to which community members feel emotionally connected to one another. it reflects the extent to which community members experience a sense of empathy, caring, and support from others within the community. commenters exhibited this theme through their investment in the lesbian tiktok community, connections with others in the community through comment sections, and the positivity expressed in their comments. the three most salient sub-themes that were identified included personal investment in the shared lived experience, peer relations, and positive regard. personal investment in the shared lived experience this sub-theme refers to the shared lived experience, referring to the commitment that the community has (and will continue to share) a history, common places, shared events, time together, and similar experiences. commenters expressed this sub-theme through their investment in both the content of the video and the creators' lesbian identity. on a video that spoke about familial rejection, users shared the commonalities in their experiences with the creator, saying “yep felt this. just hit my one year too. it gets better baby so proud of u,” and “you’re truly an inspiration, having gone through this myself it’s amazing to see the confidence once you start doing what’s best for you!” another creator made a video which discussed the stigma associated with expressing their sexuality as fluid, with commenters noting their shared experience by saying “agreed! i’m tired of explaining my $exuality and i just don’t want to have to explain myself if that makes sense ,” and “thissss is why i’ve been using queer, bc bisexual doesn’t feel right and i think it’s fluid/a spectrum.” overall, it appears that commenters used the universality of the lesbian/queer experience to connect themselves closer to the content and content creators. seven percent of the comments analyzed included this subtheme, with 145 occurrences in total. positive regard positive regard refers to positive experiences among group members. commenters expressed this positive regard through acceptance of creators and their appreciation for them. for example, commenters expressed this appreciation for two creators who announced their wedding by stating, “no matter what my mood is any video that you post showing how happy the two of you are together being married and happy just puts 95 shinbine et al. a smile on my face!” and “wow. you both look spectacular in your wedding dresses! love your strength to live your lives!” other commenters expressed positive sentiment for the creators by posting comments supporting their life, saying, “i hope life just keeps getting better for you ,” and using heart emojis ( ) to express this positivity. positive regard appeared to encapsulate feelings of approval and acceptance from commenters to creators. this sub-theme, occurring 334 times, was coded in 16.14% of the total comments. peer relations this sub-theme encompasses the relationships and bonds between members of a group. this subtheme appeared to emerge with commenters engaging with one another instead of directly with the content creator. this was achieved through commenters “atting” their friends or partners to share the content with them as a form of communication. other times, commenters would have organic interactions with each other regarding the video topic. in particular, the aforementioned video with the fake pregnancy announcement included this interaction “damn not gonna lie they had me thinking they were gonna have a kid,” and “oh ya. lol totally thought they were announcing.” in general, peer relations were driven by users sharing the content to connect with others, as well as responding to already posted comments to form a connection. in total, 234 comments demonstrated peer relations, which was 11.30% of all comments. discussion the objective of this study was to explore the sense of community experienced by lesbians within lgbtq+ specific tiktok accounts. results demonstrated that the four foundational components outlined by mcmillan and chavis' sense of community theory (1986) were displayed through the various subthemes. these findings highlight tiktok's potential as a platform for nurturing this sense of community, indicating that the "queer potential" suggested by duguay (2023) regarding tiktok's role in social movements and the future of the lgbtq+ community extends to the lesbian demographic as well. however, this study also deepened our understanding of how a sense of community may vary in digital realms, suggesting that this piece of research is foundational in further expanding our understanding of this topic. the manner in which a sense of community was exhibited demonstrates the unique ways that commenters on lesbian tiktok videos facilitate spaces of acceptance and belongingness, particularly with the platform and the content creators themselves being a conduit for certain subthemes to be expressed. for example, the subtheme of group and individual competence was established by users discussing relevant topics associated with lesbian tiktok content creators. similarly, a parasocial sort of connection with the content creators was found in the sub-themes of need fulfillment and a personal investment in the shared lived experience, as users would often praise creators in their comments and express how the content made them feel less alone regarding their lesbian identity. the relationship between isolation and parasocial relationships aligns with previous literature suggesting that parasocial relationships moderate loneliness and depressive symptoms (woznicki et al., 2021). these findings demonstrate how tiktok, as a platform and its content creators themselves, appear to be a mechanism to facilitate a sense of community for its user base. in contrast, other sub-themes appeared to align more with traditional displays of a sense of community. in particular, mutual aid was expressed through individuals offering assistance and support to other users through direct messaging, similar to what one may see in a physical space, which establishes a sense of community (baiocco et al., 2012). similarly, peer relations were sustained through users' conversations through the “reply comment” function on the app and by tagging friends in the comments. it is important to note that although peer relations pertained to interactions between users, these conversations were related to the content creators and “atting” (the practice of tagging others to a piece of content for them to view) as a way to share these creators and their content with others. this newly identified space to facilitate a sense of community may benefit lesbians who do not have access to traditional physical spaces, such as individuals who live in rural areas or do not feel comfortable visiting these spaces. these findings highlight how the content of the videos created on lesbian tiktok interplays with how a sense of community presents on the platform. however, it is essential to recognize the role of tiktok’s algorithm in shaping how a sense of community manifests within this space. the platform’s recommendation system curates content visibility based on engagement metrics such as likes, shares, and comments, 96 where did all the lesbians go? which may amplify dominant voices while deprioritizing marginalized perspectives (okoronkwo, 2024; simpson & semaan, 2021). this has implications for digital community-building, as highly engaged content may reinforce existing community norms while limiting the visibility of dissenting or less mainstream voices. furthermore, tiktok’s algorithm is known to promote viral content over more niche or marginalized narratives, meaning that certain perspectives within the lesbian community may be systematically underrepresented. previous research suggests that algorithmic bias on social media platforms disproportionately affects lgbtq+ users, particularly those at the intersections of race, gender identity, and socioeconomic status (simpson & semaan, 2021). as a result, the representation of community interactions in this study may be influenced by the algorithm’s selection mechanisms rather than reflecting the full diversity of perspectives within lesbian tiktok. future research should investigate how algorithmic visibility structures shape online queer communities and whether alternative digital platforms offer different or more inclusive community-building experiences. in addition, users also expressed their gratitude and the positive impact of having these spaces online to express their lesbian identity, suggesting that these videos and comment sections may serve a role in facilitating well-being for users. these bolstering effects align with previous research suggesting that digital spaces play a role in minimizing stressors associated with one’s lgbtq+ identity and reaffirming social identities (lopez-leon & casanova, 2023; wagaman et al., 2020). they also reaffirm burke’s (2000) findings that lesbians may use the internet to feel a higher sense of engagement with the community. this identification of tiktok as potentially bolstering for lesbian users’ well-being is promising, although future research is needed to examine the relationship between use and well-being outcomes. limitations turning attention to the limitations of the present study, they reside in the methodologies and context of the selected videos. the content in the selected videos varied between personal stories, humorous videos, and educational content, which impacted how a sense of community was expressed. additionally, the significant variance in video views, ranging from 37.8 thousand to 3.3 million across all videos, suggests differing levels of video circulation and unequal exposure, which also may have limited certain comment sections from exhibiting a sense of community due to a lack of user engagement with these videos. further, as we were unable to access demographic information on participants, findings may not reflect the diversity of community-related experiences for lesbians of different racial and socioeconomic backgrounds. moreover, the context of when the videos selected were posted may have impacted how themes were expressed. in particular, we noticed that the videos collected coincided with a period of tiktok "drama" concerning the breakup of jojo siwa and avery cyrus (i.e., celebrities in the lesbian/queer community). as such, many comments were discussing this topic, and some of the examples in the results section referred to this specific event. this event was of importance to the community, with multiple videos and comment sections referring to it. this significant occurrence in the lesbian tiktok community may have influenced the comment sections to express group and individual competence surrounding this matter. another potential limitation of this study is the selection bias inherent in analyzing only the top 100 comments for each video. tiktok’s algorithm prioritizes comments with high engagement, such as those receiving the most likes or replies, potentially amplifying dominant voices while underrepresenting the perspectives of less engaged users. this may result in an overrepresentation of more dominant viewpoints within the community while minimizing the voices of those with less visibility, such as marginalized users or those who engage with content in more passive ways (e.g., scrolling without commenting). as a research team, we prioritized collecting data from a range of influencers; however, future research could incorporate a broader sample of comments, including those with lower engagement or those posted across different timeframes, to capture a more diverse range of community interactions. lastly, due to the study’s focus on publicly accessible comments on tiktok videos, additional areas of investigation remained unanswered. for instance, the tone and intent of comments could not be accurately inferred solely from their content, potentially leading to miscoding based on the comment's explicit content rather than the underlying intent of the creator. additionally, tiktok's "direct message" feature 97 shinbine et al. allows users to privately communicate with creators, which might produce different components of a sense of community. this is of particular interest due to examples of the mutual aid sub-theme, suggesting that users may privately message each other after an initial interaction on a public video. the lack of analysis of this feature on tiktok limits the study's capacity to comprehensively explore how a sense of community is nurtured for lesbians on the platform. future directions results from the current study help establish a promising avenue of future research exploring the lesbian tiktok community. our suggestions for future research reflect the unexplored potential of this novel research topic. firstly, future studies should aim to look at how a sense of community is longitudinally created on tiktok for the lesbian community. this more widespread exploration may aid in the understanding of how a sense of community develops over time. similarly, the exploration of how certain types of videos influence how sub-themes are expressed would be a valuable endeavor, particularly when comparing comedy versus more personal content. these future investigations would help better understand how context and content influence how users express a sense of community on tiktok. alternatively, research exploring the perspectives and experiences of lesbian tiktok members may help deepen our understanding of a sense of community in this realm. qualitative interviews may assist in understanding how consumers and creators of lesbian tiktok content experience a sense of community online. the benefits of qualitative interviews are twofold, as they would both deepen the understanding of how lesbian tiktok content creators and commenters conceptualize a sense of community, as well as explore potential strengths and weaknesses that tiktok possesses as a platform for this phenomenon. such research may also inform the policies and procedures that tiktok employs to improve the well-being of its users. due to the findings that, although a sense of community can be created online, the manner in which it presents is unique, research exploring how these spaces are created and maintained is important. gaining a more comprehensive understanding of lesbian tiktok and how a sense of community is forged in this space requires further investigation into how relationships between creators and community are formed. specifically, delving into the psychological aspects of online engagement, including the formation of virtual identities and the dynamics of parasocial relationships, could provide a deeper comprehension of why specific elements of a sense of community struggle to translate effectively within comment sections. such explorations could be beneficial in establishing a newfound understanding of what a virtual sense of community looks like and the mechanisms behind forging and maintaining these spaces. tiktok as a platform appeared to be a key piece of context in the expression of certain subthemes, and further research should encompass examining the experiences of lesbians on various social media platforms they currently engage with. this broader perspective could offer insights into how a sense of community is cultivated online within this community. similarly, investigating the feedback received by content creators across different social media platforms could shed light on whether distinct platforms facilitate different facets of a sense of community. lastly, conducting a comparative analysis between fostering a sense of community in public versus private communication settings could contribute to a more comprehensive understanding of how this sense of community develops on the tiktok platform. conclusion studying online lesbian communities can inform our understanding of how lgbtq+ individuals build a sense of community in a post-covid society. it provides insights into how online platforms connect, share information, and provide support within the lesbian/queer women community at large. further, understanding online communities helps researchers comprehend the factors that shape these communities and the experiences of lgbtq+ individuals within them. however, despite the decline of lesbian-centred spaces, there continues to be a need for safe and inclusive spaces for lesbian-identifying people to gather, connect, and develop a sense of community. the current study found that social media platforms, such as tiktok, can foster a sense of community. to our knowledge, this is the first endeavour looking at a sense of community for lesbians on tiktok. the understanding of the lesbian community on tiktok needs to be further explored to gain further insight regarding how the type of content disseminated and the timeliness of relevant issues for 98 where did all the lesbians go? the community further impact how it is established. references american psychological association, apa task force on psychological practice with sexual minority persons (2021). 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(2015). resilience in community: a social ecological development model for young adult sexual minority women. american journal of community psychology, 55(1–2), 179– 190. https://doi.org/10.1007/s10464-015-9702-6 61 caution when crowdsourcing: prolific as a superior platform compared with mturk daniel oconnell1, ashley bautista1, clint johnson2, and amanda venta1 1department of psychology, university of houston, houston, tx, usa 2department of psychology, webster university, st. louis, mo, usa researchers have leveraged the internet for years, during which the use of crowdsourcing platforms has increased dramatically (aguinis et al., 2021). gosling and mason (2015) extolled the use of the internet for research a decade ago, endorsing surveys conducted through crowdsourcing platforms to reduce costs and participant attrition. moreover, it is just as easy now for researchers to collect survey data from undergraduates at their institution as it is to reach participants overseas, thereby reducing long-standing generalizability concerns (best et al., 2001; gosling & mason, 2015). online surveys bridge international borders; as of january 2023, 64.4% of the world’s population was connected to the internet (kemp, 2023). yet, this approach to data collection has limitations, particularly regarding data quality. the aim of the present study was to investigate strengths of participant pools for social scientists to obtain high-quality data. to this end, we analyzed data from a completed study drawing participants from two major crowdsourcing platforms, mturk and prolific, and evaluated both data quality and cost. history since 2005, amazon’s mechanical turk (mturk) has promised to optimize efficiency, augment data collection, reduce researcher cost, and grant access to diverse participants (https://www.mturk.com/). researchers (e.g., aguinis et al., 2021; smith et al., 2015) point to diverse participants, speed of data collection, and low cost as reasons for mturk’s widespread use. yet, researchers have found that data quality and treatment of diverse populations on these platforms can suffer (e.g., burnette et al., 2022). indeed, aguinis and colleagues (2021) highlighted ten areas in which mturk is limited in its ability to collect high-quality data. these areas include participants lying about personal information (e.g., webb & tangney, 2022), lack of english fluency (e.g., moss et al., 2021), and gathering data from professional survey takers (e.g., cheung et al., 2017), all of which can reduce effect sizes (chandler et al., 2015; newman et al., 2021). the webb and tangney (2022) study serves as a provocative example of poor data quality collected via mturk; just 14 of their 529 participants were reportedly “human beings” (p. 1). webb and tangney (2022) are not the only researchers to encounter of low-quality data from crowdsourcing platform participants (bai, 2018; simone, 2019; stokel-walker, 2018), and others have been critical of crowdsourcing from mturk (barends & vries, 2019; kennedy et al., 2020; zack et al., 2019). more recently, in 2014, prolific came to the market, similarly guaranteeing a vetted, engaged, and more diverse participant pool from numerous countries with an emphasis on ethical pay (peer et al., 2017; https://www.prolific.com/). indeed, prolific holds great potential to overtake mturk as the optimal crowdsourcing platform (palan & schitter, 2018). yet, direct comparisons between the two have yielded conflicting–and sometimes biased–results. for instance, peer et al. (2017; 2022) portrayed prolific as superior many researchers host surveys on online crowdsourcing platforms, such as amazon’s mechanical turk (mturk) and prolific. online platforms promise a convenient way to meet sample size needs while drawing on diverse pools that might not otherwise participate in science. yet, the quality of data obtained from these platforms is often questionable, so the collection must be closely monitored and reviewed. this study aimed to independently determine which crowdsourcing pool best serves researchers who plan to recruit for online surveys. to achieve this aim, we analyzed data from a recently completed study that drew participants from both mturk and prolific. we screened the collected data for both cost and quality, focusing on measures of attention, duration, and internal consistency. we found that only 9.89% of mturk participants (n = 354) and 43.34% of prolific participants (n = 345) produced high-quality data; prolific also proved to be the more affordable option. researchers considering these platforms for recruitment may weigh the evidence to make decisions when developing their own recruitment strategies. finally, we highlight best practices for social scientists conducting online research, including additional survey and screening techniques. keywords: mturk, prolific, survey, crowdsourcing, data quality graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 62 oconnel et al. in terms of participant attentiveness, comprehension, honesty, and reliability compared to mturk and cloudresearch, but both studies were funded by the prolific company. conversely, litman et al. (2021) responded in a paper sponsored by cloudresearch, a company that accesses mturk participants and aims to improve upon amazon’s platform. their results demonstrated superior data quality on mturk when paired with the cloudresearch toolkit. given directly contrasting results, it is important to establish objective criteria to fairly compare mturk and prolific recruitment, including data quality and pricing. deciding between mturk and prolific cost one basic and practical consideration is cost. prolific mandates that researchers pay their participants an ethical wage (newman et al., 2021), which is a minimum of $8 u.s. dollars (usd)/hr (https:// www.prolific.com/). meanwhile, mturkers earn a minimum pay of $0.01 usd per assignment (https:// www.mturk.com/). prolific charges a higher platform usage fee (25% base rate for academics) compared to mturk (20% base rate). however, prolific includes most participant specifiers (e.g., age or job) within their base cost, whereas mturk requires researchers to pay additional fees. therefore, when participants are compensated equally, mturk is cheaper until specifiers are added for researchers recruiting a specific population (e.g., young adults). since mturk does not enforce a minimum wage, researchers may pay participants less. crump et al. (2013) found that higher wages did not incentivize participants enough to provide higher-quality results, but it did result in lower dropout rates. conversely, litman et al. (2015) showed that monetary compensation is a primary driver for participation, tying data quality to compensation rates, thus directly contradicting findings by crump and colleagues (2013). data quality researchers also value the quality of their data when using crowdsourcing platforms. data quality is a term comprising many factors (douglas et al., 2023), operationalized herein as–on the high-quality end–higher rates of passing attention checks and task completion combined with lower rates of lying and deception. multiple methods are often combined to make conclusions about data quality (douglas et al., 2023). some techniques–often used in tandem with others–include attention checks, survey duration, and internal consistency. most studies employ attention checks (douglas et al., 2023). to evaluate attention, survey designers may ask participants to make a forced response, write an open-ended response demonstrating understanding, or perform unrelated tasks like math–though they vary in effectiveness (abbey & meloy, 2017). that said, checks like these are not without detractors. hauser et al. (2018) demonstrated that manipulation checks can confound results, particularly when implemented incorrectly (e.g., attention question placement is not randomized). another indicator researchers can use to determine data quality is survey duration (teitcher et al., 2015). by comparing individual participant survey durations to the average and pilot data, researchers can identify outlier durations (matjašič et al., 2018). participants who respond far too quickly can be identified as suspicious and of low quality (e.g., goodrich et al., 2023). a third way to evaluate data quality is through internal consistency (e.g., douglas et al., 2023). one way to evaluate internal consistency is through cronbach’s alpha (α) (cortina, 1993), as random responding contributes to low values (fong et al., 2010). when values are low (see cortina, 1993), especially compared to validated standards of a measure, researchers should be skeptical about the overall reliability of their data. previous mturk and prolific comparisons a few independent studies have been conducted to directly compare mturk and prolific, demonstrating prolific as superior. albert and smilek (2023) observed greater disengagement among mturk participants compared to those on prolific, though they only included high-performing mturk users. while using participants identified by the platforms as high-quality can be beneficial for getting attentive participants (lu et al., 2022), it limits random selection and naive respondents–those who are unfamiliar with certain measures (matthijsse et al., 2015). in another direct comparison, douglas and colleagues (2023) conducted an independent analysis across mturk, prolific, cloudresearch, sona, and qualtrics with a well-powered 500 participants per pool. they concluded that prolific and cloudresearch outperformed the other pools in terms of data quality, with no substantial differences between the two; both outperformed the unmodified 63 navigating mturk & prolific mturk. they also highlight other relevant details, such as the price per quality participant, wherein prolific ($1.90) was cheaper than cloudresearch ($2.00) and mturk ($4.36). yet, similar to albert and smilek (2023), douglas et al. limited participants by only allowing those who had already completed 100 surveys, thereby rejecting naive participants. the authors further suggest that their results ought to be regularly replicated, as pool demographic compositions fluctuate over time. the present study builds on these prior works by directly comparing mturk and prolific without pre-established participant quality standards. current study the current study aimed to directly compare the quality and cost of data gathered from identical surveys posted on mturk and prolific. most previous studies comparing mturk have pre-screened for high-performing users, limiting naive participants. in contrast, our study compared recruitment between mturk and prolific with naive and non-naive participants, representing the recruitment efforts commonly seen in contemporary research. secondary data analyses were conducted on data collected in a previously completed study. ultimately, we sought to answer the research question: how do cost and data quality from participants recruited from mturk and prolific differ without pre-screens in place? this question was answered using a thorough screening process influenced by prior research crowdsourcing data quality. method participants for the mturk sample (n = 354), most participants were white (81.64%), heterosexual (82.49%), and male (61.30%), with an average age of 26.18 years (sd = 4.54). for the prolific sample (n = 345), most participants were white (77.08%), heterosexual (63.03%), and female (67.05%), with an average age of 22.20 years (sd = 2.03). procedures this study utilized data collected through qualtrics on mturk and prolific platforms. the current study aimed to compare samples drawn from mturk and prolific for a broader study (see more https://osf. io/2n8ge), which was approved by the irb at saint louis university. two identical surveys–differing only by the inclusion of an id number for mturk participants–were launched on the morning of april 15, 2022. inclusion criteria required participants to be english-speaking young adults aged 18-25 and living in the united states. participants were told that they would be providing the company ‘ocean’ with feedback on their newly developed dating application rooted in personality. in reality, the study aimed to investigate participant preferences for romantic partners based on perceived personality and weight. nevertheless, we subjected participants to a realistic process of testing a dating app which allowed them to create an ocean profile, rate eight random profiles, provide qualitative and quantitative feedback on the “app,” and rate 34 images as high or low in bmi/weight. all participants were compensated $2 usd for approximately 15 minutes of work ($8 usd/hr rate). measures big five factor model of personality the mini-ipip (donnellan et al., 2006), a measure based on the big five factor model of personality (goldberg, 1999), was included as a component of the profile-building process to assess personality and induce psychological realism. the mini-ipip has demonstrated strong validity and internal consistency as a personality inventory (donnellan et al., 2006). this measure was used to compare internal consistency before and after the screening process through cronbach’s α levels. demographics demographics were gathered through the profile-building process. data included age, race, gender identity, sexual orientation, height, weight, and marital status. duration data total survey duration captured via qualtrics was used to compare quality before and after the screening process. based on pre-launch trials, participants were expected to take a maximum of 15 minutes to complete the survey. data quality screening process the data screening process was inspired by the webb and tangney (2022) study, wherein participants were screened out in a step-by-step process and removed from the participant pool. the calculations for the cost of each high-quality respondent were inspired by douglas et al. (2023). the sequential screening process consisted of four steps: (1) age, (2) self-reported seriousness, (3) sensible 64 oconnel et al. open-ended responses, and (4) other sensible responses. participants outside the age inclusion criteria between 18-25, inclusive, were screened out. then, the final question of the qualtrics survey asked participants: “how seriously did you take this survey?” responses ranged from 1-5, with 1 being “not very serious” and 5 being “very serious.” those who admitted to not taking the survey seriously were screened. two open-ended questions were analyzed to screen for unreasonable and duplicate responses. one of these questions asked participants to “please briefly summarize the purpose of this survey,” following the consent form (on a separate page). the second, towards the end, asked participants to “provide any remaining thoughts on ocean here.” criteria for what was considered reasonable were developed a priori using manifest content analysis (graneheim et al., 2017). responses that were marked correct must have mentioned the words “develop,” “personality,” “test,” “algorithm,” or “dating app” and sufficiently explain the purpose of the study. exactly identical response featured exactly the same words, spelling, capitalization, and punctuation were also screened out. two additional metrics were used to refine participant quality based on congruence. first, participants were asked to rate 34 images as high or low in bmi (https://osf.io/2n8ge). two images (one male and one female) were presented twice to measure consistency. second, participants who provided impossible heights and weights were screened. results data quality on mturk versus prolific results from the screening process are summarized in table 1 and explained below. age of the 354 mturk and 345 prolific participants, 125 of the mturk participants reported an age outside the restricted age range on the survey. this left 229 (64.69%) mturk and 345 (100%) prolific participants for analysis, totaling 82.12% of the sample. seriousness two mturk participants did not respond to this question, and one individual on the prolific survey reported a rating of 2, meaning they did not take it seriously. this left the participant count at 227 (64.12%) for mturk and 344 (99.71%) for prolific, or 81.69% of the total. sensible open-ended responses about a third (113) of the remaining prolific participants were removed for illogical or incorrect responses on one or both of the open-ended questions. an example of this type of response included, “the whole body of salt water that covers nearly three-fourths of the earth.” as a result, 80 (22.60%) mturk participants and 231 (66.96%) prolific participants remained, or 44.35% of the total sample. next, identical responses were removed. for example, the response “ocean developers to improve the algorithm of their new dating app.” appeared three times on mturk. this affected participants in both pools such that 64 (18.08%) mturk and 229 (66.38%) prolific participants, or 41.92% of the total, remained. other sensible responses first, participants were screened for inconsistent responses to identical questions. of the remaining participants, just 38 (10.73%) mturk and 153 (44.35%) prolific participants, or 27.32%, were consistent in rating both sets of images at this stage. next, participants were screened for impossible heights and weights. this affected three participants on mturk for entering: (1) 8 feet 8 inches while weighing 120 pounds, (2) a height of 1 foot 1 inch tall, and (3) a weight of 154324 pounds. after this step, 35 (9.89%) mturk and 153 (44.35%) prolific participants remained, representing 188 of the initial 699 (26.90%). internal consistency table 2 compares internal consistency on the mini-ipip between mturk and prolific alongside the original psychometric study (donnellan et al., 2006). both the prolific and mturk α values improved substantially after screening. although prolific scores generally began higher, both the mturk and prolific pre-screen data would be considered unreliable (cortina, 1993). moreover, after screening, all of the α values were higher for prolific except for intellect/imagination. as a result, the evidence would support the post-screen reliability in prolific but not mturk due to values below .70 (cortina, 1993). duration total survey duration was used to compare quality before and after the participant screening process. based on pre-launch trials, participants were expected to take up to 15 minutes to complete the survey. the times that participants took on mturk before (mdn 65 navigating mturk & prolific = 10 minutes and 20 seconds) and after (mdn = 10 minutes and 18 seconds) screening were slightly longer than the times that participants took on prolific before (mdn = 8 minutes and 47 seconds) and after (mdn = 9 minutes and 2 seconds) screening. using 2 sds from the mean in each sample as a metric to compare speed (matjašič et al., 2018), no responses on either mturk or prolific were considered outliers in the “fast” direction. while a handful of slow outliers were present, this was not meaningful to this study, as participants had the freedom to open the survey and complete it the following day. cost prolific was cheaper based on the total cost compared with mturk. costs included the direct payment to participants, the base hosting fee paid to the platform, additional specifier fees, and taxes. a total of $1,155 was paid to mturk, compared with $979 for prolific, a difference of $176. the difference comes primarily from mturk’s “premium qualifications” fee, which cost $0.50 extra per participant to recruit only participants aged 18-25. the cost per high-quality participant was also calculated by dividing the total cost by the respective number of users who produced high-quality data (douglas et al., 2023). prolific ($6.40 per high-quality participant) was still cheaper than mturk ($33 per high-quality participant). discussion the aim of the current study was to compare the practical and data-driven differences between two popular participant pools, mturk and prolific, building upon work by douglas et al. (2023), webb and tangney (2022), and others. data analyzed in this study were drawn from a completed study conducted primarily to make conclusions about online dating behavior in young adults, with data collected across two crowdsourcing platforms: amazon’s mechanical turk and prolific. this comparison sought to understand the cost and quality of data gathered across both platforms. based on pricing and data quality–assessed through attention checks, duration, and internal consistency–prolific proved to be the superior crowdsourcing platform compared to mturk for these samples. nonetheless, prolific still demonstrated notable room for improvement within this sample. in this study, only about a quarter of the sample produced high-quality data. of the 188 that remained after screening, most (n = 153) came from prolific, compared with mturk (n = 35). nearly 18% of mturk participants fell outside the inclusionary age range–despite the added cost–an effect also observed by webb and tangney (2022). as a result, even the mean age (26.18) was outside of the inclusion criteria range (18-25). internal consistency further supported prolific; cronbach’s α values were higher for all factors except for intellect/imagination. notably, the change in α values after screening demonstrates that participant exclusion based on data quality can alter conclusions, an idea supported by previous research (desimone & harms, 2018). finally, duration of the survey appeared equivalent for prolific and mturk. prolific also outperformed mturk on cost. on an absolute basis, prolific was cheaper ($979 usd) compared to mturk ($1,155 usd) for gathering the same number of participants (n = 350). while compensation for the participants was held even ($2), the host fees and specifier charges led to the observed differences. a steep increase in cost may lead to a moral conundrum in which researchers may lower participant wages to afford the hosting of their survey. as a better alternative, we recommend opting for a cheaper platform, which depends on exclusion criteria (i.e., base rate and the need for specifiers). on a relative basis, prolific was still the cheaper option. as determined through the cost per high-quality participant, mturk participants necessitated $33 compared to $6.40 for prolific participants. effectively, we paid mturk five times the u.s. dollar value for fewer “usable” participants. based on this detailed comparison of the samples gathered, the authors perceive prolific as the winner in this direct comparison between mturk and prolific. limitations & future directions several platform capabilities were not tested in the present study. this study was not longitudinal, so the tools that both companies offer for this type of research could not be compared as they have in other studies (e.g., henderson et al., 2021; kothe & ling, 2019; paas et al., 2018; stoycheff, 2016). additionally, this was an experimental psychology study that took around 15 minutes to complete. there is reason to believe that studies presented in different fields (e.g., follmer et al., 2017; reid et al., 2022; wagner et al., 2021) and durations (e.g., aguinis et al., 2021; hamby & taylor, 2016) may find different success with each platform. 66 oconnel et al. additionally, it is difficult to determine the source of low-quality data. it is quite common to read papers that describe the data spoilers as “bots” (e.g., goodrich et al., 2023; stokel-walker, 2018; webb & tangney, 2022). however, deeper dives suggest that international participants, not “bots” or computer programs, are a primary source of lower data quality (moss et al., 2021). international participants are often excluded, so they may lie about demographic information (e.g., native language and current location), which can confound results (dennis et al., 2020). it is recommended that further research be conducted on these topics. moreover, a reproduction of this study is warranted to evaluate ever-changing pools. recommendations for researchers as researchers develop increasingly sophisticated methods to detect low-quality data or robots, participants and programmers evolve strategies to evade detection. while there is no perfect solution, steps can be taken by researchers and crowdsourcing companies to improve the science generated on these platforms by filling their online surveys with relevant attention checks, participant verifiers, and logic. goodrich et al. (2023) recommend considering embedded survey components, including captcha, honeypot questions, and institutional knowledge checks to improve participant screeners. captchas (completely automated public turing test to tell computers and humans apart) vary in form, including checking the “i’m not a robot” box, selecting all of the pieces of the stoplight in a given picture, or decoding distorted letters (moradi & keyvanpour, 2015). honeypot questions are ones embedded and hidden in surveys, making them invisible to human survey takers but visible to robots (goodrich et al., 2023). if one is answered, you have good evidence that your survey was answered by an actual robot. finally, institutional knowledge can be checked in a similar way to the aforementioned logic check implemented in the present study. goodrich and colleagues (2023) suggest a question about the participant’s zip code and then a follow-up about a nearby landmark, such as the closest university. ip addresses can also be used to vet participants who have signed up more than once in one location (aguinis et al., 2021). unfortunately, several drawbacks are present when collecting ip addresses. anonymity is violated, prohibiting a guarantee of identity protection. moreover, even if identifiable data are secured, as they should be, this check would not guarantee that the participant is only completing the survey once. most survey takers know that they can use free vpns (virtual private networks) that allow them to appear, to internet service providers, as if they are in different places across the world (dennis et al., 2020). this also may unfairly disqualify multiple individuals who use the same device to participate, such as public library computers or devices shared between family members. aguinis and colleagues (2021) recommend considering response speed and consistency in the process of screening participants. apart from reviewing the entire survey time, which should fall around a certain predetermined duration based on trials, researchers can look at individual question response times. it is unlikely that participants could respond to certain questions in under a second (wood et al., 2017) unless they are extremely familiar with a given measure or the objective is to respond rapidly. therefore, tracking question response time, can alert researchers to suspicious data. moreover, inattentive participants can be identified if they mark the same response several times in a row (e.g., “strongly agree” for all ten questions on a given measure; aguinis et al., 2021). several methods exist to analyze response patterns of this sort that may be used to flag bots (desimone & harms, 2018; dunn et al., 2018). finally, researchers should become aware of techniques not implemented in this study or discussed herein to identify participants who supply low-quality data, lie about answers, or submit multiple responses. several researchers have done excellent work in compiling recommendations, which should be reviewed in tandem with reflection on this paper (aguinis et al., 2021; goodrich et al., 2023; hunt & scheetz, 2019; hydock, 2018; kennedy et al., 2020; newman et al., 2021; sauter et al., 2020; stanton et al., 2022). conclusion this study leveraged a screening process similar to webb and tangney (2022), with heavy influence from douglas et al. (2023), to compare mturk and prolific recruitment potential based on data quality and cost. based on these metrics, prolific outperformed mturk for recruitment. however, while prolific outperformed mturk on our survey, researchers with different protocols may observe different results. most meaningful67 navigating mturk & prolific ly, researchers ought to critically evaluate the impact that using low-quality data in publications may have on societal outcomes for generations. as we found surprisingly few high-quality participants across both prolific and mturk, it is clear that improved survey methodologies are warranted regardless of platform. with this in mind, researchers should incorporate survey strategies demonstrated in this work as well as the highlighted best practices from other researchers. references abbey, j. d., & meloy, m. g. 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(2019). can nonprobability samples be used for social science research? a cautionary tale. survey research methods, 13(2), 215-227. https://doi.org/10.18148/srm/2019. v13i2.7262 oconnel et al. 70 table 1 summary of results from the screening process 71 navigating mturk & prolific table 2 reliability metrics for the validated mini-ipip (donnellan et al., 2006), mturk, and prolific note. “before” signifies the data prior to screening, and “after” signifies the data following screening. 72 response time to detect careless responding and its relationship with and prediction of emotional distress kristen e. zentner & seyma n. yildirim-erbasli department of psychology, concordia university of edmonton computerized self-report measures have revolutionized the administration of psychological measures by offering researchers and clinicians a more efficient and convenient means of collecting data. however, the potential of computerized testing has yet to be fully realized. additional data available in computerized testing (e.g., response time), which are not available through traditional pen-and-paper administration, offer significant contributions to the psychometric utility of these tests. response time is recognized for its ability to provide a broader representation of responses, going beyond the responses themselves (van der linden et al., 2010). it has considerable potential to reveal psychometrically relevant information, assess profile validity (i.e., the extent to which an individual’s test score represents the true level of the trait or ability being measured), and develop increasingly precise and accurate adaptive testing methods. emotional distress and response behavior there is strong evidence to suggest the impact of emotion on performance on cognitive tasks in the cognitive psychology literature (e.g., castaneda et al., 2008, 2011; eysenck et al., 2007; gross, 2015; hubbard et al., 2016). given that emotion and cognition interact to impact behavior, it is necessary for experimental researchers to consider how this interaction may impact the quality of self-report data in various contexts. for example, research indicates that individuals with greater levels of emotional distress have biases in their self-report data linked to this level of emotionality (ashley & shaughnessy, 2021; conijn et al., 2020). furthermore, researchers are often interested in measuring emotion itself. the profile of mood states (poms; mcnair et al., 1971), the multiple affect adjective checklist (maacl; zuckerman & lubin, 1985), the positive and negative affect scale (panas-x; watson & clark, 1994), and the depression anxiety and stress scale (dass-42; antony et al., 1998) are frequently used self-reports that measure various aspects of emotional states. when a participant completes such self-reports, they are engaging in a cognitive task (i.e., completing the survey itself) that involves emotional content (i.e., the item content) which may interact with or influence the emotional or cognitive state of the participant, such as instigating a heightened emotional response or engagement in emotional regulation strategies (castaneda et al., 2008; gotlib & joormann, 2010; gross, 2015; hubbard et al., 2016; sun & alkon, 2014). despite recent research, gaps exist in our understanding of how emotion and cognition interact to impact response behavior on surveys. cognitive symptoms of emotional distress can impact data quality on self-report measures. self-report surveys require a degree of effort to complete, and factors that compromise sustained effort may impact survey response styles. several theoretical models have been applied to understand the relationship between emotion and cognition in response behavior. for example, cognitive bias literature suggests that mood-congruent information increases working memory in depressed individuals; that is, they have a bias to pay attention to information that reaffirms their depressive cognitions (hubbard et al., 2016). however, drawing on cognitive behavioral theory, ashley and shaughnessy (2021) proposed that individuals with depression engage in avoidance behaviors when completing surveys, adopting strategies that people experiencing emotional distress struggle with cognitive and motivational decline, which has been correlated with patterns of careless responding. although several methods have been used to detect careless responses in emotionally distressed respondents, the response time has not been widely explored. the current study conducted secondary data analyses on a sample (n = 37,819) who completed the depression anxiety stress scale (dass-42) in an online survey between 2017 and 2019. first, a response-time-based approach––a normative threshold method––was used to identify careless responding and examine its association with emotional distress using the dass-42. second, four machine learning models––decision tree (dt), random forest (rf), support vector machine (svm), and naive bayes (nb)––were trained on dass-42 item responses and response times to predict emotional distress severity level. a significant correlation was found between the number of careless responses and subscale scores of anxiety and stress. in addition, mann-whitney u tests showed statistically significant differences between careless and careful responders in depression, anxiety, and stress. regarding the machine learning models, svm was found to be the best predictive model for classifying distressed people with an accuracy, sensitivity, and specificity exceeding 90%. our results suggest that, in addition to survey responses, response time can identify careless responders and predict distressed responders. keywords: response time, machine learning, psychological distress, careless responding graduate student journal of psychology fall 2025 vol. 25 copyright 2025 by the department of counseling and clinical psychology teachers college, columbia university 73 reduce the impact of distressing survey content by minimizing effort, attention, and time to completion. this calls into question whether self-reports of emotional distress are responded to with heightened attention due to the mood-congruent nature of the items, or with inattention (i.e., careless responding) due to concentration difficulties and avoidance behaviors characteristic of depression, anxiety, and stress symptoms. it is recognized that the cognitive impairments associated with depression, anxiety, and stress impact how these individuals respond to self-report measures, potentially threatening their profile validity and rendering scores inaccurate (ashley & shaughnessy, 2021; conijn et al., 2020). studying the patterns of response behavior on self-report measures in emotionally distressed respondents may clarify how their cognitive symptoms are impacting their survey responses and provide an effective way to assess profile validity. careless responding tends to be higher in populations with mental health concerns, with rates ranging from 6.0% (lepagea et al., 2001) to 12.6% (conijn et al., 2015). moreover, findings indicate that those with more severe psychopathology are more likely to show aberrant response styles (conijn et al., 2015, 2018; keeley et al., 2016; wardenaar et al., 2015). comorbid anxiety and depression appear to be associated with even greater aberrant responses because of the interacting effects of the two forms of psychological distress on working memory capacity (e.g., beaudreau & o’hara, 2009). the relationship between anxiety alone and response bias is less clear (ferreri et al, 2011; salthouse, 2012), possibly because those with anxiety do not consistently exhibit cognitive symptoms (castaneda et al., 2008). conijn et al. (2020) proposed and tested a theoretical explanation for careless responding in clinically depressed and anxious populations. they argued that cognitive symptoms of depression, specifically concentration, comprehension, and memory, limit cognitive abilities and make aberrant responses more likely (hubbard et al., 2016). in testing their model, they found that cognitive symptoms mediate the relationship between depression or anxiety and response biases. another study indicated that higher levels of anxiety, distress, and sadness were associated with inattention on surveys (ashley & shaughnessy, 2021). when researchers fail to detect and report instances of careless responding, it impacts findings, jeopardizing the overall quality of knowledge production in the field. this threat to the psychometric properties of self-report measures has been reported and studied by many researchers, and its relevance to clinical settings has been explored (e.g., cuijpers et al., 2010; keeley et al., 2016; tada et al., 2014). when self-report questionnaires are used diagnostically, clinicians base their clinical decision-making and diagnosis on information that may overestimate or underestimate symptom severity (keeley et al., 2016). given the findings from previous research and the psychometric utility of attending to careless responding, a clear understanding of careless response detection is needed. approaches to understanding response behavior there are a variety of approaches to detect careless responding (see ward & meade, 2023, for review). proactive indices are those that place items within the survey itself to assess inattention, such as “because i am paying attention, i will answer this question with ‘very little’” (ashley & shaughnessy, 2021, p. 4). however, these single-item proactive indices provide little contextual information about the pattern of careless responding throughout an entire survey. reactive indices are those that flag inattentive responders through detection of careless response styles during data cleaning and analysis phases, such as longstring detection (i.e., the selection of the same response option for several consecutive responses), and participant-specific reliability (i.e., the consistency of a participant’s responses on items measuring the same trait; ashley & shaughnessy, 2021). curran (2016) noted that the use of a single response style approach is insufficient to detect careless responders because they may have response style patterns that are detectable with some approaches but not others. for example, participants who use a longstring response style would have high participant-specific reliability and would not be identified by detection approaches designed to detect even-odd response styles where participants select extreme ends of a scale (meade & craig, 2012). to account for this diversity in response styles, researchers have suggested that the use of multiple detection approaches is necessary to identify careless responders (ashley & shaughnessy, 2021; curran, 2016). in their review of careless responding, ward and meade (2023) suggest that extensive screening methods may be necessary when analyzing large datasets or with populations that are more likely to engage in careless responding, such as emotionally distressed individuals. for example, ashley and shaughnessy (2021) found that proactive items and short survey response time were associated with negative emotional states (i.e., sadness, anxiety, distress) while other detection methods (e.g., longstring, participant-specific reliability) were not. response time approaches response time approaches, which operate on the assumption that careless responders will have unreasonably zentner & yildirim-erbasli 7474 response time to identify careless responders using a general response time threshold applied to all questions as has been done previously (huang et al., 2012; wise & ma, 2012). the normative threshold approach involves the use of response time cut-off scores to identify individual items that are responded to carelessly (wise & ma, 2012). response time approaches have been of limited utility in psychological research compared to other careless responding detection methods because this metric is typically available at a page or survey level (ashley & shaughnessy, 2021; ward & meade, 2023). however, with item response time available at the item level, researchers and clinicians can gain precision in identifying response time patterns of careless responders in emotional distress. the greatest contribution of item response time to the careless responding literature might be its potential to detect careless responders regardless of the responders’ specific response style (e.g., long string), which gives researchers detailed information on survey response patterns while blocking respondents’ attempts to mask their response style (curran, 2016). computerized surveys that provide access to response time at the item level also create opportunities for more sophisticated analyses. for example, computerized adaptive testing uses an algorithm to select items based on previous responses to gain efficiency and precision in the measurement of the ability or trait with the administration of fewer items (wise, 2020). companies that produce widely used psychological measures are increasingly moving to computerized adaptive formats for reduced testing time and ease of administration and scoring (forbey et al., 2012). wise (2020) notes that traditional approaches to computerized adaptive testing in education, which use only item difficulty in adaptation algorithms, could be expanded to use behavioral measures such as response time to improve the precision and accuracy of measurement. computerized adaptive testing relies on advanced modeling, such as machine learning approaches, which can be used to examine response and response time patterns to predict emotional distress. machine learning approaches to predict emotional distress several researchers have used machine learning methods with item response data to explore patterns that inform psychologists about how emotionally distressed individuals respond to self-report surveys. this line of research stems from machine learning’s ability to capture subtle patterns not evident through traditional approaches and its effectiveness in handling the complex interactions and dependencies among variables, which are likely to be common in psychological assessment data collected by surveys such as the dass. for rapid survey response times consistent with the motivation to finish the survey quickly, have received considerable review within the literature (ashley & shaughnessy, 2021; curran, 2016; jones et al., 2022; ward & meade, 2022). researchers have identified that response time has the potential as a detection method on computerized tests because it is more difficult to manipulate than other methods (e.g., longstring, participant-specific reliability; curran, 2016). for example, careless responders who wish to appear as careful may be motivated to provide response patterns that mimic normal responses (e.g., selecting responses consistently at one end of the scale with enough variability to avoid pattern detection of longstring and even-odd styles). due to their desire to finish the survey quickly, however, they will likely still have shorter response times than careful responders, as demonstrated by schnipke and scrams (1997). careless and careful responders exhibit distinct distributions in response time, with an initial spike in response time distribution attributed to the former. curran (2016) used simulated data to explore distributions of response time in careless and careful responders and highlighted consideration of type i (i.e., falsely identifying a careful responder as careless) and type ii errors (i.e., falsely identifying a careless responder as careful) in establishing cut-off scores due to the significant overlap between distributions. researchers have used various calculations to determine cut-off scores, including 1.5 quartiles above or below the median (funke, 2016), two standard deviations above or below the mean (heerwegh, 2003), one standard deviation above or below the mean (ashley & shaughnessy, 2021), and various percentiles (e.g., first percentile, fifth percentile; gummer & roßmann, 2015; harms et al., 2017). some researchers have explored cut-off scores on an individual item level. for example, a 2-second-per-item cut-off score is considered a conservative approach, limiting type ii errors at the cost of missing some careless responders (bowling et al., 2016; huang et al., 2012). several methods have been used to determine response time thresholds for individual items, including a two-state mixture model (schnipke & scrams, 1997), surface-level characteristics of items (i.e., character count; wise & kong, 2005), and visual inspection of the response time-frequency distribution (wise, 2006). these three approaches tend to identify similar item response time thresholds (kong et al., 2007). considering that items vary in the amount of text or how mentally taxing they are, what may be classified as rapid responding varies by the item. this implies that greater accuracy of careless response detection may be gained by identifying a normative threshold specific to each item, rather than 75 zentner & yildirim-erbasli example, budiyanto et al. (2019) used text mining from social media posts to measure depression and anxiety using a closed-loop machine learning approach, with an nb algorithm as a training process and the dass-21 parameters as a learning process. from this approach, budiyanto et al. (2019) demonstrated the usefulness of machine learning methods to collect novel information about emotional distress. other studies have found that various machine learning models are useful in predicting depression, anxiety, and stress from the dass-42 and dass-21, with some machine learning models showing greater accuracy and efficiency than others (kumar et al., 2020; priya et al., 2020; srinath et al., 2022). kumar et al. (2020) predicted five severity levels of emotional distress by investigating eight machine learning algorithms trained on dass-42 item responses, and then the same methods were applied to a second dass-21 dataset. the results showed that these models could be used to predict emotional distress, with accuracy rates between 96.02% and 97.48% for the subscales (kumar et al., 2020). priya et al. (2020) applied five machine learning models trained on item response data, including dt, rf, nb, svm, and k-nearest neighbor, to predict depression, anxiety, and stress levels from a sample of dass-21 data. they found that the rf classifier demonstrated the best performance, with accuracy rates between 71.4% and 79.8% for dass subscales. srinath et al. (2022) compared svm and logistic regression using parameter tuning to predict depression, anxiety, and stress from dass-42 item response data. they found that logistic regression had the highest performance, with an accuracy of 98.15% for depression, 98.05% for anxiety, and 98.45% for stress. in recent years, researchers have begun to explore the utility of machine learning models using response time on behavioral tasks (i.e., perceptual matching task) and using neuroimaging and physiological data (i.e., magnetic resonance imaging; liu et al., 2022). these studies suggest that machine learning has predictive potential within clinical and counseling psychology. moreover, priya et al. (2020) noted that the sensitivity and specificity afforded by machine learning models make these approaches particularly helpful within healthcare contexts. current research considering how often self-report is used to measure, research, and reduce impairment from negative emotional states such as depression, anxiety, and stress, further exploration of careless response identification is needed to enhance data quality and continue to elucidate the impact of emotion on cognitive tasks. while response time has been used as a measure of response behavior (e.g., kong et al., 2007), more study of careless response detection within emotionally distressed populations is needed to determine effective ways to identify and deal with potentially invalid data. in addition, the use of machine learning approaches can facilitate the identification of complex patterns and relationships that may not be apparent through traditional statistical methods. there is a recent body of literature on the use of machine learning approaches to predict emotional distress using item response data (e.g., srinath et al., 2022). however, this study proposes incorporating response time in addition to item responses, as response time can provide insights beyond the responses themselves (van der linden et al., 2010). the present exploratory study aims to address these gaps in the literature by examining the relationship between careless responding and emotional distress, as well as exploring the potential utility of incorporating response time in machine learning models for predicting emotional distress. in this paper, the following research questions were investigated: 1. is there an association between careless responding and emotional distress (i.e., depression, anxiety, and stress)? 2. can machine learning models identify emotionally distressed people using item responses and response time? methods the dass-42 is a well-established measure of emotional distress with 42 items such as, “i felt that life was meaningless” in the depression subscale, “i was aware of dryness in my mouth” in the anxiety subscale, and “i found that i was very irritable” in the stress subscale on a scale of 0 (did not apply to me at all) to 3 (applied to me very much or most of the time; lovibond & lovibond, 1995). the subscales assess depression (α = .97), anxiety (α = .92), and stress (α = .95) as separate constructs with 14 items each, and each demonstrates high internal consistency (antony et al., 1998). to address the research questions in this study, the dataset was pulled from the open source psychometrics project (2019), which offers public datasets. the survey was open for anyone to complete, meaning the sample may include a mixture of clinical and non-clinical populations. participants received only their personalized results in return for their participation. the dataset was pre-cleaned upon download–– negative response times were recoded to missing values, and milliseconds were transformed into seconds. data analysis was conducted using jamovi and r programming languages. the sample consisted of 37,819 participants who completed the online survey on a scale of 1 to 4 between 2017 and 2019, 76 aged 13 to 79 years (m = 23.39, sd = 8.57). sociodemographic characteristics of the sample are displayed in table 1. question 1: association between careless responding and emotional distress figure 1 encapsulates the methodology employed to address our primary research question. to answer our first research question, we identified careless responses by calculating a normative threshold based on wise and ma’s (2012) response time approach. second, we classified participants as careless or careful upon considering the total number of careless responses they exhibited. third, we examined the association between the number of careless responses and emotional distress scores. finally, we conducted mann-whitney u tests to compare emotional distress scores between careless and careful responders. the normative threshold for an item is calculated as “a percentage of the elapsed time between when the item is displayed and the mean of the response time distribution for the item, up to a maximum threshold value of ten seconds” (wise & ma, 2012, p. 9). for example, if an item takes a mean of 60 seconds for participants to complete, the 10% normative threshold (i.e., nt10) would be six seconds. various normative thresholds can be compared to determine the cut-off that yields the greatest accuracy for identifying careless responders (wise & ma, 2012). we chose to use the 20% normative threshold (nt20) based on literature showing that this cut-off is appropriate for low-stakes environments (rios & soland, 2021) and due to the positively skewed distribution of dass-42 scores in the dataset. to calculate the nt20, the mean response time was calculated for each item, and 20% of the average response time served as the nt20 cut-off score. we recoded careless responses (i.e., responses below the nt20 cut-off) as missing values. the reason behind this is that previous studies have pointed out how the presence of careless responses in the dataset can introduce bias into estimates of item and person parameters (e.g., guo et al., 2016). various cut scores have been used to classify careful and careless responders (i.e., demonstrating a substantial number of careless responses throughout the survey; e.g., wise & kong, 2005). the purpose of the tool and the sample under study are crucial factors in determining appropriate cut scores. for example, a cut score of 20% was used in a lowstakes assessment (e.g., wise & kong, 2005). when a survey is used diagnostically for clinical purposes, prudent clinicians must be confident that the data are not impacted by careless responding, while putting more weight on other data sources (i.e., interviews) if the survey data have questionable validity (american psychological association, 2020). stated another way, increasing false positives (classifying careful responders as careless) may be necessary for evaluating the validity of clinically relevant data. given that the survey in the current study measures clinically relevant variables, a cut score of 10% was chosen. by setting the threshold at this level, we aimed to be inclusive enough to detect individuals who may exhibit a notable pattern of inattentive responses across the survey items. at the same time, the 10% threshold is chosen to avoid categorizing individuals as careless responders when they may, in fact, be providing thoughtful and considered answers to the survey questions. participants who showed between 0 and 4 careless responses within the dass-42 items were classified as careful responders (n = 37,025), and participants who showed between 5 and 20 careless responses were classified as careless responders (n = 551). participants with 20 or more careless responses were considered extremely careless responders (n = 243) and were excluded from analyses because their survey scores would have been significantly biased by the severity of their careless responding. this is consistent with previous literature that uses a 50% careless response rate as a cut-off for removal from the dataset (arias et al., 2020; curran, 2016). given that data from carelessly responded items is invalid and introduces bias (e.g., guo et al., 2016), it is necessary to recode these responses as missing values and compute scores accordingly. therefore, after identifying careless responses, dass-42 subscale scores were adjusted to represent only carefully responded items by recoding these responses as missing values and calculating the adjusted total scores. the adjusted subscale score is the sum of the scores for carefully responded items divided by the maximum possible total score for those items. we presented the adjusted scores as percentages to facilitate the interpretation of the results. for example, if a participant had careless responses on three items on the depression subscale (14 items), their depression subscale score would be the sum of their scores on the remaining carefully responded 11 items, with a score range of 11 (11 × 1 point) to 44 (11 × 4 points). if the participant scored 39 on these 11 carefully responded depression items, their adjusted subscale score in percentage would be calculated as follows: 39/44 =0.87×100=87. a spearman correlation analysis was used to determine whether an association exists between the number of careless responses and emotional distress scores. next, mann-whitney u tests were used to compare dass-42 subscale scores between participants classified as careless and careful. question 2: predicting emotional distress with maresponse time to identify careless responders 77 zentner & yildirim-erbasli chine learning figure 2 encapsulates the methodology employed to address our second research question. to answer our second research question, we used dass-42 data consisting of item responses and response times of 37,819 respondents. responders were classified into five severity levels on an ordinal scale for depression, anxiety, and stress based on their scores using the guide for severity levels of emotional distress in dass-42 (see table 2). total scores were calculated on a 0 to 3 scale by subtracting one from each response, as the initial dataset included responses ranging from 1 to 4. for each emotional distress, we used 80% of the dataset for training and 20% for testing. validation was conducted within the training process through 10-fold cross-validation (i.e., the number of groups that the dataset is randomly split into) and a random search for hyperparameter optimization. we trained four machine learning algorithms–dt, rf, svm, and nb (james et al., 2017)–to predict the severity levels of responders for each emotional distress. dts split data into progressively smaller subsets based on selected features to form a simple, interpretable tree structure. rfs enhance this approach by combining multiple dts built from random subsets of data and features to improve accuracy and reduce overfitting. nb applies bayes’ theorem under the assumption that all features are independent to generate probability-based classifications. svms identify the optimal hyperplane with the maximum margin to separate data points for predictive performance. after the training, we evaluated the performance of the trained models using the test sets and reported standard classification metrics (i.e., sensitivity, specificity, and accuracy). results careless responding and emotional distress there were statistically significant correlations between the number of careless responses and subscales of anxiety (rs(37,574) = .03, p < .001) and stress (rs(37,574) = .02, p = .001), but not the subscale of depression (rs(37,574) = -.001, p = .836). in terms of the subscale of depression, careless responders (mdn = 67.3) had higher scores than careful responders (mdn = 62.5), and the difference between careless and careful responders was statistically significant (u = 9.58e+6, p = .01, r = .06; see figure 3). similarly, a statistically significant difference was found between groups on the anxiety subscale (u = 9.00e+6, p < .001, r = 0.12) with careless responders (mdn = 57.1) scoring higher on anxiety than careful responders (mdn = 51.8). finally, higher stress subscale scores were found among careless responders (mdn = 65.9) than careful responders (mdn = 62.5) with a statistically significant difference (u = 9.62e+6, p = .02, r = .06). in summary, careless responders had higher scores of depression, anxiety, and stress than careful responders. predicting emotional distress table 3 shows single classification metrics of the four machine learning models for five different severity levels of each emotional distress. even though machine learning models showed roughly similar performance, dt, rf, and nb yielded inconsistent sensitivity values for mild, moderate, and severe levels. in terms of the depression subscale, classification metrics for almost every level exceeded the acceptable threshold of 70% or the optimal threshold of 80% with several exceptions of sensitivity values being less than the acceptable threshold. overall, the svm outperformed the other models with classification metrics exceeding the optimal threshold for each level. regarding the anxiety subscale (see table 3), with the exception of svm, the other models showed mixed and extremely low sensitivity values for the levels of mild, moderate, and severe, while others exceeded the optimal threshold of 80%. similar to depression, svm surpassed the other models with classification metrics above the optimal threshold for each level. for the stress subscale (see table 3), dt, rf, and nb showed mixed and low sensitivity values for the levels of mild, moderate, and severe. other measures went over the optimal threshold of 80% and, in particular, svms dominated the other models in terms of sensitivity and specificity, which were either 100% or very close. we also macro-averaged the single metrics by calculating the averages of sensitivity and specificity values over severity levels (see figure 4). based on the macro-averaging, four machine learning models for three types of emotional distress showed similar results in terms of specificity values being larger than 90%, exceeding the optimal threshold, whereas they showed mixed results for sensitivity. only svm exceeded the optimal threshold, with sensitivity values being larger than 90% across all three types of emotional distress. these results reveal that true negatives can be predicted with optimal sensitivity and specificity by all four classification models. however, both true positives and true negatives can be predicted with optimal sensitivity and specificity by only svm. in addition, among all four machine learning methods, svm had the highest accuracy of classification compared to the other methods across all three emotional distress, followed by rf, dt, and nb (see figure 5). 78 discussion the current exploratory study contributes to the literature by investigating the relationship between careless responding and self-reported depression, anxiety, and stress using response behavior information (i.e., response time). additionally, the inclusion of item response time in machine learning models was explored for predicting depression, anxiety, and stress severity levels. these findings are germane to researchers who use computerized self-report measures, as response time can aid in the identification of careless responders who bias datasets and invalidate individual testing profiles. furthermore, machine learning models can efficiently predict the severity level of emotional distress by taking not only item responses but also response time patterns into account. response time measures at the page and survey levels have been shown to have limited utility compared to other measures of careless responding (ashley & shaughnessy, 2021; ward & meade, 2022); however, in line with previous research, the current study illustrated the usefulness of behavioral response data at the individual item level. since careless responders are assumed to have rapid response times, which is consistent with their motivations to finish the survey quickly, the item response time is expected to catch careless responders regardless of their response style (curran, 2016). this careless response detection method has potential utility for any self-report dataset with item-level response time. in addition to the detection of careless responders for data quality purposes, the findings of the current study indicate that item response behavior provides clinically relevant information: emotional distress is correlated with a behavioral measure at an item-specific level. researchers have drawn theoretical links between negative emotional states (i.e., depression, anxiety, and stress) and careless responding behavior (ashley & shaughnessy, 2021; conjin et al., 2020). the cognitive and emotional characteristics of emotional distress are theorized as the mechanism explaining high rates of careless responding in emotionally distressed individuals (ashley & shaughnessy, 2021; conjin et al., 2020). however, additional research is needed to clarify the links between careless responding and depression, anxiety, and stress. for example, some theories suggest that depressed individuals have heightened attention towards mood-congruent stimuli (e.g., survey items), while others suggest that avoidance of mood-congruent stimuli is typical in depressed individuals (hubbard et al., 2016). the association between item response time and emotional distress found in the current study suggests that item response time can be a novel and precise approach to testing theories of emotional distress by unpacking the patterns of careless responding associated with specific emotional states (castaneda et al., 2008, 2011; snyder et al., 2015a, 2015b). finally, the current study found that machine learning trained on dass-42 item response and response time can be another approach to predicting the severity of emotional distress, which corroborates previous research (e.g., kumar et al., 2020; priya et al., 2020; srinath et al., 2022). while achieving 100% accuracy may not be feasible or necessary, the goal of using machine learning in this paper was not necessarily to outperform simple arithmetic summation, but rather to show the potential of a data-driven approach to analyze and predict emotional distress by considering both item response and response time. however, using machine learning based on item responses and response times can offer several advantages over the simple arithmetic summation of response data. first, it can allow for capturing subtle patterns that may not be evident through simple arithmetic summation. second, machine learning techniques can handle complex interactions and dependencies among variables, which are very likely to be present in psychological assessment data such as dass. furthermore, these models have the potential to generalize to new datasets and populations, provided that they are trained on diverse and representative samples. this could enhance the applicability of the predictive models across different settings and populations, ultimately improving their utility in research contexts or other applied settings (e.g., healthcare). implications and recommendations psychological measurement is in a period of advancement, with computerized testing affording researchers new ways to collect and interpret data. item response time can be used to identify careless responding, and it has the potential to untangle the psychological mechanisms behind carelessness, particularly in those experiencing emotional distress. the relationship between careless responding and emotional distress, as well as the prediction of emotional states considering both item response and response time, can have important implications for cognitive psychology researchers. thus, the current study has several research, psychometric, and applied implications and future directions for consideration. first, researchers who use online self-report surveys can use the normative threshold method to flag careless responders, which allows the researchers to identify if these responders and their responses are influencing the data and obscuring important findings. this may be of particular response time to identify careless responders 79 zentner & yildirim-erbasli importance among research pools in which the participants are receiving incentives to complete a survey. in such cases, participants may be motivated to finish the survey as quickly as possible to earn the incentive, leading to careless responses. this can result in low-quality data and invalid conclusions drawn from the survey results. if researchers are specifically using measures of emotional distress, such as the dass-42, response time may help to identify those who have higher scores due to careless responding versus those who are genuinely emotionally distressed. second, the use of response time methods has clinical utility in assessing the profile validity of individuals who may be carelessly responding due to their emotional distress. many commonly used psychological tests, including the dass-42, do not include profile validity measures. one reason for this is that additional profile validity scales, such as positive impression management or defensiveness, add items to measures that are otherwise constructed to be as short and efficient as possible. using response time to assess profile validity adds no additional items to these measures. similar to profile validity measures, response time may also provide clinically relevant information to improve our understanding of the cognitive impairments that accompany emotional states. for example, item response time may help ascertain whether an emotionally distressed respondent tends to respond carelessly to avoid mood-congruent information and when they are biased to attend more carefully to mood-congruent information (ashley & shaughnessy, 2021; hubbard et al., 2016). this is valuable information for treatment planning because useful interventions may vary based on whether a client over-attends to negative information (i.e., ruminates) or employs avoidance behavior. thus, in terms of the first research question addressed in this study, understanding the relationship between careless responding and emotional distress can provide insight into the cognitive processes underlying emotional states. regarding the second research question, machine learning models can be utilized to analyze hidden patterns in both item response and response time for predicting self-reported measures of emotional states. considering the current research that has demonstrated an association between emotional distress and response time, it is essential to incorporate response time into the assessment of emotional distress severity rather than relying solely on the arithmetic summation of responses. by doing so, we can achieve a better understanding of emotional distress. machine learning models that incorporate behavioral data, such as item response time, also have practical applications for adaptive testing. wise (2020) suggested that the inclusion of item response data in adaptive testing allows test developers to provide a measure of attention to be considered in profile validity. with real-time monitoring of attention using item response data, developers can intervene to re-engage a respondent who is exhibiting careless responding. for example, if a respondent has several consecutive careless responses, a prompt may appear to remind them to carefully attend to each item. in educational contexts, response time has been included in adaptive testing models, but behavioral measures have not been widely used in computerized adaptive testing of personality and psychopathology. limitations and future research there are several limitations in the current study. first, the use of large datasets is at higher risk of finding spurious correlations between variables. the current findings are situated within the theoretical and research literature supporting the assertion that cognitive symptoms of emotional distress impact response behavior, and thus provide greater confidence in the validity of the findings. second, due to the nature of survey data, the direction of causation between careless responding and emotional distress cannot be confirmed. other factors that were not studied in the current research (e.g., education, age, and formal diagnoses) may be confounding the relationship between emotional distress and careless responding. similarly, the normative response method used to identify careless responses may be impacted by confounding variables, such as technical issues experienced by respondents, item wording, and item valence. additional research is needed to understand how patterns of slow response time may be related to emotional distress due to low processing speed and poor concentration, and to differentiate these responses from slow, careful responders. the literature would benefit from a direct comparison of the normative threshold method with other detection methods (e.g., longstring). there are also several limitations related to the second research question. first, there was a positive skew in our dataset with an overrepresentation of emotionally distressed responders. kumar et al. (2020) noted the problem of determining the best predictive model when data is imbalanced between classification categories. given the potential increase in computation time and considering the primary focus of our paper, we opted not to perform class balancing techniques. future research can study different sampling methods, such as undersampling, oversampling, and rose techniques, to address the class imbalance. second, the algorithm used in the machine learning model and its parameters may 80 response time to identify careless responders have impacted model performance. the current study used dt, rf, nb, and svm algorithms, but future research can study other algorithms not included here. third, machine learning models may make biased predictions for groups belonging to different demographic categories, such as race, gender, and age. future research must consider these demographic variables to understand the generalizability of the model to different populations. finally, to mitigate concerns of circularity, we split the data into separate training and validation sets, ensuring that predictive analyses were conducted on an independent dataset. future research could further strengthen the validation of response-time-based indicators by examining their predictive utility using additional independent outcome measures. the current study stimulates several future research directions. first, future research may specify which emotional states (e.g., depression, anxiety, excitement, and boredom) and demographics (e.g., age and gender) are associated with higher levels of carelessness for enhanced psychometric accuracy. this approach especially benefits individuals who score low on the dass-42 due to poor insight into or masking of their emotional state but whose cognitive impairment is indicated by a behavioral measure, such as response time. second, the identification of patterns in the data that are indicative of certain levels of emotional distress, which could help to improve the diagnostic accuracy of the dass-42 scale, should be explored. for example, researchers can investigate whether a client’s carelessness increases, ebbs and flows, or has a consistent rate throughout the survey. thirdly, the normative response time approach may be applied within cognitive psychology and emotion regulation research to explore how different emotion regulation strategies impact cognitive processes and to compare response time cut scores amongst different populations. finally, more research is needed to explore how machine learning models that include response time can be incorporated effectively into clinical and psychological assessments, such as adaptive testing and wellness-oriented smartphone applications. conclusion careless responding is a significant source of bias in online self-report surveys–a common data collection method in the field of psychology. the normative threshold method is an important approach for researchers to identify careless responders, and it circumvents the limitations of other approaches for detecting response bias. the normative threshold method also offers a novel behavioral measure for studying the impact of emotional distress on cognition. while all researchers using self-report measures hold responsibility and accountability for collecting valid and reliable data, those conducting research on emotional distress face additional validity threats because of the relationship between emotional distress and careless responding. the current study provides preliminary evidence that incorporating normative response thresholds into routine data cleaning practices and machine learning models may enhance the accuracy with which psychological researchers can describe and predict emotional distress. references american psychological association. 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(1985). manual for the multiple affect adjective check list. san diego: educational and industrial testing service. 84 response time to identify careless responders figure 1 methodological framework for addressing research question 1 85 zentner & yildirim-erbasli figure 2 methodological framework for addressing research question 2 86 response time to identify careless responders figure 3 comparison of dass-42 subscale scores between careful and careless responders 87 zentner & yildirim-erbasli figure 4 macro-averaged classification metrics for emotional distress note. dt: decision tree; rf: random forest; nb: naive bayes; svm: support vector machine. 88 response time to identify careless responders figure 5 accuracy of classification for machine learning models note. dt: decision tree; rf: random forest; nb: naive bayes; svm: support vector machine 89 zentner & yildirim-erbasli table 1 sociodemographic summary 90 response time to identify careless responders table 2 guide for severity levels of emotional distress in dass-42 91 zentner & yildirim-erbasli table 3 single classification metrics for emotional distress by each level 92 response time to identify careless responders table 3 (continued) 93 zentner & yildirim-erbasli table 3 (continued) note. dt: decision tree; rf: random forest; nb: naive bayes; svm: support vector machine. bold indicates the highest, with 70% acceptable and 80% optimal thresholds in each subscale. 92 graduate student journal of psychology spring 2024 vol. 22 copyright 2024 by the department of counseling and clinical psychology teachers college, columbia university decoding factors influencing mental health help-seeking in asian international students: a correlational survey study mental disorders have a significant impact on a substantial portion of the global population. warren (2023) noted that approximately 50 million individuals in the u.s. are affected by a diagnosable mental disorder. in march 2022, the world health organization reported a 25% increase in anxiety and depression diagnoses worldwide, alongside an increased risk of suicidal ideation (kola, 2022). notably, college students represent a demographic with a higher incidence of mental health issues. a comprehensive study by auerbach et al. (2018) revealed that out of 13,984 american college students surveyed, 35% tested positive for at least one of six mental health disorders. the study further indicated a prevalence rate of 31.4% for mental health disorders within the past year and a lifetime prevalence of 35.3% (auerbach et al., 2018). more recent data underscores this concern. the american college health association's (acha) 2022 national college health assessment, which surveyed over 54,000 undergraduate students, found that approximately 77% were experiencing moderate to serious psychological distress. while the mental health of college students is a broad concern, international students represent a particularly vulnerable group. shadowen (2019) discovered that international students often report high levels of depression and anxiety. in his study of 490 individuals, 45.3% met the criteria for clinically significant depression on the center for epidemiologic studies depression scale (ces-d), and 24.7% showed moderate to severe anxiety symptoms as per the beck anxiety inventory (bai). further emphasizing this issue, jamshaid (2023) conducted a longitudinal study revealing that international students experienced increased levels of depression and anxiety during and following the covid-19 pandemic. despite the high prevalence of mental disorders, the rate at which individuals seek treatment remains concerningly low. khoury and ammar (2014) found that only 23% of individuals with mental illnesses in the united states sought treatment. data from the national health interview survey (nhis) in 2019 indicated that just 19.2% of adults aged 18 and over had received any mental health treatment in the previous 12 months, a figure that increased slightly to 21.6% by 2021 (terlizzi, 2022). although warren (2023) reported a rise in treatment prevalence to 45% in 2023, the situation appears different within the college student population. according to the american college health association-national college health assessment (acha-ncha), only 24% of students diagnosed with depression sought treatment, and this percentage was even lower among international students. mesidor (2014) found that a mere 17.7% of international students (n=34) with mental health concerns intended to seek help. further, a study by zhou et al. (2021) highlighted a significant disparity in service utilization between international and domestic students (n=96,567), with respective rates this study investigates the effects of gender, age, perceived socioeconomic status, and attitudes toward mental health treatment, alongside the awareness and accessibility of mental health services, on the propensity of asian international undergraduate and graduate students in u.s. colleges to seek mental health support. utilizing an online survey, responses from a diverse group of 116 participants, aged 18 and above, from universities across the nation were examined through correlation analysis. findings indicated no significant gender differences in attitudes toward mental health treatment. however, factors such as higher educational level, superior socioeconomic background, longer u.s. residency, and increased awareness and accessibility of mental health services positively influenced attitudes. this quantitative study extends previous qualitative research addressing similar questions, filling a gap by offering broader empirical insights into this population’s mental health service utilization. the outcome underscores the need for university counseling centers to develop targeted interventions that acknowledge the needs of asian international students. future research should explore the longitudinal impacts of these factors on mental health help-seeking behaviors to inform ongoing service improvement. keywords: mental health treatment, attitudes toward mental health, asian international students, awareness and accessibility, socioeconomic influences yuanruo xu derner school of psychology, adelphi university 93 of 32.0% and 49.8%. this low prevalence of treatment-seeking behavior in both the broader college population and particularly among international students remains a major concern for many universities. given the gap between the need for mental health services and the actual rates at which individuals, especially international students, seek out these services, one cannot help but wonder what specific challenges are faced by this population that further complicate this scenario. are cultural perceptions, stigma, or perhaps the lack of culturally sensitive resources exacerbating their reluctance to seek help? imagine the internal struggle of a student, thousands of miles away from home, facing not only the usual stresses of academic life but also navigating a foreign mental health system that feels alien to them. as we delve into the specific mental health issues faced by this group, we must consider these unique barriers, and explore how universities can bridge the gap between the need for and utilization of mental health services among international students. the mental health landscape of international students many existing studies have identified international students as particularly vulnerable to mental health challenges, arising from a combination of factors including academic pressures, language barriers, cultural adjustment, financial stress, and a reluctance to seek help (dombou et al., 2023; friday, 2018; jiang et al., 2020; mohammadifirouzeh et al., 2023). these students face not only intense academic competition but also overwhelming stress and anxiety (asif et al., 2020). furthermore, adapting to new food, climate, and societal systems can significantly exacerbate these stressors, potentially leading to conditions such as depression (cianconi et al., 2020). prieto-welch (2016) encapsulates this by noting that “international students face unique pressures and struggles which may interact with and amplify the expected stressors,” leading to grave outcomes such as academic difficulties, addiction, suicidal ideation, and broader health concerns. among these myriad challenges, language barriers emerge as a particularly pivotal issue, exacerbating feelings of isolation and communication difficulties (smith & khawaja, 2011; wilczewski & alon, 2023). this sense of isolation extends beyond social aspects, potentially impairing international students’ academic performance as they may struggle to comprehend lectures, participate in discussions, or seek assistance from peers and instructors. smith and khawaja (2011) underscore how these language barriers intensify the stress associated with adjusting to a new academic environment. however, the journey of adaptation for international students does not end with overcoming language obstacles. the impact of cultural adjustment on the mental health of international students is also significant (razgulin et al., 2023). mori (2000) posits that adapting to an unfamiliar cultural environment is a multifaceted and challenging process, often resulting in “culture shock.” this can manifest as anxiety, confusion, and depression, as students attempt to reconcile their cultural norms with those of the host country. international students commonly experience homesickness, and longing for family, friends, and familiar environments (mekonen & adarkwah, 2023; sawir et al., 2008). this sense of loss can amplify feelings of loneliness and alienation, further exacerbating mental health concerns. beyond cultural and social challenges, financial pressures constitute another critical factor impacting the mental health of international students. they typically incur higher tuition fees and living expenses, along with limited work opportunities due to visa constraints (lee & rice, 2007; olatunji et al., 2023). such financial burdens can induce considerable stress and anxiety, as students grapple with fulfilling both their expenses and familial expectations. compounding these issues is the stigma associated with mental health challenges and a lack of familiarity with the host country’s mental health services, which often leads to reluctance to seek help (guo et al., 2019; poyrazli & lopez, 2007). without timely and appropriate intervention, these compounded stresses can exacerbate existing mental health conditions, underscoring the urgent need for accessible and culturally sensitive support systems for international students. the majority of international students are vulnerable to the repercussions previously mentioned, making these issues a primary concern for many higher educational institutions. despite this, the inclination to seek professional mental health assistance remains notably low among international students, particularly those from asian backgrounds. nilsson et al. (2004) found a significantly lower prevalence of mental health treatment among international students at university counseling centers compared to their domestic u.s. counterparts. wong et al. (2013) highlighted that, xu 94 asian international student mental health help-seeking due to acculturation challenges, asian international students have the lowest rate of mental health treatment among all international student groups. empirical research further reveals the susceptibility of asian international students to mental health issues. sun et al. (2020) reported that perceived discrimination and cultural adjustment difficulties significantly contribute to increased psychological distress in chinese international students. additionally, yu et al. (2023) identified language barriers and social isolation as major stressors, often resulting in anxiety and depression. these findings gain added significance considering the large population of asian international students at u.s. universities, underscoring the urgent need for targeted mental health support. korhonen (2023) reported that the majority of international students in the u.s. are from china (289,526), india (268,923), and south korea (43,847), making asians the most populous regional group. as such, korhonen (2023) underscored the critical need to understand and address the unique mental health challenges of this significant portion of the international student body. neglect of mental health importance in asian cultures many asian international students face significant mental health challenges upon their arrival in the united states for study, largely due to cultural perceptions of mental health in their home countries (alegría, 2017). in these cultures, mental health issues are often overlooked, and seeking professional help is perceived as a weakness (martinez, 2020). this cultural backdrop may lead to a lack of essential understanding among these students about mental health, available treatment options, and resources in their new environment, potentially discouraging them from seeking help or limiting their opportunities to gain mental health education (jang, 2007). the reluctance to address mental health concerns is deeply embedded in the traditional values and societal norms of many asian cultures, where stoicism and self-reliance are highly valued (chen & jiang, 2022). mental health issues are frequently viewed as personal failings rather than medical conditions that require attention, thus perpetuating stigma and discouragement from seeking help (yin et al., 2020). this viewpoint is further supported by zhang et al. (2019), who reported that in many asian societies, mental health problems are often not recognized as legitimate health issues. instead, they are seen as a source of embarrassment or stigma. yang et al. (2019) expand on this, noting that mental health issues are frequently interpreted as a disruption of social harmony or a sign of weakness. moreover, studies by martinez et al. (2020) reveal that in some asian cultures, there is a strong emphasis on family reputation and honor, which often takes precedence over individual well-being. as a result, mental health concerns are often hidden to avoid bringing “shame” to the family. in their qualitative study, chen and vivekananda (2021) found that this leads to a significant underreporting of mental health issues among asian populations. in many asian cultures, mental health issues are heavily stigmatized and often concealed due to societal perceptions that categorize them as personal failures, sources of shame, or burdens to the family (misra et al., 2021). societal pressures and gender expectations can exacerbate these concerns, making it particularly challenging for individuals to voice their struggles with mental health. for instance, societal norms often impose additional obstacles on women, as they are frequently expected to prioritize their family's and community's needs over their mental well-being (kundadak et al., 2020). the disparity in mental health awareness between asian communities and western societies, as noted by tse and haslam (2021), further complicates the situation. many individuals from asian backgrounds may not recognize symptoms of mental health disorders or know how to seek appropriate help. this lack of awareness, alongside a preference for traditional healing practices and community support over formal mental health care, can limit access to and utilization of necessary mental health services (pham et al., 2021). while these traditional methods can be beneficial, they may not always be sufficient for treating complex mental health disorders. yakunina and weigold (2011) explored the interplay between cognitive variables and cultural factors influencing asian international students' intentions to seek counseling. their findings indicated that participants who endorsed more traditional asian values reported less favorable attitudes toward counseling and lower intentions to seek help. this result highlights the significant impact of cultural values on mental health help-seeking behavior among asian international students. in summary, the neglect of mental health impor95 tance in asian cultures is a complex issue, influenced by traditional values, societal norms, family dynamics, and a lack of mental health awareness. this further complicated as asian international students navigate the acculturation process in their host countries, where the clash between these deeply ingrained cultural norms and the new societal context can create significant barriers to seeking mental health support. acculturation issues preventing help-seeking acculturation issues pose significant barriers for asian international students seeking mental health support in the united states. ma et al. (2020) identified that the adjustment to social and cultural norms of the host country often exacerbates existing mental health conditions and deters help-seeking due to fears of misunderstanding or judgment. this situation is compounded by cultural dissonance, where conflicts between students' native cultural beliefs and those of the host country led to increased stress and anxiety, a phenomenon martinez-taboada (2018) found to be prevalent among these students. the challenge of navigating between maintaining one’s cultural identity and conforming to a new environment adds another layer of complexity to their experiences. furthermore, language barriers, as lasauskiene and bagdonaviciute (2023) point out, play a critical role in intensifying feelings of isolation and helplessness, particularly among students with limited english proficiency. this difficulty in communicating emotional and psychological needs effectively is a significant hurdle. suh et al. (2023) add to this narrative by emphasizing the impact of perceived discrimination and stereotyping on these students' mental health. such experiences can foster a sense of alienation and reluctance to seek help, for fear of further marginalization or stigmatization. navigating the u.s. mental health care system presents its own set of challenges, as highlighted by clough et al. (2018). asian international students may be unfamiliar with how mental health services operate in the u.s. and lack knowledge about available resources, significantly deterring help-seeking. ra (2023) discussed the importance of social support networks in the acculturation process, noting that a lack of supportive relationships in the host country can lead to increased vulnerability and a decreased likelihood of seeking mental health services. the accumulation of these factors illustrates the complex interplay between acculturation stress, systemic barriers, and individual challenges in hindering the mental health help-seeking process among asian international students. the findings of miller et al. (2011) enrich our understanding of the intricate dynamics between acculturation, enculturation, and their effects on mental health and attitudes toward seeking professional psychological help among asian international students. their study revealed that higher levels of acculturation were linked to improved mental health outcomes, while a strong sense of behavioral enculturation was positively correlated with mental health. this research unearthed significant differences in the experiences of foreign-born and u.s.-born students, particularly concerning the impact of acculturative stress on mental health. such distinct finding underscores the complex challenges faced by asian international students in the u.s., not only in navigating their mental health concerns but also in their attitudes toward seeking help. this complexity points to the necessity for a nuanced approach to providing culturally sensitive mental health services tailored to their unique experiences. study aims building upon these insights, the present study aims to delve deeper into the underexplored terrain of asian international students’ perspectives on mental health treatment in the united states. specifically, it seeks to: (1) quantitatively assess the attitudes of asian international students towards mental health treatment, examining factors such as gender, the duration of study in the u.s., education level, subjective socioeconomic status, and awareness and accessibility to mental health treatment options. (2) propose targeted interventions based on the findings, aimed at improving access and effectiveness of mental health services for asian international students. while related studies in australia (lamontagne, 2023; mulder, 2015; redfern, 2016) have begun to address this topic, the unique experiences of asian students in the u.s. remain less explored. our research is inspired by xu's (2023) qualitative study, which examined the factors influencing chinese international students' barriers to psychotherapy in the u.s. interestingly, xu identified cultural differences as significant factors affecting attitudes toward mental health treatment, rather than as barriers. xu also found that accessibility and knowledge about mental health were positively correlated with xu 96 asian international student mental health help-seeking treatment attitudes. as a quantitative extension of this work, our study seeks to enhance understanding of the factors influencing the mental health treatment attitudes of asian international students more broadly. we hypothesize that several factors significantly influence asian international students' attitudes toward seeking mental health treatment. these include gender, which may shape help-seeking behaviors due to societal norms and expectations prevalent in some asian cultures. the duration of study in the u.s. is also considered a crucial factor, as it could affect levels of acculturation and, subsequently, attitudes toward mental health care. furthermore, the level of education might influence such attitudes, with higher education potentially linked to increased mental health awareness. subjective socioeconomic status is expected to play a role, affecting both the affordability of treatment and its perceived value. equally important are the awareness of and accessibility to mental health treatment options; a lack of these may prevent asian international students from seeking the help they need. by identifying these factors and understanding precisely how they influence attitudes towards mental health treatment, this study aims to uncover the nuances of mental health care perceptions and identify potential areas for improvement in accommodating asian international students, particularly for whom english is a second language. our findings are expected to lead to the development of culturally sensitive and accessible outreach programs and interventions tailored to the unique needs of asian international students within college counseling settings. the goal is to bridge between these students and the mental health services available to them, ensuring that interventions are designed with an accurate awareness of the challenges they face. by customizing outreach efforts and services to address the identified factors, we aim to foster more positive attitudes toward mental health treatment among asian international students. ultimately, this study seeks to enhance the overall mental health and well-being of this student population in the united states, contributing to a more inclusive and supportive academic environment. methods this study focused on participants who met inclusion criteria. they had to be 18 years of age or older, enrolled full-time in a u.s. educational institution as international students, and self-identified as ethnically asian. there were no specific exclusion criteria. participants were recruited from a selection of one hundred universities across the u.s., which were randomly chosen from a comprehensive list of u.s. institutions. our research team approached the international student office of each selected university via email to request permission to disseminate the recruitment email through their international student listservs. upon receiving consent from the international students office, we distributed a recruitment email to the listservs. this email included a brief overview of the study and a link to the online survey, which was also accessible via a qr code. interested participants, upon accessing the survey, encountered a series of self-report questionnaires. these questionnaires were designed to gather socio-demographic data, including gender, age, and subjective socio-economic status. additionally, the survey included the attitudes toward seeking professional psychological help (atspph) and specific items to assess participants' awareness and accessibility of mental health treatment options. to gain a comprehensive understanding of the participants' mental health context, the survey also inquired about any existing mental health diagnoses and previous experiences with mental health treatment. the study was conducted under the supervision of a university’s institutional review board to ensure ethical compliance. all participants were informed that they could withdraw from the study at any time without any penalty, ensuring their autonomy and respect for their decision-making. additionally, data protection measures were implemented, with all survey responses stored in a password-protected electronic format on qualtrics, and personal identifiers such as ip addresses were not collected. this approach guarantees that participants' confidentiality is maintained, and their contributions are securely managed, fostering an environment of ethical integrity in the research process. a self-administered online questionnaire was developed via qualtrics, encompassing two sections. the first section solicited sociodemographic information, including age, gender, ethnicity, nationality, and family income. additionally, it comprised queries concerning the participants' current visa status, their educational institution's location, their year in college, their major, the number of years they have spent in the u.s., and 97 any previous experiences with mental health treatment. a copy of this measure can be found in appendix a. the questionnaire's second portion included items designed to elicit students' attitudes toward mental illness and treatment, utilizing fischer and turner's attitudes toward seeking professional psychological help (atspph) scale from 1970. this is a 29-item measure comprised of four factors: recognition of the need for professional psychological help, stigma tolerance associated with psychological help, interpersonal openness about one's problems, and confidence in mental health professionals. this scale is frequently used in the u.s. to examine help-seeking attitudes among diverse racial and ethnic groups, immigrants, and international students. sample statements include: "i would want to see a counselor if i was worried or upset for a long period of time" and "there are experiences in my life i would not discuss with anyone." participants rated these statements on a four-point likert scale, ranging from "strongly agree" to "strongly disagree." the scoring was such that "strongly agree" responses were assigned three points, while "strongly disagree" responses received one point. the total score for each participant was calculated by summing the points of each item's response. eighteen items were reverse-coded, with a higher score signifying a more positive attitude toward mental health treatment. the atspph has demonstrated internal consistency, with coefficients ranging from 0.82 to 0.84 (elhaiet al., 2008). its reliability and validity have been established in several studies; for instance, fischer and farina (1970) reported high internal consistency reliability coefficients (cronbach's alpha) ranging from .82 to .93 across various samples. vogel et al. (2006) found good 1-month test-retest (.80) and internal consistency (.84) reliabilities for the atspph, as it correlated significantly with measures of mental health stigma and help-seeking behavior. furthermore, the application of the atspph in diverse research settings underscores its versatility and relevance in exploring attitudes toward mental health. by employing this validated scale, researchers can draw insights into the complex dynamics of stigma, cultural variability, and educational impacts on mental health behaviors (mcandrew et al., 2019; park et al., 2018; vogel et al., 2013). the decision to utilize the atspph in this research is grounded in its proven capacity to provide reliable and valid measures across different populations and settings. this choice reflects a methodological commitment to employing tools that not only have strong psychometric properties, but also offer the potential to contribute significantly to our understanding of key factors influencing mental health help-seeking behaviors. the questionnaire's final section aimed to ascertain students' familiarity with counseling or psychotherapy treatment options. the items in this section were divided into two key areas, encompassing four items on awareness and three items on accessibility. sample statements included: "i am aware of the mental health services available for students on campus" and "i can access mental health services when needed." participants rating these statements as "strongly agree" were assigned four points, while "strongly disagree" responses were given one point. the total score for each participant was calculated by summing the points of each item's response. a higher score indicated greater awareness and accessibility to mental health treatment options. given the lack of a validated scale specifically designed to assess the awareness and accessibility of mental health resources in a university setting, we developed our own concise survey. this decision ensured our inquiry precisely targeted our research objectives, examining the nuances of students' awareness and access to mental health support within their academic environments. this bespoke approach aligns closely with our research methodology, ensuring that we captured the specific aspects of mental health resource accessibility and awareness among university students, thereby enhancing the study's relevance and accuracy. this measure's full version can be found in appendix b. to evaluate the internal consistency reliability, cronbach’s alphas were calculated. we compared atspph scores and awareness and accessibility scores according to participants’ characteristics using an independent t-test or one-way analysis of variance (anova). spss statistics 28 (ibm corp., armonk, ny) was used to perform all statistical analyses, chosen for its widespread acceptance and reliability within the psychological research community. this software is particularly favored for its comprehensive set of tools that facilitate a broad range of statistical tests, including those employed in our study, thereby ensuring accuracy and efficiency in our data analysis. a p-value less than .05 was considered significant. xu 98 asian international student mental health help-seeking 98 results of the 208 survey responses collected, 47 records were excluded since they did not satisfy the criteria for international students. additionally, three responses were removed because they did not identify as asian. furthermore, 37 participants discontinued the survey after providing demographic information, and five participants bypassed more than eight questions. these instances were regarded as invalid responses and were consequently excluded from the analysis. after eliminating invalid responses, a total of 116 participants provided valid data for the analysis. the majority (85.3%, n=99) were aged between 18 and 26 years old, including 43.1% (n=50) in the 18-22 age group and 42.2% (n=49) in the 23-26 age group. meanwhile, 14.7% (n=17) were over 27 years old, with 9.5% (n=11) in the 27-30 age group and 5.2% (n=6) aged 30 or above, indicating their educational level. approximately 51.7% (n=60) of participants were enrolled in graduate schools, slightly more than the 44.8% (n=52) who were college students. in terms of ethnicity, 91.4% (n=106) identified as chinese, 2% (n=4) as vietnamese, 2% (n=4) as south korean, 1% (n=1) as pakistani, while the rest did not specify their ethnicity. of the participants, 69.8% (n=81) identified as female, 25% (n=29) as male, and 5.2% (n=6) as nonbinary or preferred not to disclose their gender. geographically, 44.8% (n=52) of participants were studying in new york state, with another 12.9% (n=15) in california. the top three majors were psychology (30.2%), business management, marketing, and related support (12.1%), and education (9.5%), covering 18 major categories. regarding mental health history, 36.2% (n=42) reported prior mental health treatment, 18.1% (n=21) had a previous diagnosis of a mental disorder, and 12.1% (n=14) reported receiving ongoing mental health treatment. the study participants rated their subjective socioeconomic status (ses) on a scale of 1 to 10, where 10 represented the highest status with the most wealth, education, and prestigious jobs, and 1 represented the lowest status with the least wealth, education, and low-paying jobs or unemployment. on average, participants rated their subjective ses at 6.35, with a standard deviation of 1.41, and a mode of 7. table 2 presents the atspph scores based on the participants' characteristics. one-way anova suggested no significant difference was found between the mean atspph scores of females, males, and the nonbinary/prefer not to say gender group (1.96 vs. 1.85 vs. 1.70, p=.31). however, a significant correlation was observed between educational level and atspph scores. specifically, an independent t-test suggested that participants enrolled in graduate school exhibited significantly higher mean atspph scores compared to their undergraduate counterparts respectively (2.01 vs. 1.82, p=.004). moreover, the analysis, conducted using one-way anova, revealed a significant correlation between age groups and atspph scores (p=.036). participants aged 30 and above reported the highest mean atspph score of 2.14, with a standard error of the mean (sem) of .16, suggesting a more positive attitude towards mental health treatment. this was followed by the 23-26 age group, which had a mean score of 2.02 and an sem of .04. notably, the 18-22 and 27-30 age groups displayed comparable mean scores of 1.84, with sems of .06 and .12, respectively. these findings further emphasize the potential influence of age on attitudes towards mental health treatment. although the independent t-test results were not statistically significant, participants with a history of mental health treatment, either past or current, exhibited slightly higher mean atspph scores compared to those without such history (2.00 vs. 1.88, p=.077). this observation warrants further investigation in future studies. table 3 showcases the item-total correlations and cronbach's alpha values related to the awareness and accessibility of mental health treatment. the cronbach's alpha for this entire section was found to be .903, indicating high internal consistency within the section. table 4 illustrates the two-tailed pearson correlation associations between socio-demographic characteristics and atspph scores. univariate analyses revealed significant positive associations between family income (r=.243, p=.009) and years spent in the us (r=.245, p=.008) with atspph scores. furthermore, the table presents the pearson correlation between socio-demographic factors and atspph scores, as well as between the awareness and accessibility of mental health treatment. notably, the number of years spent in the us (r=.230, p=.014) showed a significant positive association with awareness. additionally, both awareness (r=.331, p<.001) and accessibility (r=.234, p=.012) displayed signif99 icant positive correlations with atspph scores. moreover, awareness was significantly and positively associated with accessibility scores (r=.826, p<.001). discussion our findings suggest that certain factors, including higher family income, longer duration spent in the us, enhanced awareness of mental health treatment, and improved accessibility to mental health services, are associated with more positive attitudes towards seeking professional psychological help among asian international students. redefining gender norms the findings of the current study indicate that gender does not significantly influence the attitudes of asian international students toward seeking psychological help, with female, male, and nonbinary or unspecified gender groups exhibiting similar tendencies regarding mental health treatment. this observation contracts traditional views within asian cultures, which often depict men as stoic and decisive, burdened with greater social expectations and responsibilities (kramer, 2002). such gender norms have been linked to social stigma, potentially informing negative attitudes among men toward mental health treatment (chatmon, 2020; livingston, 2018). however, our results indicate a departure from these conventional beliefs, especially among the younger generation of asian international students. zhang and hui (2021) provide corroborating evidence, suggesting that exposure to western norms among asian international students might attenuate the influence of traditional gender roles on their help-seeking behavior. contemporary research emphasizes the role that educational settings play in transforming beliefs and attitudes. scholz et al. (2016) assert that environments fostering gender equality and mental health awareness can lessen the impact of deep-seated cultural stereotypes on help-seeking behavior. this finding is supported by tse and haslam (2021), who found that asian international students are likely to adopt help-seeking behaviors within supportive and inclusive academic communities, irrespective of gender. in addition, advancements in mental health advocacy and the proliferation of information through digital media have likely contributed to this trend. both niederkrotenthaler et al. (2014) and kim (2022) stress the role of online platforms and media in normalizing discussions around mental health, potentially narrowing the gender gap in attitudes toward seeking assistance. given these findings, it seems that the younger, globally-minded asian international students are embracing more progressive views on mental health, consistent with the inclusive attitudes prevalent in their host nations. this shift implies that while conventional cultural expectations might continue, they are being reshaped by the combined effects of acculturation, the influence of educational environments, and the worldwide discourse on mental health. however, it is important to point out that the gender imbalance in the study sample, with a higher number of female participants, may suggest inherent differences in help-seeking attitudes between genders among asian international students. this imbalance could indicate that female students are more willing or able to participate in studies about mental health, reflecting a broader openness towards seeking help or discussing mental health issues. for the study's results, this means conclusions drawn about gender effects on help-seeking attitudes might not fully represent the male and nonbinary perspectives, potentially skewing the perceived shift towards more progressive views on mental health. further research with balanced and diverse gender representation is crucial to accurately assess these attitudes and their implications in the context of cultural and acculturation influences on asian international students in the u.s. influence of education on mental health help seeking our results reveal differences in the willingness to seek mental health assistance across various educational levels, reinforcing the well-established correlation between higher educational attainment and more proactive attitudes toward seeking mental health support (eisenberg et al., 2007; eisenberg et al., 2013; jorm, 2004; wong et al., 2017). specifically, our data indicate that individuals engaged in graduate school education are more likely to hold and express favorable attitudes toward utilizing mental health services. this tendency is likely due to the increased exposure to mental health discussions that higher education provides, fostering comfort in seeking help (farley, 2023). institutional initiatives, such as university-led mental health awareness campaigns and accessible counseling services, create an environment that normalizes help-seeking behavior (pace et al., 2016). the academically stimulatxu 100 asian international student mental health help-seeking ing environment of higher education, which promotes critical thinking and self-reflection, may heighten students' awareness of their mental health needs, and encourage proactive help-seeking (liu et al., 2021). furthermore, in a 2021 report by the national academies of sciences, engineering, and medicine titled “mental health, substance use, and wellbeing in higher education: supporting the whole student,” the importance of integrating topics of psychological well-being and mental health literacy into the curriculum and classes within higher education institutions is emphasized, further strengthening students' attitudes towards mental health services. the impact of this education is particularly pronounced among asian international students, who may originate from cultures where open discussions about mental health are less prevalent (dessauvagie et al., 2022). the study result underscores the significant role that educational environments play in shaping the mental health-seeking behaviors of students, with a notable effect on asian international students who may face cultural barriers to acknowledging and addressing mental health issues. while it has been observed that higher education levels correlate with positive attitudes toward mental health, and a longer stay in the u.s. enhances mental health awareness among asian international students, the relationship between these two factors is complex. it is not straightforward to link prolonged u.s. residency with higher education levels due to varied arrival times in the u.s. for education. for example, an individual who came to the u.s. solely for a ph.d. program might have a five-year stay, whereas another person who arrived during middle school and only completed a bachelor's degree could have resided in the u.s. for a longer duration. since detailed data on the duration of stay relative to educational attainment is not available, making definitive assumptions about their relationship is challenging. future research could explore how the length of stay and educational level together impact mental health awareness, considering the diverse educational pathways of asian international students in the u.s. wealth and wellness our study uncovered a significant positive association between family income and attitudes toward seeking professional psychological help (atspph) scores. students from higher-income families showed more positive attitudes toward seeking mental health treatment. this observation aligns with existing research suggesting that financial capabilities often improve access to mental health care services (cummings et al., 2013). families with higher incomes not only have the financial resources to afford mental health treatment, but their children are also more likely to receive a higher level of education. this educational advantage typically fosters a more informed and proactive attitude towards mental health help-seeking (mackinnon et al., 2010). the correlation between family income and attitudes towards mental health can be attributed to broader socio-economic factors that shape an individual's access to healthcare and information. according to a longitudinal survey study by bialowolski (2021), economic stability often correlates with improved mental health literacy, a critical factor in recognizing mental health issues and seeking appropriate help. additionally, the financial security provided by higher-income families may reduce the stress and anxiety associated with financial constraints, which are known barriers to mental well-being (knapp & wong, 2020). ryu and fan (2023) found that financial stress significantly impacts students' mental health, indicating that higher family income can indirectly contribute to better mental health by alleviating such stressors. furthermore, students from affluent families might have earlier and more frequent exposure to mental health discussions and treatments, either through their family network or community, normalizing the concept of seeking help for mental health issues. cultural perceptions within one’s immediate social circle, including family, significantly influence attitudes towards mental health services (aarons & sawitzky, 2006; turner et al., 2015). in summary, family income emerges as a pivotal factor in shaping attitudes towards mental health treatment among asian international students. this underscores the need for comprehensive mental health strategies that consider the socio-economic backgrounds of students to ensure equitable access to mental health resources. acculturation and mental health attitudes our results indicate that a prolonged stay in the u.s. leads to increased mental health awareness among asian international students. this increase is not merely a byproduct of time, but is intricately linked to the influence of the american education system, 101 xu which prioritizes mental health education and support. u.s. educational institutions proactively offer resources aimed at student well-being, ranging from admission orientations that introduce mental health topics to ongoing support services. such consistent exposure not only deepens students' understanding of mental health issues but also cultivates a proactive attitude towards seeking help (eisenberg et al., 2009). acculturation plays a pivotal role in this dynamic, serving as a bridge between mere exposure and active integration of healthier attitudes toward mental health. over time, asian international students assimilate not just superficial elements of american culture but also its progressive stances on mental health. research by knaifel et al. (2022) found that increased acculturation correlates with decreased stigma around mental health, thereby facilitating help-seeking behaviors. the social networks that students develop over time in the u.s. can also influence their attitudes toward mental health. peer interactions, especially with students who embody more liberal views on mental health, serve as a catalyst for changing perceptions and reducing the stigma associated with seeking psychological help (makhmud et al., 2022; sun et al., 2022). moreover, increased familiarity with the u.s. healthcare system over time can reduce barriers to accessing mental health services. as students become more knowledgeable about available resources and how to navigate the system, their willingness to seek help may increase (alqassim et al., 2022). the observed changes suggest that cultural competence in mental health strategies is not just beneficial, but essential. the process through which students' attitudes toward mental health evolve highlights the critical need for culturally sensitive approaches to mental health support. it points to the necessity of designing mental health interventions and resources that are not only accessible, but also resonate with the diverse cultural backgrounds of international students. this perspective encourages a more nuanced understanding of how cultural factors influence mental health awareness and help-seeking behaviors. by fostering an environment that values cultural competence, educational institutions can play a transformative role in supporting the mental well-being of international students, making a case for the integration of cultural sensitivity into all levels of mental health strategy and intervention planning. we recognize that the predominance of chinese international students in our sample presents a limitation that may not fully encapsulate the diverse experiences and attitudes toward mental health found across different asian cultures. this sampling bias indeed restricts our ability to generalize our findings to all asian international students. however, it also provides a unique opportunity to reflect on the differences within asian cultures, especially concerning mental health perspectives. for instance, cultural attitudes toward mental health in chinese society, which are often influenced by confucian values emphasizing stoicism and familial harmony, might differ significantly from those in other asian cultures where religion and individualism play a more substantial role (tung & li, 2014). while our study's limited sample size of participants from other ethnicities constrains the statistical power to make broad comparisons, preliminary observations suggest that chinese international students may exhibit particular coping strategies, stigma perceptions, and help-seeking behaviors that are shaped by their cultural background (chen et al., 2020). the influence of collectivist values in chinese culture may lead to a greater emphasis on maintaining social harmony and face, potentially affecting students' willingness to seek mental health support (gao et al., 2022). in contrast, students from south asian cultures, where there is a different interplay between individualism and collectivism, or from southeast asian countries, where community support systems and religious beliefs might offer alternative coping mechanisms, could exhibit distinct attitudes and behaviors towards mental health challenges (kim & lee, 2022; singal & chopra, 2023). given these considerations, it becomes evident that future research must strive for a more diverse representation of asian international students to explore the intricate ways in which cultural factors influence mental health perceptions and help-seeking behaviors. in summary, the duration of stay in the u.s. is a significant factor in developing mental health awareness among asian international students. this relationship underscores the need for educational institutions to continuously engage with international students throughout their educational journey, fostering an environment conducive to mental health awareness and help-seeking. however, it is essential to empirically validate which specific elements of the u.s. education system contribute most significantly to this 102 asian international student mental health help-seeking heightened awareness. future research should aim to dissect these aspects to better understand and enhance the support systems available to international students. navigating mental health pathways our study revealed that heightened awareness and accessibility to mental health services are crucial in shaping positive attitudes toward mental health treatment among asian international students. specifically, students who are well-informed about available mental health resources, possess the ability to effectively navigate these resources, and have unobstructed access to services, tend to exhibit more favorable attitudes toward seeking mental health treatment. this correlation underscores the vital role that educational institutions play in providing comprehensive mental health education and ensuring the availability of robust support systems (lipson, 2014). awareness and accessibility are interconnected factors that significantly influence mental health outcomes. a study by shim et al. (2022) highlighted that knowledge about mental health issues and familiarity with treatment options can significantly reduce the stigma associated with seeking help. when institutions make a concerted effort to provide easily accessible mental health services, they normalize the process of seeking help, thereby encouraging students to take proactive steps toward their mental health. the unique challenges faced by asian international students, such as cultural barriers and unfamiliarity with the host country's healthcare system, further accentuate the need for targeted mental health initiatives. martirosyan et al. (2019) suggested that tailored programs that address the specific needs of international students can effectively increase their awareness and utilization of mental health services. another critical aspect is the use of technology in improving accessibility. digital platforms and telehealth services have been identified as effective means to overcome geographical and logistical barriers, providing students with easier access to mental health care (bulkes et al., 2022; mcbain et al., 2023). this approach is particularly beneficial for international students who may face language barriers or have limited transportation options. in conclusion, our study highlights the significance of awareness and accessibility in fostering positive attitudes toward mental health treatment among asian international students. educational institutions play a crucial role in enhancing these factors through strategic initiatives and resource allocation, ultimately contributing to the mental well-being of this student population. conclusion the current study elucidates the multifaceted factors shaping asian international students' attitudes toward seeking professional psychological help in the u.s. it reveals not only the significance of socioeconomic status, duration of stay, gender norms, educational attainment, and acculturation but also underscores the paramount importance of mental health awareness and accessibility. our findings demonstrate a progressive shift away from traditional gender norms, reflecting a broader cultural adaptation among asian international students influenced by supportive educational environments and acculturation processes. the positive correlation between socioeconomic status and attitudes towards mental health help-seeking highlights it as a critical factor in access to mental health care. moreover, the study brings to light how heightened awareness and unimpeded accessibility to mental health services are indispensable in cultivating positive attitudes toward mental health treatment. students who are well-informed about and able to navigate mental health resources effectively show a greater propensity to seek professional help. this emphasizes the critical role of educational institutions in promoting mental health literacy and ensuring the availability of comprehensive support systems. these findings advocate for a departure from traditional cultural norms and underscore the necessity of implementing supportive, inclusive, and culturally competent mental health strategies within both educational and healthcare settings. as we pivot to the clinical and research implications of our study, it becomes crucial to leverage these insights in devising targeted interventions that address the unique needs of asian international students. this approach necessitates a nuanced understanding of how cultural, socioeconomic, educational, and systemic factors converge to influence mental health help-seeking behaviors, aiming to foster environments that enhance mental health awareness and ensure equitable access to mental health services. clinical and research implications drawing upon our study's findings, we recommend that university counseling centers and therapists who work with asian international students imple103 xu ment outreach programs aimed at boosting mental health awareness through comprehensive, culturally sensitive education and resources. emphasizing the significance of mental well-being and reducing stigma around seeking help is pivotal, with initiatives potentially encompassing orientation programs, workshops, informational materials, and online resources, as advocated by reavley et al. (2012). to meet the diverse needs of this demographic effectively, it is essential to tailor services by offering varied workshops or support groups and collaborating with departments such as international student services to develop a unified support strategy, as echoed by pedersen and pave (2014). enhancing services’ accessibility and affordability, addressing financial constraints through information on insurance and financial aid, and simplifying the access process is critical to overcoming barriers to care, as noted by komiya et al. (2000). moreover, partnering with student organizations can lead to more targeted, culturally attuned programming, enhancing the effectiveness of mental health education for asian international students. this holistic approach, integrating varied services and collaborative efforts, promises a more supportive and inclusive environment conducive to their mental health needs. to address these challenges effectively, we propose the following detailed action plans and strategies: step 1: developing culturally informed outreach programs assessment of needs. conduct surveys and focus groups with asian international students to understand their specific mental health concerns, preferences for receiving information, and barriers to accessing services. program design. based on the assessment, design outreach programs that incorporate culturally sensitive materials and resources. these should address common mental health issues, debunk myths and stigma associated with seeking help, and highlight the importance of mental wellness. implementation. launch the programs through various channels, including orientation sessions for new students, workshops throughout the academic year, and online platforms that provide 24/7 access to resources. step 2: tailoring services to diverse needs service diversification. expand the range of services to include not only traditional one-on-one counseling, but also support groups, workshops, and seminars that focus on issues pertinent to asian international students. language and cultural competency. ensure that counseling staff are trained in cultural competency and, where possible, provide services in multiple languages or offer interpreter services to mitigate language barriers. feedback mechanism. establish a system for collecting feedback on the services provided, enabling continuous improvement and adaptation to student needs. step 3: enhancing accessibility and affordability of mental health services financial support information. clearly communicate information about the cost of services, insurance coverage, and financial aid options for mental health care, including partnerships with community providers for affordable treatment options. simplified access. streamline the appointment scheduling process and reduce wait times by leveraging technology for booking sessions and offering virtual counseling options. community provider partnerships. develop partnerships with local mental health providers to offer extended services to students, ensuring continuity of care for those requiring long-term support. step 4: collaborating with campus and student organizations partnership development. foster collaborations with campus departments, such as international student services and diversity and inclusion offices, to create a unified approach to supporting asian international students' mental health. student organization engagement. actively work with student organizations, including any asian student organizations and international student groups, to co-host events, provide culturally relevant programming, and facilitate peer support networks. step 5: integrating culturally informed practices training for counselors and staff. implement ongoing training programs on cultural competence, focusing on the unique challenges faced by asian international students, including those with advanced degrees and other specific groups. incorporation of cultural practices. explore the integration of traditional asian mental health 104 asian international student mental health help-seeking practices and perspectives into counseling services, offering a blend of western and eastern approaches to treatment. by systematically implementing these strategies, university counseling centers can significantly improve the mental health support system for asian international students, fostering a more inclusive, supportive, and culturally sensitive environment. this tailored approach not only aligns with our study's findings, but also sets a foundation for future research and continuous improvement in the delivery of mental health resources. to ensure these interventions remain effective and responsive, it is crucial to establish mechanisms for ongoing evaluation and improvement. regular feedback collection from students, staff training updates based on the latest research, and continuous assessment of program outcomes are essential. incorporating a cycle of evaluation, feedback, and refinement will enable counseling centers to adapt their strategies to meet the evolving needs of asian international students, demonstrating a commitment to providing the highest level of mental health support. this proactive stance towards constant enhancement ensures that mental health initiatives remain aligned with student needs, cultural shifts, and advancements in psychological research, thereby sustaining a dynamic and effective support system. strengths and limitations several limitations may impact the generalizability of the findings from this study, necessitating caution when extending these results beyond the sampled population. primarily, the recruitment of participants was confined to a limited number of universities, predominantly located in new york and california. given the unique sociocultural and educational environments of these states, the relatively large percentage of the sample drawn from these locations may introduce a selection bias, limiting the representativeness of the study. this geographic concentration may not fully capture the varied experiences and perspectives of asian international students across the u.s., making it prudent to apply these findings to other regions or demographics with caution. the overrepresentation of chinese international students within our sample poses another significant limitation. while providing variable insights into this subgroup, it might not accurately portray the attitudes and experiences of students from other asian countries, potentially skewing the results towards the perspectives prevalent within chinese student communities. this disproportionate representation underscores the need for a more diverse sample that includes a wider array of nationalities, to ensure a more comprehensive understanding of the mental health attitudes of asian international students. moreover, the cross-sectional nature of this study limits the ability to infer causality or track changes in attitudes over time. the reliance on a survey that, while informative, may not have undergone extensive validation or been widely used in previous research to assess mental health awareness and accessibility among asian international students, presents a limitation in accurately gauging the effectiveness of existing support structures. the use of a non-validated survey can introduce biases or inaccuracies in measuring the intended constructs, limiting the reliability and generalizability of the results. potential confounding variables, such as the participants' prior exposure to mental health education, variations in cultural background, and personal experiences with mental health services, were not fully controlled in our method. these factors could influence participants' responses and interpretations of the survey questions, thereby affecting the study's overall conclusions. longitudinal studies would be required to understand the evolution of mental health attitudes and behaviors as students adapt to their host country's culture and education system. such an approach would also allow for the examination of how prolonged exposure to the u.s. education system and its mental health resources impacts students from various asian backgrounds over time. by acknowledging these limitations, we emphasize the need for caution in generalizing the study's findings beyond the specific universities or states in our sample, or the predominant representation of chinese students. this acknowledgment is crucial for readers to understand the study's contextual limitations, ensuring a nuanced interpretation of the results. future research should aim to employ more robust sampling methods to ensure a broader and more representative sample of asian international students from multiple states and countries. implementing stratified or random sampling techniques could help mitigate some of the biases inherent in convenience sampling. additionally, expanding the geographic scope of the study and including 105 xu ing the geographic scope of the study and including longitudinal elements could provide a richer, more nuanced understanding of the mental health attitudes and needs of this diverse student population. incorporating qualitative research methods such as focus groups or interviews can significantly enhance our understanding of the intricate factors influencing asian international students' attitudes toward mental health treatment. for instance, insights into the specific cultural misconceptions about mental health can inform targeted educational campaigns, while understanding preferences for certain types of support can guide the development of more effective, culturally sensitive counseling approaches. despite the outlined limitations, this study offers data about international students of asian descent studying in the u.s., explicitly examining their attitudes toward seeking mental health assistance. the research fills a gap in the existing literature, which predominantly focuses on domestic college students. this study's findings illuminate the attitudes of a distinctive group of students who grapple with unique cultural and linguistic barriers. these students may be reluctant to seek mental health assistance due to factors like social stigma. consequently, the insights offered by the current research are vital for understanding the help-seeking behaviors of asian international students. they can inform the design of targeted interventions and services to address their 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(2021). prevalence of common mental concerns and service utilization among international students studying in the u.s. counselling psychology quarterly, 35(3), 483–502. https://doi.org/10.1080/09515070.2021.1875400 xu 112 appendix a eligibility screening questions demographic information asian international student mental health help-seeking 113 demographic information (cont.) xu 114 demographic information (cont.) asian international student mental health help-seeking 115 appendix b awareness and accessibility to mental health treatment xu 116 table 1 social-demographic characteristics and ses of respondents asian international student mental health help-seeking 117 table 2 comparison of atspph according to participants’ characteristics note. *p < .05, **p < .01 xu 118 table 3 item-total correlations and cronbach’s alphas for awareness and accessibility for mental health treatment (n=116) asian international student mental health help-seeking 119 table 4 association between characteristics variable and atspph scores note. *p < .05, **p < .01 xu